Do No Harm
Have the number of ethical dilemmas in radiology overshadowed the legendary vow?
Three words summarize the basis of most medical ethic statements: Do no harm, a phrase included in the original Hippocratic Oath. But if he were alive today, Hippocrates might consider expanding on that expression.
After all, the Greek physician couldn't have foreseen the number of medical specialties, the nature of expert-witness testimony, the possibilities of radiation overexposure, or the many other ethical dilemmas that radiologists face today.
Daily Lessons in Ethics
All ethical predicaments have the same basic formula. "Ethical conflicts arise when different values are given to available choices or alternatives," writes retired radiologist John D. Armstrong II, M.D., in the American Journal of Roentgenology.1 For example, physicians practice medicine to save lives, while patients need the freedom to decide whether they want to be saved — two sides of the same coin that are often not weighted equally. Additionally, "As radiologic physicians, we could experience this conflict when an acutely traumatized patient refuses a diagnostic examination, and we override the patient's wishes and perform the examination, perhaps with sufficient justification," Armstrong notes.1
Luckily, radiologists likely don't have to face such quandaries every day. So then, how often does the issue of ethics arise? According to Peter Kalina, M.D., from the Mayo Clinic in Rochester, Minn., "Numerous things come up on a daily basis that we have to think about that might not involve the question 'is this ethical?' but relate to the best care for a patient," says Kalina, who also chairs the ACR Committee on Ethics. "Keeping patients' needs first and foremost above what's best for you and your partners is part of ethics."
Richard A. Mintzer, M.D., from the NorthShore University HealthSystem in Evanston, Ill., and member of the ethics committee, concurs. "Radiologists are ethically challenged every day," he says. "It's an ethical consideration not to 'image up' and order expensive procedures, which also may or may not add unnecessary radiation when you don't really need them." ('Imaging up' is defined as ordering an MRI or CT when plain films or ultrasound will answer a clinical question.)
Appropriate imaging utilization, as Mintzer suggests, is not only good practice ethically but often good use of evidence-based radiology. "While the process of [evidence-based radiology] is often thought of as referring solely to scientific facts, it is by essence a continuous search for good practice, even though it does not have an explicit ethical terminology," according to Jean Raymond, M.D., and Isabelle Trop, M.D., M.P.H., in an article that appeared in Radiology.2
“There’s a lot of room here for people to behave with less than 100 percent morality.” — Peter Kalina, M.D.
Laws and Ethics
And although radiologists learn about ethics throughout their careers, initial ethics training starts early. Besides the general ethics overview in the Hippocratic Oath, the topic is often covered as a resident within lessons related to professionalism, one of the six competencies that residents must acquire, as required by the ACGME. "At Washington University in St. Louis, we had one of the first ethics courses of any medical school in the United States," says Michael J. Kelley, M.D., interventional radiologist from Charlotte Radiology in Charlotte, N.C., also a member of the ACR Committee on Ethics. "The course was a wake-up call. It covered how to talk to terminally ill patients and provide end-of-life care — things that none of us had really thought about. Because at that level of training, you're convinced that you're going to save the world, and every patient will go home." That early exposure to ethical issues regarding life and death issues is something that stays with you throughout your career.
Any ethics course also likely covers what to do if you make a mistake when providing care. However, admitting mistakes amidst the threat of legal action may not happen as often as such radiologists like Leonard M. Berlin, M.D., FACR, from NorthShore University HealthSystem, an expert on medical ethics, would like. According to a DiagnosticImaging.com article, at RSNA 2011, "Berlin cited several studies that showed ... radiologists are loath to disclose errors to patients." This attitude of nondisclosure goes against part of the AMA Code of Ethics where all physicians are urged to "deal honestly with patients and colleagues."
"We are frequently advised by our attorneys to not admit or say anything, and we've been so attuned to malpractice litigation that we're fearful of saying 'I'm sorry, I missed something,'" says Mintzer. Marc D. Ginsberg, radiology malpractice attorney, states in the article that sometimes it's acceptable to acknowledge fault. "In cases of cut-and-dried radiologist misses ... it's okay to admit a mistake to patients. You'll probably end up settling anyway. But otherwise, choose your words carefully."
“Often, radiologists testifying as experts are asked to draw conclusions that they can’t or shouldn’t make based on their knowledge level.” — Richard Mintzer, M.D.
Standards in Expert Testimony
The combination of law and ethics often creates situations that put radiologists between a rock and a hard place, especially when they testify in court as experts to either contradict or verify testimony of another imager. It happens more than you might think and makes up the majority of issues brought to the ACR Committee on Ethics.
Problems arise when the radiologists hired as experts "aren't honest with themselves," says Mintzer. "Often, radiologists testifying as experts are asked to draw conclusions that they can't or shouldn't make based on their knowledge level." In other words, sometimes radiologists overestimate their expertise. "It's just as important to understand what you know as it is to understand what you don't know," Mintzer adds.
So how do you know you're an expert? "Part of it is educational, and part of it is expertise," says Mintzer. "If you're going to testify in a case sophisticated enough that it takes a neuroradiology background, you should have extra certification ... along with plenty of expertise."
Although not every radiologist will be asked to be an expert witness, Kelley, who has served as such, has one lesson to share. "I have strong training in cardiac imaging, and one of the cases I was involved in required a knowledge of cardiac anatomy," says Kelley. "It was second nature to me, but such knowledge wasn't necessarily second nature to the interpreting radiologist. Sometimes you have to stand in someone else's shoes to look at his or her training and practice before you give your own opinion. The view from the ivory tower is often not the same as the view from the trenches."
“Sometimes you have to stand in someone else’s shoes … before you give your own opinion.” — Michael J. Kelley, M.D.
The Best You Can Be
A number of other ethical concerns can arise during a radiologist's career, but perhaps one of the issues wrought with potential for daily questions involves patient communication. "As an interventional radiologist, being direct and honest with my patients is important, especially when we're getting consent [for procedures]," says Kelley. "But that's not foolproof — even if you think you're communicating well with patients, they're not always hearing what you're saying. Consent is unfortunately a two-way street."
This two-way street is the crux of the complicated nature of ethical decision making — each person involved in an ethical dilemma has a different outlook. Those various perspectives muddy the black and white colors of easy decisions. When in doubt, seek another opinion of someone within your organization's ethics committee. If you don't have one, check out the College's resources. The ACR has developed a number of tools to help members related to ethics, including article, guidelines, and more. Visit http://bit.ly/uk3Bcz for all the details and be sure to visit www.jacr.org and check out the December 2011 JACR special issue on ethics.
"There's a lot of room here for people to behave with less than 100 percent morality," says Kalina. "If we want radiology to continue to be the great field that it is and to be respected by clinicians and patients, we have to always do the right thing and do what's best for our patients." Isn't that what each physician agrees when taking the Oath — to do the best for patients? Perhaps Hippocrates got it right the first time.
1. Armstrong J. “Perspective: Morality, Ethics, and Radiologists’ Responsibilities,” American Journal of Roentgenology 1999;173:279–284.
2. Raymond J., Trop I. “The Practice of Ethics in the Era of Evidence-based Radiology,” Radiology 2007;244:643–649.
By Raina Keefer