Introducción

This is the fourth publication on ethics published by the Peruvian Journal of Gynecology and Obstetrics (RPGO) in the last 12 years, in keeping with the importance given to this discipline in the work of physicians, particularly obstetricians and gynecologists^1-3. Due to the importance assigned to the subject, the Peruvian Society of Obstetrics and Gynecology (SPOG) held a contest in 2009, together with the Peruvian Medical College (CMP), in which different topics of ethics in sexual and reproductive health were highlighted⁴. In the same year, it was part of a Workshop on Values Clarification, in Trinidad, Bolivia⁵.

Although it is true that scientific knowledge, attitudes and skills are transcendent in the training of physicians, the ethical and bioethical component also plays an important role and is transversal to all disciplines of medical science to ensure the integral performance of the professional. The development of science and technology, in general, has expanded the role of medicine and physicians, but the technological progress of mankind has not gone hand in hand with ethical reflection, so that eventually the sustainability of human life and that of other living beings has been put at serious risk⁶.

Since the ancient times of medicine, it is said that Hippocrates coined the idea of "first do no harm" (primum non noscere), in the same way that he recognized privacy and professional secrecy as a necessity in the doctor-patient relationship³. This paternalistic way of practicing medicine was maintained for centuries, until the mid-twentieth century when ideologies began to change. It was after the Second World War, following the Nuremberg trial (1947), that the Nuremberg Code (1949) was created, which incorporated the right of individuals to autonomy, to decide about diagnostic, therapeutic and experimental means⁷. In other words, to informed consent.

Later, in 1964, the World Medical Association drew up the first version of the Declaration of Helsinki, which recognizes the right of individuals to qualified medical care and the importance of ethics committees⁸. It was the medical pathologist Potter who initiated a turn in the ethical doctrine through his publication "Bioethics the Science of Survival"⁹. The Congress of the United States of America, faced with abuses in experimental research in the Tuskegee Syphilis Study, carried out from 1932 to 1972, created a special committee which, in 1979, signed the Belmont Report (named after the place where it was signed), in which three principles of bioethics are recognized: Beneficence (maximum benefit with minimum risk), Respect for persons (self-determination, autonomy and informed consent) and Justice (equitable selection of the participant)¹⁰, to which was added the following year the principle of Non-Maleficence (do no harm), in the publication of Beauchamp and Childress¹¹. This is how the principlism of bioethics is constructed in the USA, which has not been exempt from criticism, so that more principles have been added, such as solidarity and others.

As we can see, the ethical framework of medical paternalism has changed to an ethical framework based on the rights of individuals, where the principles of bioethics, which are not consistent with human rights, have their place. Within this framework, the World Conference on Population and Development, held in 1994 in Cairo, recognized the provision of health care based on human rights (HR) and recognized Sexual and Reproductive Rights (SRHR)¹², which were confirmed in Beijing, the following year, during the World Conference on Women¹³. The SRHR have been exquisitely and extensively developed by Dr. Rebeca Cook and collaborators¹⁴.

In our country, the General Health Law of 1997 recognizes the individual's right to autonomy, as well as medical confidentiality, conscientious objection and some other items related to sexual and reproductive health¹⁵. Similarly, medical and non-medical institutions have developed activities on the recognition of sexual and reproductive rights and specifically on their ethical aspects¹⁶.

In the context of this background and in the knowledge of the deep moral crisis we are living is that the SPOG, and specifically the Editorial Committee of the RPGO, consistent with the doctrinal and theoretical aspects of medical ethics, has considered incorporating a Section of Ethics and Bioethics in the practice of our specialty and we start with the edition of this article, which develops the reflection on the practice of colposcopy that requires not only the medical professional with sufficient training in the structure and pathology of the cervix, mainly in the diagnosis of cancer. It also requires professional performance with strict adherence to bioethical conduct, taking care that their practice is not supplanted by unqualified professionals and is conducted on the basis of the provisions of the Code of Ethics and Deontology of the Peruvian Medical Association¹⁷ and the ethical recommendations of the International Federation of Gynecology and Obstetrics FIGO^18).

