Winner: BONUS Essay Competition 2025

We are really excited to announce the winners for BONUS Essay Competition this year. Thanks to all medical students and junior doctors for submitting their essays, we have really enjoyed reading and found them interesting.

Our winners for the BONUS Essay Competition 2025 are:

Andy Choi
Medical Student at University College London

Jack Greenwold
Medical Student at University of Bristol

What is the biggest ethical dilemma that oncologists face in their research or clinical practice? Justify your answer.

Andy Choi's Essay

“How many oncologists do you need to be pallbearers at a funeral? Five. Four to carry the casket, one to hang the chemo.” This dark joke, though morbid, reflects the reality of some practices––the tendency to continue highly aggressive treatments even when the benefits are minimal. When patients are facing their final days, oncologists must decide whether to attempt to prolong life or provide respite in the final moments. However, the decision is far more nuanced than it seems on paper. Patients and their families may cling to even the slimmest hope, while oncologists must balance their duty to uphold patient autonomy with their responsibility to do no harm. Simultaneously, financial considerations, societal values, and psychological burdens on oncologists add further complexities. At its core, this dilemma raises a fundamental question: at what point does the pursuit of extending life undermine its very intrinsic properties? Deeply tied to this question is the direct conflict between autonomy and nonmaleficence, the extension of the Hippocratic Oath’s “Primum non nocere” (1). Oncologists must respect a patient's choices, even if they lead to harm, while simultaneously being ethically bound to prevent suffering. This includes allowing patients to opt for aggressive end-of-life interventions despite a lack of proven benefits and the potential for severe toxicity. Such trends are evident across healthcare systems worldwide. From Sweden to South Korea to Australia to the US, between 15-30% of patients were given chemotherapy in the last month of their lives (2,3). This is despite strong evidence that aggressive end-of-life care often leads to reduced patient quality of life, greater risk of dying from treatment-related complications, and an increased risk of psychiatric illness in bereaved caregivers (4)

Beyond patient well-being, aggressive end-of-life interventions also raise concerns about healthcare resource allocations, especially with the rise of cancer cases globally (5). In the US, up to 30% of the Medicare budget has been spent on care for people in the last year of their lives,much of it on high-cost interventions offering little benefits (6). Similarly, in the UK, end-of-life care accounted for nearly 10% of all hospital costs (7). Hence, while patient autonomy must be upheld, the principle of nonmaleficence also requires oncologists to advocate for treatments that provide meaningful benefits rather than prolonging suffering, especially when aggressive treatments divert limited healthcare resources from other patients who may benefit more. Yet, end-of-life care is growing increasingly aggressive across cancer types (3,8). When qualitative research was conducted into reasons why patients choose to pursue invasive treatments until the end, it was found that both patients and their families often had unrealistic expectations, overestimating the effectiveness of treatments and underestimating side effects (9).

Fatigue, for instance, was worse than expected in around 30% of patients in one study, significantly impacting quality of life and aggravating other symptoms (10). Cultural narratives surrounding cancer further complicate decision-making––when having cancer is portrayed as a “battle”, discontinuing treatment seems like resignation rather than a rational decision prioritizing comfort and dignity (11)

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Moreover, oncologists themselves may struggle with transitioning patients to palliative care, especially due to the close bonds they form (12). This reluctance is further exacerbated by the emotional burden of delivering terminal diagnoses, as well as systemic pressures—such as financial incentives in private healthcare models (13), the lack of formal training in end-of-life conversations (14), and cultural attitudes toward disclosure (15). In Western cultures, physicians frequently use euphemisms, avoid prognostic discussions, and knowingly administer ineffective treatments to preserve hope in patients (15). The impact of this communication gap is evident in a study of nearly 600 advanced cancer patients in the US, where 71% wanted to know their prognosis, yet only 17.1% were informed (16). This highlights a paradox: while patient autonomyforms the cornerstone of medical ethics, it is frequently compromised by inadequate communication and unrealistic optimism.

