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In spite of the demonstrated benefits, the question of HPV massive vaccination is still subject to intense discussions and controversies. The protection against cancer is still unproven and need more time to be accurate about the quantification of the decrease in cervical cancer. The analysis of HPV vaccine relevance is very complex due to several overlapped levels to be considered. The authors analyze many of the ethical, sociological, economic, political and finally scientific issues involved. The population trust in vaccines has been affected owing to dubious practices of many pharmaceutical companies. Faced with this manipulation of information on a worldwide scale, general practitioners have organized themselves to fight this uncertainty. Quaternary prevention, a concept supported by the World Organization of Family doctors, advocates the application of ethically acceptable procedures in health care. This opinion article addresses some of the multiple dimensions involved to encourage reflection on this issue ; A pesar de los beneficios demostrados, la cuestión de la vacunación masiva contra el VPH todavía está sujeta a intensas discusiones y controversias. La protección contra el cáncer aún no está probada y necesita más tiempo para la precisión sobre la cuantificación de la disminución del cáncer cervical. El análisis de la relevancia de la vacuna contra el VPH es muy complejo debido a varios niveles superpuestos que se deben considerar. Los autores analizan muchas de las cuestiones éticas, sociológicas, económicas, políticas y finalmente científicas involucradas en este análisis. La confianza de la población en las vacunas se ha visto afectada debido a prácticas dudosas de muchas compañías farmacéuticas. Ante esta manipulación de información a escala mundial, los médicos generales, de familia y comunidad, se han organizado para luchar contra la incertidumbre. La prevención cuaternaria, un concepto apoyado por la Organización Mundial de Médicos de Familia, aboga por la aplicación de procedimientos éticamente aceptables en la atención médica. Este artículo de opinión aborda algunas de las múltiples dimensiones involucradas para favorecer la reflexión sobre este tema. ; Peer reviewed

Who does decide about systematic screening and how is it confronting the individual autonomy? Mammographic breast cancer screening global controversy is not a new issue. It was installed from more than two decades and Gøtzsche and Olsen paper published on 2000 was the hurricane that caused intense evidence review that has accumulated facts in this important discussion. There is general agreement among researchers to assume that the decline in mortality must be attributed to the improvement of treatments, better access to them and improvement in social conditions, more than to massive breast cancer screening programs. The conclusion is that this "overscreening" does not affect the global incidence of advanced cancer. During 2013 and 2014 BMJ published communications and letters explaining the situation of Uruguayan women. Today, still all Uruguayan female workers between 40 and 59 years are obligated to be screened for breast cancer every two years. When massive screening programs are evaluated from public health perspective, one must assess the balance of concerns and controversies about the efficacy and pertinence of this decision. Ana is a woman that opposed herself to the enforced mammography program. This was exposing her to problems concerning her working license, as she was then not fulfilling the reglamentation of this new law. It would implicate sanctions like salary cessation. Therefore she wrote a book in which one can precisely follow up her fight. She had to fight four years against the government in order to receive an answer: end of September 2016 a superior court spoke in favour of hers. Talking about mammography screening It is not only a scientific or personal position but what is worrying is the situations of all the women out there that today must feel very confused. Thus mandatory and obligatory mammography used to apply massive screening is confronting with the individual autonomy. General practitioners must modulate how to apply general recommendations and guidelines to individuals adapting his resolution with their patients own beliefs and values, in order to orientate a "healthy" decision making process. It is imperative to promote reflection from ethic and practice perspective on how to proceed when the exercise of individual autonomy is been confronted in this way.

Quaternary prevention (P4), born from a reflection on the doctor-patient relationship, began as an answer of family doctors facing overmedicalization. It aims to protect the patient or population against the danger of medicine. Harmful effects can appear with preventive activities (example: prostate cancer screening by PSA) as well as by therapeutic interventions (example: disruptive medicine). P4 promoted by the World Organization of Family Doctors (WONCA) is practiced in different ways around the world through the activity of the WONCA Special Interest Group on Quaternary Prevention and Overmedicalisation (P4&O). There are multiple initiatives and backgrounds of P4. All these multiple initiatives that lead to P4 have their origin in denouncing the inadequacies of the Hegemonic Medical Model and the excesses perpetrated in the pursuit of profit. There are many schools of thought that try to solve this situation, such as "Medicines Based on ." These contributions are valuable but usually point to a single dimension of the problem so they do not change the situation too much. The P4, however, have understood the centrality of the political and economic dimensions and, that is why, P4 has become a movement. P4 has understood that the root causes far exceed the limits of medicine, have understood that the problem includes ethical, political, economic and epistemological aspects of medicine. It is for this reason that the definition of P4 has shifted to the function of foundational idea since the movement that has been generated around this concept has surpassed this initial definition centered in a, yet complex, but still medical vision. P4 has understood that a new model of medicine and a new pact with society is necessary. P4 is a counter-hegemonic movement with predominant development in peripheral countries. This movement includes many other perspectives developed in the central countries but is the only one that has an ideological position that discusses the current paradigm of medicine that legitimates the same causes that give rise to P4, proposing to think a new way of practice the medicine that includes Ethical values, other forms of knowledge and the return to human medicine for humans with place for uncertainty, compassion, the encounter between people and non-commodified. Justice in health care is a central aspect of this new way of conceiving the medicine that we propose. Remember what Rudolf Virchow said in the nineteenth century "Physicians are the natural advocates of the poor and social problems fall largely under their jurisdiction. Medicine is a social science, and politics is nothing more than medicine in large scale". We must reformulate our contract with society and for this we must be very clear that our loyalty must always be with the sick, the poor and those who are weak. For this new contract we must also take into account the magnitude of the power that has been given to us and to live up to such responsibility. In the Rio manifesto (2016) we propose to "Avoid and denounce the naturalization of: hunger, exclusion, manipulation, inequality, violence, racism, exploitation, which harm health more than "diseases"" . There is a better and fairer world, let's fight to get it! More about P4 on www.ph3c.org/p4

Le concept de prévention quaternaire, issu d'une réflexion sur la relation médecin-patient, est présenté d'une part comme un renouvellement d'une exigence éthique séculaire ; d'abord ne pas nuire et d'autre part comme un plaidoyer pour un autocontrôle du médecin. L'origine du concept, son approbation par l'Organisation mondiale des médecins de famille (WONCA) et l'Union Européenne des Médecins Omnipraticiens (UEMO), sa diffusion et les débats auxquels il a donné lieu, sont présentés par un panel d'auteurs de 12 pays et trois continents. Ce texte collectif traite plus spécifiquement de l'éthique de la prévention, de l'importance de l'enseignement de la prévention quaternaire et de la médecine factuelle, des implications sociales et politiques du concept de prévention quaternaire, et de ses dimensions anthropologiques. ; The concept of quaternary prevention, resulting from a reflection on the doctor-patient relationship, is presented as a renewal of the age-old ethical requirement: first, a doctor must do no harm; second, the doctor must control himself/herself. The origin of the concept, its endorsement by the World Organization of Family Doctors (WONCA) and the European Union of General Practitioners (UEMO), its dissemination, and the debates to which it has given rise, are presented by a panel of authors from 10 countries. This collective text deals more specifically with : the ethics of prevention, the importance of teaching Quaternary prevention and Evidence Based Medicine, the social and political implications of the concept of Quaternary prevention, and its anthropological dimensions. ; Peer reviewed