Clinical description

The case is of a 20-year-old woman, G0P0, with sexual debut at the age of 19 years, with only one sexual partner. She attended a gynecologic evaluation referring pruritus in the external genitalia. On gynecological examination, abundant whitish leucorrhea and erythema were found at the level of the external genitalia. The vagina and cervix had no evident alterations. A cervical smear was taken for cytological examination (Papanicolaou), the result of which was ASCUS, so she was indicated to require colposcopy. On colposcopic examination, a visible squamo-columnar junction with faint whitish epithelium was found. A biopsy of the cervix was taken, which was reported to have 'areas suggestive of mild dysplasia'. She was instructed to undergo cone LEEP. The patient consulted for a second opinion.

The case is of a 20-year-old woman, G0P0, with sexual debut at the age of 19 years, with only one sexual partner. She attended a gynecologic evaluation referring pruritus in the external genitalia. On gynecological examination, abundant whitish leucorrhea and erythema were found at the level of the external genitalia. The vagina and cervix had no evident alterations. A cervical smear was taken for cytological examination (Papanicolaou), the result of which was ASCUS, so she was indicated to require colposcopy. On colposcopic examination, a visible squamo-columnar junction with faint whitish epithelium was found. A biopsy of the cervix was taken, which was reported to have 'areas suggestive of mild dysplasia'. She was instructed to undergo cone LEEP. The patient consulted for a second opinion.

Case discussion

Diagnostic procedures

Regarding the management of the screening test result, the patient has a cytology of ASCUS, which means that there are atypical cells or cells with minor alterations that the pathologist cannot determine their actual significance. As explained above, transient HPV infections are very common in young women and are commonly associated with minor cytologic changes that do not have premalignant potential. The ALTS study²⁴ conducted by the National Cancer Institute (NCI) in the USA has shown that only a minority of patients with ASCUS have HPV infection; the vast majority of times, ASCUS is associated with other causes without malignant potential such as lower genital tract infections, hormonal changes, among others.

Something very important to consider is the training of the pathologist who reads the cytology or cervical biopsy slides. It is commonly assumed that all pathologists have adequate training to evaluate Pap or biopsy specimens, but multiple studies have shown that there is high variability in pathologists' diagnoses. One way to assess whether the pathologist requires special training is by measuring the percentage of specimens he or she reports as ASCUS; it is accepted that only 5% to 10% of cytology specimens should have a diagnosis of ASCUS. If the pathologist reports ASCUS in a higher percentage of specimens it can be considered that he/ she should have additional training and/or specialized supervision.

Following the evaluation of the patient's results, we find that even though she should not have had cervical cancer screening due to her age, we are in the need to act on the reported ASCUS result. The recommendation of the American Society for Colposcopy and Cervical Pathology (ASCCP)²⁵ is that a patient with a cytologic result of ASCUS should be rescreened in 12 months. We should be clear that no additional procedure is indicated in a patient with ASCUS cytology. The colposcopic evaluation indicated for the patient described in this article is not recommended by any existing national or international management guidelines (See Figure 1).

Figure 1 Management of young women with ASCUS cytology results. 

It is important to highlight that colposcopic evaluation is not recommended in patients with inflammatory processes of the lower genital tract. The reason is that the inflammatory process is usually associated with benign reactive changes in the cervical epithelium, such as squamous metaplasia, which can be observed as faint acetowhite epithelium, which the inexperienced colposcopist may confuse with epithelium with premalignant changes, and trigger unnecessary biopsies.

The histopathological study of the biopsy was reported as "areas suggestive of mild dysplasia". It is important to emphasize again that the experience of the pathologist is very important in the reading of cervical biopsies; and there is considerable discrepancy in the reading performed by different pathologists. The report of "areas suggestive of mild dysplasia" indicates that the pathologist is unsure of the diagnosis and should compel us to request a review of the pathology slide by a pathologist with experience in evaluating cervical specimens.

