| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Evidence-based Radiology Series |
1 From the Department of Radiology, Interventional Neuroradiology Section (J.R.) and Breast Imaging Section (I.T.), Centre Hospitalier de l'Université de Montréal, Notre-Dame and St-Luc Hospitals, 1560 Sherbrooke East, Suite M8206, Montreal, QC, Canada, H2L 4M1. Received December 12, 2005; revision requested January 24, 2006; revision received February 13; final version accepted February 21. Address correspondence to J.R. (e-mail: dr_jean_raymond{at}hotmail.com).
 |
ABSTRACT |
|---|
 TOP ABSTRACT INTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
© RSNA, 2007
|
INTRODUCTION |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
Science sans conscience n'est que ruine de l'âme. (Science without conscience is but ruin of the soul.)François Rabelais, 1532 (1)
The theme of this article is the good practice of radiology. A MEDLINE search on the ethics of radiology can provide only poor recommendations based on level 5 evidence (ie, expert opinion) (2). Thus, we will refrain from offering guidelines; they may soon appear inappropriate to the moving target of patterns of practice, variable in times and places. Policies and obligations proposed or enforced by professional organizations will not be mentioned, so as not to stifle autonomous reflection. Our aim is the production of a greater consciousness about moral and ethical issues in the practice of radiology. This difficult task involves generalizing without theorizing and arousing interest without preaching. A predetermined set of values that would apply to different fields, cultures, and particular settings and would be generally acceptable to all parties would be empty. "When the universal does not agree with the particular, it presents itself as an abstraction that fails to include the particular and hence, ignoring its rights, appears as something extraneous that has no substantial reality for human beings" (3). A morally serious practitioner has to be prepared to submit to this process of reflection freely, without any spoon-feeding. In this sense, our topic can be defined on a more personal, practical level. Perhaps it is better expressed as, "What should I do?" At the centerpiece of our reflection, we placed the average working radiologist or radiology resident, who is perplexed by a practice that evolves too rapidly. We kept in mind that he or she may be involved in diverse activities, such as screening mammography or interventional radiology, in various contexts such as training programs, public institutions, or private offices.
The philosophy in which this inquiry about the ethical dimension of practice will take place is evidence-based radiology (EBR), a voluntary move away from the authority of tradition and from the concept of intuitive clinical knowledge that sometimes translates into dogmatic opinions and habits. Habits and intuitions are often referred to as "clinical experience," which we believe to be inadequate justification for actions that are committed for the good of the patient.
We will first review, in the Background section, some pertinent features of the world in which we practice today. In the Evidence-based Practice: Science and Care of the Individual section, we will expose arguments used to resist a transition to EBR and the ethical uneasiness felt in the tension between science and everyday practice. We will then attempt, in the Search for a Method to Enhance Ethical Reflection in Daily Practice section, to construct and justify an analytic method to promote the moral dimension of practice inspired by EBR.
|
BACKGROUND |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
The context in which we practice modern radiology can be characterized by a general background and by features that are more specific to radiology.
In the background, there are deceit (4), large-scale financial scandals, a long-standing and pervasive tendency to practice defensive medicine, the exponential rise in health care costs, growing social inequalities, the emergence of the supremacy of third-party control, and the aging of a particular class—the baby boomers, sometimes perceived as individuals who could divert medical technology toward the pursuit of eternal health and youth (5). If we add to this portrait multileveled potential conflicts of interest with regard to continuing medical education secured at conferences (speakers and audience who are financed by industry) and if we consider that randomized clinical trials, the "reference standard" of scientific medicine, can be supported, designed, and influenced by industry, then one does not wonder when encountering moral apathy but rather marvels about the low prevalence of cynicism (6).
On a more positive side, health has probably never enjoyed such a preponderant place among human values, and modern societies dedicate a major share of time, resources, and energy to its promotion. Medical imaging is ensured a central role in this set of human values.
In this general background are players that are specific to radiology. The image, the equipment, and the referring physician are all interposed between the patient and the radiologist, who should keep sight of the final purpose of his work.
The Image
It may appear to be a paradox that recent advances in medical imaging could become a threat to good practice. The first radiologists, unaware of adverse effects, used fluoroscopy to monitor patients with therapeutic pneumothoraces induced for treatment of tuberculosis. Television monitors have redirected the gaze of radiologists away from the patient, and the use of teleradiology can further increase the distance between the radiologist and the patient for whom he provides care.