Given these challenges, the biggest ethical quandary oncologists face is navigating the delicate balance between ensuring patient autonomy and preventing unnecessary suffering. While some patients will inevitably choose highly aggressive treatments for marginal improvements (17), evidence suggests that when oncologists engage in comprehensive end-of-life conversations, patients make more informed choices, often opting for palliative care, experiencing fewer unnecessary hospitalizations, and reporting better quality of life in their final months (18). Achieving this, however, requires broader cultural and systemic changes—restructuring healthcare incentives in some systems, integrating end-of-life communication into medical education, and normalizing discussions about death. Ultimately, oncology is not just about treating the disease but about treating the person. The best oncologists are not those who “fight” till the end but those who know when letting go is the most compassionate option.

References

1. Rawbone R. Principles of Biomedical Ethics, 7th Edition: Occupational Medicine [Internet]. 2015 Jan [cited 2025 Feb 20];65(1):88–9. Available from: https://academic.oup.com/occmed/article/65/1/88/1433004

2. Braga S. Why do our patients get chemotherapy until the end of life? Annals of Oncology [Internet]. 2011 Nov [cited 2025 Feb 20];22(11):2345–8. Available from: https://www.annalsofoncology.org/article/S0923-7534(19)37727-0/fulltext

3. Earle CC, Neville BA, Landrum MB, Ayanian JZ, Block SD, Weeks JC. Trends in the Aggressiveness of Cancer Care Near the End of Life. Journal of Clinical Oncology [Internet]. 2004 Jan 15 [cited 2025 Feb 20];22(2):315–21. Available from:

   https://ascopubs.org/doi/10.1200/JCO.2004.08.136

4. Karim SM, Zekri J, Abdelghany E, Dada R, Munsoor H, Ahmad I. Time from last chemotherapy to death and its correlation with the end of life care in a referral hospital. Indian Journal of Medical and Paediatric Oncology : Official Journal of Indian Society of Medical & Paediatric Oncology [Internet]. 2015 [cited 2025 Feb 20];36(1):55–9. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC4363852/

5. Zhao J, Xu L, Sun J, Song M, Wang L, Yuan S, et al. Global trends in incidence, death, burden and risk factors of early-onset cancer from 1990 to 2019. BMJ Oncology [Internet]. 2023 Sep 5 [cited 2025 Feb 20];2(1). Available from: https://bmjoncology.bmj.com/content/2/1/e000049

6. Riley GF, Lubitz JD. Long-Term Trends in Medicare Payments in the Last Year of Life. Health Services Research [Internet]. 2010 Apr [cited 2025 Feb 20];45(2):565–76. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1475-6773.2010.01082.x

7. Cummins L, Julian S, Georghiou T, Kumar G, Scobie S. Public expenditure in the last year of life [Internet]. Marie Curie. 2025 Feb [cited 2025 Feb 20]. Available from: https://www.mariecurie.org.uk/document/public-expenditure-in-the-last-year-of-life-report

8. Chen RC, Falchook AD, Tian F, Basak R, Hanson L, Selvam N, et al. Aggressive care at the end-of-life for younger patients with cancer: Impact of ASCO’s Choosing Wisely campaign. Journal of clinical oncology [Internet]. 2016 May 20 [cited 2025 Feb 20];34(15):LBA10033–3. Available from: https://ascopubs.org/doi/10.1200/JCO.2016.34.15_suppl.LBA10033

9. Ikander T, Jeppesen SS, Hansen O, Raunkiær M, Dieperink KB. Patients and family caregivers report high treatment expectations during palliative chemotherapy: a longitudinal prospective study. BMC Palliative Care [Internet]. 2021 Feb 26 [cited 2025 Feb 20];20(37). Available from: https://bmcpalliatcare.biomedcentral.com/articles/10.1186/s12904-021-00731-4

10. Mende M, Trautmann K, Rentsch A, Hornemann B, Schuler US, Ehninger G, et al. Patients’ perspectives on palliative chemotherapy of colorectal and non - colorectal cancer: a prospective study in a chemotherapy- experienced population. BMC Cancer [Internet]. 2013 Feb 7 [cited 2025 Feb 20];13(66). Available from:

    https://link.springer.com/article/10.1186/1471-2407-13-66

11. Hauser DJ, Schwarz N. The war on prevention II: Battle metaphors undermine cancer treatment and prevention and do not increase vigilance. Health Communication [Internet]. 2019 Sep 9 [cited 2025 Feb 20];35(13):1–7. Available from: https://www.tandfonline.com/doi/full/10.1080/10410236.2019.1663465

