Informed or misinformed choice? Framing effects in a national information pamphlet on colorectal cancer screening

In March 2014 the Danish Health Authority established a national screening programme for colorectal cancer. During a four-year period all Danish citizens aged 50–74 years will receive an invitation along with an information pamphlet about the benefits and harms of participating. There is an international consensus that participation in cancer screening should be based on informed consent, as all screening programmes for cancer have the potential to bring about both benefits and harms. To enhance the possibility of making an informed choice about participation, it is essential to provide individuals with understandable and adequate information. The aim of this article was to examine to what extent a small, non-probability, but nevertheless heterogeneous sample of Danish citizens were able to understand the chances of benefits and risks of harms in the Danish national information pamphlet. We also explored whether the framing of the information had a ‘nudge effect’ on choice concerning participation. In March and April 2015 we conducted 14 individual semi-structured interviews. Through analysis using a ‘meaning condensation’ approach, we found evidence that the participants misunderstood important parts of the pamphlet. Our results further indicate that the information was framed so it nudged citizens to participate in screening. We argue that insufficient information and framing effects are in conflict with the requirements of informed consent and leave the citizen at risk of participating in potentially harmful procedures without understanding the consequences. Our analysis raises important ethical and legal questions regarding the pamphlet and its basis for making an informed choice.