Radiology has been characterized as the most rapidly evolving specialty within medicine (7). Only 20 years ago, many anatomic details and pathologic lesions remained invisible or could be inferred only by using indirect contrast material techniques. Some of us vividly recall the astonishment we felt upon clearly recognizing, in patients who would now be imaged with ultrasonography, computed tomography, or magnetic resonance imaging, some features of anatomy we had up to then seen only in textbook diagrams. We realized we were entering a new era, perhaps as important to the evolution of medicine as the turning point provoked by the emerging science of pathologic anatomy (with Morgagni and Bichat in the 18th and early 19th centuries), when physicians focused on "lesions," or objects localizable in space (8).
The credibility and popularity of imaging techniques in the public and in the medical community have skyrocketed, with the peculiar impression that nowadays no treatment can be initiated without confirmation and no patient can be discharged or reassured without exclusion of some lesion by using imaging. Yet imaging remains imperfect, as are human nature and anatomy. As collateral damage, there is negligence of other concepts, perhaps more human, such as holistic medicine. Particularly problematic is the incidental discovery of irrelevant but potentially dread-inducing lesions, real or artifactual, with subsequent iatrogenic physical or psychological injuries, all of which increasingly confront the morally conscious radiologist as the availability of his services increases.
Residents are trained to detect the smallest anomaly and to obtain complementary tests when in doubt. They fulfill only too faithfully the sole principle they are taught—the more information, the better. This attitude of extreme sensitivity, this common fear of missing the lesion, is reinforced in experienced practitioners by the threat of lawsuits (9). But information is not always pertinent, nor is it without consequences. The responsibilities of modern radiologists must include the need to accompany patients in the difficult decisional contexts brought on by our own technologies, the need to help patients understand that the uncertainty regarding the pertinence of findings cannot be simply resolved, and the professional requirement that we should not act as if we know (10).
In trying to objectively assess the value of our work, it may be impossible to distinguish the role of diagnostic imaging from the positive or negative effects of treatment. Hence, the gulf between radiologic actions and eventual patient outcome may never be surmounted, which leaves doubts with regard to the evaluative enterprise (11). Imaging shares a paradox with genetics: With the new information provided by using modern technologies, the individual should gain power and liberty to better control his future and to take charge of his present life. But the power he dreamt of is slipping out of his control. Knowledge of his internal anatomy or of his genetic composition neither ensures ascendancy on his present life nor guarantees his future. With increasing frequency, he must face a painful question that can negate all our previous efforts: Would it have been better not to know (12)?
The Referring Physician
A peculiar but essential aspect of our practice is that cooperation with the referring physician can be an important source of ethical tension. Who is responsible for unnecessary tests or for harmful interventions based on incidental findings? Who will take charge in the painstaking task of scientifically assessing the clinical benefits of imaging in the detection, treatment, and follow-up of common conditions? If modern medicine depends on seeing lesions and monitoring their evolution with treatment, and if radiology is conceived as the "eyes" of medicine, how can we disconnect diagnoses from clinical decisions? Surely, clinical work cannot be akin to a game of blind man's bluff, in which the referring physician would be guided by directions uttered by the imaging specialist. This dichotomy does not survive the test of an increasingly used therapeutic strategy—image-guided minimally invasive therapy. This uncomfortable relationship can be resolved by the practice of interventional radiology, in which both diagnosis and clinical care are performed by radiologists, or by the increasing use of imaging techniques by nonradiologists. Both solutions are the source of turf battles and potential ethical conflicts. In many areas of imaging, the necessity for better communication between the two parties and harmonization of scientific efforts to integrate diagnosis and patient outcome cannot be escaped.
The Equipment
Whether in private or public systems, we rely on expensive high-technology equipment. This dependence can lead to close binding relationships between colleagues, or even contractual engagements between referring clinicians and radiologists, so as to raise sufficient capital for business opportunities or to justify public expenditures. Modern imaging is an important factor in the explosion of health care costs, and the morally serious practitioner must take into consideration the effect of his practice on the availability of other valuable goods in a health system with limited resources.