12. Horlait M, Chambaere K, Pardon K, Deliens L, Van Belle S. What are the barriers faced by medical oncologists in initiating discussion of palliative care? A qualitative study in Flanders, Belgium. Supportive Care in Cancer [Internet]. 2016 Apr 16 [cited 2025 Feb 20];24(9):3873–81. Available from: https://link.springer.com/article/10.1007/s00520-016-3211-5

13. Malin JL, Weeks JC, Potosky AL, Hornbrook MC, Keating NL. Medical Oncologists’ Perceptions of Financial Incentives in Cancer Care. Journal of Clinical Oncology [Internet]. 2013 Feb 10 [cited 2025 Feb 20];31(5):530–5. Available from: https://ascopubs.org/doi/10.1200/JCO.2012.43.6063

14. Harnischfeger N, Rath HM, Alt-Epping B, Brand H, Haller K, Letsch A, et al. Effects of a communication training for oncologists on early addressing palliative and end-of-life care in advanced cancer care (PALLI-COM): a randomized, controlled trial. ESMO Open [Internet]. 2022 Nov 7 [cited 2025 Feb 20];7(6):100623. Available from: https://www.esmoopen.com/article/S2059-7029(22)00257-5/fulltext

15. Baile WF, Lenzi R, Parker PA, Buckman R, Cohen L. Oncologists’ Attitudes Toward and Practices in Giving Bad News: An Exploratory Study. Journal of Clinical Oncology [Internet]. 2002 Apr 15 [cited 2025 Feb 20];20(8):2189–96. Available from: https://ascopubs.org/doi/10.1200/JCO.2002.08.004

16. Enzinger AC, Zhang B, Schrag D, Prigerson HG. Outcomes of Prognostic Disclosure: Associations With Prognostic Understanding, Distress, and Relationship With Physician Among Patients With Advanced Cancer. Journal of Clinical Oncology: Official Journal of the American Society of Clinical Oncology [Internet]. 2015 Oct 5 [cited 2025 Feb 20];33(32):3809–16. Available from: https://ascopubs.org/doi/10.1200/JCO.2015.61.9239

17. Matsuyama R, Reddy S, Smith TJ. Why Do Patients Choose Chemotherapy Near the End of Life? A Review of the Perspective of Those Facing Death From Cancer. Journal of Clinical Oncology [Internet]. 2006 Jul 20 [cited 2025 Feb 20];24(21):3490–6. Available from: https://ascopubs.org/doi/abs/10.1200/JCO.2005.03.6236?casa_token=Pi8Z9TX6sDkAAAAA%3AU-82S7NohZkYyV5tVcRc3sw6aE2Qow95lYh-DnCpSD4KpOza829GQ00fXGBGCHFXLycnf0XT2BZRXA

18. Mack JW, Weeks JC, Wright AA, Block SD, Prigerson HG. End-of-Life Discussions, Goal Attainment, and Distress at the End of Life: Predictors and Outcomes of Receipt of Care Consistent With Preferences. Journal of Clinical Oncology [Internet]. 2010 Feb 1 [cited 2025 Feb 20];28(7):1203–8. Available from: https://ascopubs.org/doi/10.1200/JCO.2009.25.4672
    

Jack Greenwold's Essay

Introduction

In an age of data-based and AI-driven healthcare, the ethical challenges faced by oncologists transcend beyond the typical dilemmas of patient care and extend into the domain of technology ethics. Whilst traditionally, ethical issues in oncology tend to focus on end-of-life care or experimental treatments, the conflict between protecting sensitive patient data against utilising vast datasets to advance personalised treatments has largely been overlooked. This essay aims to explore the rise in personalised oncology, its reliance on data, and the ethical implications associated with this. However, this dilemma poses a unique opportunity to redefine and shape trust in modern medicine and revolutionise cancer outcomes.

The Rise of Personalised Oncology

Cancer is a undoubtedly a major long-standing public health concern, involving complexpathophysiology subsequently creating various challenges regarding treatment. [1] Personalised oncology involves tailoring cancer treatment based on genomic, proteomic and patient-specific data.[2, 3] Whilst only available for a select few cancer subtypes, personalised treatment has huge potential to save lives by offering targeted, optimal therapies, contrasting a ‘one size fits all’ previous approach to cancer treatment. The Cancer Genome Atlas, which has thoroughly screened the DNA of33 cancer types, is an example of utilising genomic data, combined with artificial intelligence, to analyse and predict patient-specific tumour responses to personalise the most effective treatment. [4]Whilst still in its infancy, personalised treatment has proven to reduce cancer mortality, with a 2020study highlighting the 3-year survival rate for patients with advanced cancer who received molecular-specific therapy was 30% higher than those who received traditional therapies. [5] Therefore, adopting personalised cancer treatments represents an innovative, promising advancement in oncology.