Assuming that the review of the slides confirms that the patient has mild dysplasia, she does not require any type of surgical intervention. The MINSA guidelines clearly indicate that a patient with CIN 1 (mild dysplasia) should not receive treatment and a repeat cytology should be performed at 12 months. A similar recommendation is found in the US ASCCP guidelines.

Bioethical discussion

The bioethical principle of beneficence indicates that we should act in the best interest of our patients, promoting their interests and suppressing any prejudice (maximum benefit with minimum risk). In the case of the patient described in this article, this ethical principle, which is fundamental in the practice of medicine, has not been complied with. The patient has not had the evaluations she should have had at her age and excessive action has been taken without any benefit to her. The patient was exposed to invasive tests (colposcopy and biopsy) that are unnecessary for the patient's age and clinical picture, exposing her to unnecessary risks, which clearly violates the principle of non-maleficence. Although the patient was not finally submitted to cone LEEP because she went to another physician for a second opinion, such surgery was indicated without considering the patient's benefit and, more importantly, without considering the obstetric complications resulting from cone excision using LEEP loop, affecting the patient's obstetric future.

If we consult the Code of Ethics and Deontology of the Peruvian Medical Association(17), in this case the Declaration of Principles 3, the principles and ethical values in Medicine, has been violated, which reads as follows:

Ethical principles and values are social and personal aspirations. As far as society is concerned, these highest aspirations are solidarity, freedom and justice, and as far as the individual is con-cerned, respect for dignity, autonomy and integrity. In the professional practice of medicine, these aspirations are realized through the precepts of beneficence -which consists of seeking the good of the patient- and non-maleficence -which consists of preventing any form of harm or injury from occurring.

And articles 1, 9, 55, 63 clause d, of the same code, which literally say:

Art 1.- It is the duty of the physician to perform his profession competently, having, for this purpose, to continuously improve his knowledge, skills and attitudes and to practice his profession integrating himself into the community, with full respect for the socio-cultural diversity of the country.

Art 9.- The physician shall practice medicine on a scientific basis and shall be guided by validated medical procedures.

Art 55.- In patients who require diagnostic or therapeutic procedures that involve risks greater than the minimum, the physician must request written informed consent, by means of which they are informed of what they consist of, as well as the possible alternatives, the probable duration, the limits of confidentiality, the benefit/risk and benefit/cost ratio.

Art 63.- The physician shall respect and seek the most appropriate means to ensure respect for the patient's rights, or their reestablishment in case they have been violated. The patient has the right to:

(d) Obtain all information that is truthful, timely, understandable, about his diagnosis, treatment and prognosis.

Key clinical messages

Cervical cancer screening should not be initiated in women under 25 years of age as there is no benefit for the patient.

HPV infection is very common in young women and the vast majority do not require any intervention because in most women the infection is cleared naturally by the immune system.

Patients with ASCUS should not have colposcopy and/or biopsy. International recommendations indicate that they should be followed up in 12 months.

Colposcopy should not be performed when there are inflammatory processes of the lower genital tract since the inflammatory process triggers benign changes that may confuse the colposcopist.

LEEP should not be performed in young women or in women who wish to have children due to the obstetric implications of such surgery. Premalignant lesions can be treated with ablative methods that do not alter the anatomy or function of the cervix.

Ethical recommendations

1. To develop the teaching of Ethics and Bioethics as a transversal discipline in the medical profession.

2. To strengthen moral values in the medical professional.

3. To provide correct and complete information to the users of the gynecological practice.

4. Empowering women users of gynecological services to make their own decisions.

5. Adequately train gynecology and obstetrics medical personnel in the practice of colposcopy.

6. To provide colposcopy services with strict adherence to bioethical principles.