Wheeler et al. BMC Cancer 2011, 11:148 http://www.biomedcentral.com/1471-2407/11/148 D E B A T E Open Access Applying strategies from libertarian paternalism to decision making for prostate specific antigen (PSA) screening David C Wheeler1*, Konrad M Szymanski2, Amanda Black3 and David E Nelson4 Abstract Background: Despite the recent publication of results from two randomized clinical trials, prostate specific antigen (PSA) screening for prostate cancer remains a controversial issue. There is lack of agreement across studies that PSA screening significantly reduces prostate cancer mortality. In spite of these facts, the widespread use of PSA testing in the United States leads to overdetection and overtreatment of clinically indolent prostate cancer, and its associated harms of incontinence and impotence. Discussion: Given the inconclusive results from clinical trials and incongruent PSA screening guidelines, the decision to screen for prostate cancer with PSA testing is an uncertain one for patients and health care providers. Screening guidelines from some health organizations recommend an informed decision making (IDM) or shared decision making (SDM) approach for deciding on PSA screening. These approaches aim to empower patients to choose among the available options by making them active participants in the decision making process. By increasing involvement of patients in the clinical decision-making process, IDM/SDM places more of the responsibility for a complex decision on the patient. Research suggests, however, that patients are not well- informed of the harms and benefits associated with prostate cancer screening and are also subject to an assortment of biases, emotion, fears, and irrational thought that interferes with making an informed decision. In response, the IDM/SDM approaches can be augmented with strategies from the philosophy of libertarian paternalism (LP) to improve decision making. LP uses the insights of behavioural economics to help people better make better choices. Some of the main strategies of LP applicable to PSA decision making are a default decision rule, framing of decision aids, and timing of the decision. In this paper, we propose that applying strategies from libertarian paternalism can help with PSA screening decision-making. Summary: Our proposal to augment IDM and SDM approaches with libertarian paternalism strategies is intended to guide patients toward a better decision about testing while maintaining personal freedom of choice. While PSA screening remains controversial and evidence conflicting, a libertarian-paternalism influenced approach to decision making can help prevent the overdiagnosis and overtreatment of prostate cancer. Background Screening for prostate cancer using prostate specific anti- gen (PSA) has become widespread despite the controversy surrounding the practice. For men, prostate cancer is the most commonly diagnosed cancer in the US and the sec- ond leading cause of cancer death. In 2010, approximately * Correspondence: dcwheels@gmail.com 1Occupational and Environmental Epidemiology Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD 20892, USA Full list of author information is available at the end of the article 217,730 men were diagnosed with prostate cancer and 32,050 men died, illustrating the public health burden of this disease and the need for the identification of effective methods to reduce prostate cancer mortality [1]. Unfortunately, there is a lack of conclusive evidence of the value of PSA screening in the reduction of mortality; two randomized controlled PSA screening trials, one in Europe and the other in the US, recently reported dispa- rate results for the effect of PSA testing on prostate can- cer mortality [2,3]. The European study reported a 20% relative reduction in prostate cancer mortality with © 2011 Wheeler et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.