Ethical Implications of Data Privacy

Whilst personalised treatments and utilising ‘big data’ presents an exciting frontier in battling cancer, the risk of data breaches exposing sensitive, individual genomic information could have catastrophic consequences, not only undermining trust in oncologists but also the broader healthcare system. Astudy from the USA found that 255 million patients were affected from healthcare hacking incidents between 2010-19, highlighting the scale of healthcare breaches, undermining the pillar of confidentiality, central to modern medicine. [6] Moreover, patients may not be fully informed of how their genomic data will be used for treatment and who would be able to access and share their sensitive bioinformation. This is significant, especially given the vulnerability of cancer patients, who are likely to be inherently distressed regarding their diagnosis, making patients perhaps more likely to agree to data sharing without thoroughly understanding the implications.

Following diagnosis, cancer patients should be given sufficient time to process and reflect on this life-changing news whilst in their most vulnerable state before making important decisions about personalised treatment options. This approach allows for thoughtful consideration and facilitates an informed consultation with their oncologist to discuss tailored data and treatment pathways. Furthermore, this presents an opportunity to redefine the patient-oncologist relationship, whereby data-sharing can be framed as a partnership, with patients contributing to broader cancer advancements and outcomes. Building meaningful patient-oncologist relationships enhances transparency and trust, especially important given the benefits of coherency between all those involved in cancer treatment.

New Role for Oncologists

Given that utilising data and AI for personalised cancer therapies remains in its infancy, this presents a groundbreaking opportunity for oncologists as educators for patients, the public and healthcare professionals on the clinical significance and safety of data in personalised medicine. Oncologists can pioneer policies for balancing innovation and robust privacy protection and data encryption, allowing the safe and exciting utilisation of patient data to improve cancer outcomes. In this role, oncologists would have a unique role in shifting public perception of data-based healthcare, revolutionising personalised medicine.

Conclusion

The ethical dilemma of balancing data privacy with the promise of personalised cancer treatments is currently the defining challenge oncologists face. Instead of viewing data-based healthcare as a barrier, this dilemma offers a unique chance to pioneer ethical relationships centred around patient trust, impacting the wider foundations of modern healthcare. By embracing the domain of data privacy, oncologists can shape a future where personalised medicine not only preserves lives but does so with respect for the dignity and autonomy of every patient.

References

1. Mao C, Wang X, Miao S, et al. Personalized medicine in the era of precision oncology: a review. Precis Oncol. 2019;3(1):1. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6352312/

2. Cancer Research UK. Personalised medicine. [Internet]. London: Cancer Research UK; [updated 2024; cited 2024 Oct 27]. Available from: https://www.cancerresearchuk.org/about-cancer/treatment/personalised-medicine

3. James CD, Gulley JL, Allegra CJ. A perspective on the future of personalized medicine in oncology. Mol Cancer Ther. 2012;11(12):2527-2535. Available from: https://www.sciencedirect.com/science/article/abs/pii/S0026049512003204

4. The Cancer Genome Atlas (TCGA) Research Network. [Internet]. Bethesda, MD: National Cancer Institute; [cited 2024 Oct 27]. Available from: https://www.cancer.gov/ccg/research/genome-sequencing/tcga

5. UC San Diego Health. Personalized cancer therapy improves outcomes in advanced disease, says study. [Internet]. San Diego, CA: UC San Diego; 2020 Oct 2. [cited 2024 Oct 27]. Available from: https://health.ucsd.edu/news/press-releases/2020-10-02-personalized-cancer-therapy-improves-outcomes-in-advanced-disease-says-study/

6. Zhou Q, Luo X, Tan Y, et al. The Landscape of Personalized Medicine: Current Status and Future Perspectives. Healthcare (Basel). 2020;8(3):133. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7349636/#sec6-healthcare-08-00133