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Ethical Radiologic Practice
EDITORIAL
BRUCE J. HILLMAN, MD
Ethical Radiologic Practice The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. —Plato
The December issue of JACR is a very special one. For the third consecutive year, Associate Editor for Health Services Research and Policy Ruth Carlos has selected an international coeditor (Pia Sundgren, MD, PhD) and produced an in-depth look at an important aspect of radiologic practice. This year, the special issue focuses on medical ethics. The articles they recruited and labored over reflect the intersection of US and international views on such issues as insurance coverage for imaging innovations, the potential for the future rationing of health care, and the balancing of radiologists’ responsibilities to patients and society. The topic is well chosen. Many radiologists have little training and give little thought to medical ethics in their daily practice. Those who do are most likely to fall back on memories of taking the Hippocratic Oath during graduation from medical school. However, much of the thinking about medical ethics has changed since many of us were in medical school. The application of medical ethics to radiologic practice is a blind spot. Bioethicists have promulgated 4 key ethical principles to modern medical practice [1]: 1. 2. 3. 4.
respect for autonomy, nonmaleficence, beneficence, and justice.
Many radiologists, especially those who have very limited direct patient contact, may look at this list and say, “What does this have to do
with me?” To those radiologists, I say, “Quite a lot. Read on.” The requirement for respect for autonomy signals that the often observed paternalism of physicians for their patients, our modus operandi for centuries, has been replaced by a new understanding: given sufficient information, patients are rational beings with preferences and the right to make decisions about their own care. An obvious symbol of respect for autonomy is the written informed consent document. However, there is much more implied by this principle, which is strongly based in a mutually understanding patient-physician relationship. Radiologists may most actively address respect for autonomy when they are involved in face-toface patient interactions. Nonmaleficence is most simply summarized by the dictum primum non nocere (first, do no harm). More expansively, physicians should risk no harm to their patients in either their commission or omission of care. Radiologists risk violating this principle when, for example, they overcall or attach too much significance to findings that have little probability of being important to patients’ health (incidentalomas). Another example of radiologists’ failing to adhere to the principle of nonmaleficence is when they fail to intercede when referring physicians request unnecessary or inappropriate tests. Beneficence is the moral duty of physicians to provide benefit to patients. Although there is greater notoriety attached to the overuse of medical imaging, it is quite clear that some important radiologic
tests are being used less frequently than they should. The profession has the responsibility to conduct the research needed to identify situations when our patients will benefit from underutilized imaging evaluation; individual radiologists have the responsibility of thinking critically and using such research judiciously. Justice is the application of principles of fairness to health care. There is a sizable need for care among those who have trouble accessing the US health care system, which contrasts with the excessive use of health care resources among a segment of our population. Falling prices for radiologic services will doubtless encourage some practices to set up higher barriers to underinsured patients and those with lower paying insurance accessing their services. I can’t say I don’t understand such behaviors. I do. But they are nonetheless demeaning to both ourselves and our patients. Ultimately, the intersection of radiology and medical ethics can be summed up in a quotation from the works of physician-philosopher Martin Fischer: “Only one rule in medical ethics need concern you— that action on your part which best conserves the interests of your patient.” But don’t stop with that. There is interesting explanatory detail that is essential to putting that sentiment into practice. Much of that detail is to be found in this special issue of the journal. REFERENCE 1. Beauchamp B, Childress J. Principles of biomedical ethics. 4th ed. New York: Oxford University Press; 1994.
Bruce J. Hillman, MD, UVA-Radiology Research, Box 801339, Charlottesville, VA 22908; e-mail: [email protected].
818
© 2011 American College of Radiology 0091-2182/11/$36.00 ● DOI 10.1016/j.jacr.2011.08.016
BRUCE J. HILLMAN, MD
Ethical Radiologic Practice The greatest mistake in the treatment of diseases is that there are physicians for the body and physicians for the soul, although the two cannot be separated. —Plato
The December issue of JACR is a very special one. For the third consecutive year, Associate Editor for Health Services Research and Policy Ruth Carlos has selected an international coeditor (Pia Sundgren, MD, PhD) and produced an in-depth look at an important aspect of radiologic practice. This year, the special issue focuses on medical ethics. The articles they recruited and labored over reflect the intersection of US and international views on such issues as insurance coverage for imaging innovations, the potential for the future rationing of health care, and the balancing of radiologists’ responsibilities to patients and society. The topic is well chosen. Many radiologists have little training and give little thought to medical ethics in their daily practice. Those who do are most likely to fall back on memories of taking the Hippocratic Oath during graduation from medical school. However, much of the thinking about medical ethics has changed since many of us were in medical school. The application of medical ethics to radiologic practice is a blind spot. Bioethicists have promulgated 4 key ethical principles to modern medical practice [1]: 1. 2. 3. 4.
respect for autonomy, nonmaleficence, beneficence, and justice.
Many radiologists, especially those who have very limited direct patient contact, may look at this list and say, “What does this have to do
with me?” To those radiologists, I say, “Quite a lot. Read on.” The requirement for respect for autonomy signals that the often observed paternalism of physicians for their patients, our modus operandi for centuries, has been replaced by a new understanding: given sufficient information, patients are rational beings with preferences and the right to make decisions about their own care. An obvious symbol of respect for autonomy is the written informed consent document. However, there is much more implied by this principle, which is strongly based in a mutually understanding patient-physician relationship. Radiologists may most actively address respect for autonomy when they are involved in face-toface patient interactions. Nonmaleficence is most simply summarized by the dictum primum non nocere (first, do no harm). More expansively, physicians should risk no harm to their patients in either their commission or omission of care. Radiologists risk violating this principle when, for example, they overcall or attach too much significance to findings that have little probability of being important to patients’ health (incidentalomas). Another example of radiologists’ failing to adhere to the principle of nonmaleficence is when they fail to intercede when referring physicians request unnecessary or inappropriate tests. Beneficence is the moral duty of physicians to provide benefit to patients. Although there is greater notoriety attached to the overuse of medical imaging, it is quite clear that some important radiologic
tests are being used less frequently than they should. The profession has the responsibility to conduct the research needed to identify situations when our patients will benefit from underutilized imaging evaluation; individual radiologists have the responsibility of thinking critically and using such research judiciously. Justice is the application of principles of fairness to health care. There is a sizable need for care among those who have trouble accessing the US health care system, which contrasts with the excessive use of health care resources among a segment of our population. Falling prices for radiologic services will doubtless encourage some practices to set up higher barriers to underinsured patients and those with lower paying insurance accessing their services. I can’t say I don’t understand such behaviors. I do. But they are nonetheless demeaning to both ourselves and our patients. Ultimately, the intersection of radiology and medical ethics can be summed up in a quotation from the works of physician-philosopher Martin Fischer: “Only one rule in medical ethics need concern you— that action on your part which best conserves the interests of your patient.” But don’t stop with that. There is interesting explanatory detail that is essential to putting that sentiment into practice. Much of that detail is to be found in this special issue of the journal. REFERENCE 1. Beauchamp B, Childress J. Principles of biomedical ethics. 4th ed. New York: Oxford University Press; 1994.
Bruce J. Hillman, MD, UVA-Radiology Research, Box 801339, Charlottesville, VA 22908; e-mail: [email protected].
818
© 2011 American College of Radiology 0091-2182/11/$36.00 ● DOI 10.1016/j.jacr.2011.08.016