Technology creates its own necessities (13). The pressure to tolerate self-referral patterns or to promote screening tests of questionable clinical pertinence may become excessive (14). Loyalty to the group may then conflict with a morally impeccable practice. Relaxation of peer-binding relations may in turn jeopardize the unity of the group, opening the door to third-party infiltration, along with external entrepreneurial interests. Practice yields an attractive return to investors, and, with the growing class of entrepreneur-physicians, this type of conflict can increasingly become "internal" to an imaging practice. Some authors fear that medicine today is losing control of many fundamental aspects of the profession. Private or public financing organizations now employ authoritative protocols to decide whether or not services are appropriate. They predict that in this climate, "all but the most heroic physicians will be prevented from acting ethically toward their patients" (15).
|
EVIDENCE-BASED PRACTICE: SCIENCE AND CARE OF THE INDIVIDUAL |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
Some moral issues are pertinent, although not always in an explicit fashion, in the clinical resistance to EBR. An appeal to reason may not suffice to change physicians' opinions and conduct (18). "So long as an opinion is strongly rooted in feelings, it gains rather than loses in stability by having a preponderating weight of argument against it. For if it were accepted as a result of argument, the refutation might shake the solidity of the conviction; but when it rests solely on feeling, the worse it fares in argumentative contest, the more persuaded its adherents are that their feeling must have some deeper ground, which the arguments do not reach" (19). In our opinion, the question is not whether medicine is to be based on evidence, but rather how and according to which methods and principles should actions be justified. Would it be superfluous to remind ourselves that science and technology were meant to serve humanity, or would it be absurd to request some evidence that our actions do benefit patients?
A confrontation between a traditional clinical mentality and the scientific method has regularly surfaced for decades. It may be interesting to review how this confrontation is perceived outside the medical field and how the clinical and scientific mentalities can be stereotyped by a sociologist (20). The physician has been described as a pragmatic mind centered on action. He feels entitled to use all available technologies to optimize the care of a single patient. The physician would rather act than abstain, even if there might be a minimal chance of success. His actions are guided by intuition and personal experience that may override the authority of science. There is little room for doubt, which can be paralyzing. The physician has faith that his actions are more often beneficial than harmful, but he may be unhappy about submitting his actions to scientific inquiry. He is entirely dedicated to the uniqueness of each case (21). On the other hand, the scientist aims at generalizable knowledge. He prefers facts, supported by scientific proof, to expert opinions and can thus be accused of sacrificing the needs of individual on the altar of science. By using patients as research objects and by searching for a solution that will apply to the majority, the scientist could neglect the specific needs of the individual (22).
Despite the apparent opposition between these two views, it is possible to reconcile both the necessity to care for the individual and the need to search for a reliable evaluation of the results of our actions.
In daily practice, our priority is to grasp the particular, or the care of this individual. Still, clinical judgment must be based on some relationship between the present individual and the previous ones. Experience is not simply the accumulation of individual observations; a general overview and a valid method are necessary to infer meaning from previous events, or useful knowledge is impossible. Furthermore, the feedback necessary to judge the results of one's actions is hardly within reach of individual experience, especially when consequences are infrequent or are delayed for months or years. Physicians use the most valid test to exclude or confirm a diagnostic impression. Similarly, they should rely on the best tool available to grasp the variability inherent in medicine—that is, statistics. It is here that many offer objection by using the phrase, "The patient is not a statistic." Physicians want the best for their patients, and statistical analysis can help physicians recognize limitations in knowledge. Omniscience has never been a requirement of medical practice. "After all, persons are licensed as physicians because they have validated knowledge, not after they reveal superior capacity for guessing" (22).
Reconciliation is not only possible but necessary (23). Science must be included in a triangular relation of care and trust between physicians and patients. Without verification, or science, the medical profession would be subjected to cultural interpretations, variable in time and place, and its knowledge would be no more certain and no less biased than political opinions. Genuine respect for patients requires that practice meet scientific norms of excellence. The essence of good clinical work is the art of applying to an individual person, with his explicit consent, the reliable knowledge acquired from previous experiences through scientific methods.
But what if scientific evidence does not exist or is inapplicable to a given patient? This situation may be common, rather than the exception (24). Even though final evidence may not be available, the habit of critically appraising medical knowledge provides insight into the harm that can result from trying to help and keeps one on the path toward good practice.
|
SEARCH FOR A METHOD TO ENHANCE ETHICAL REFLECTION IN DAILY PRACTICE |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
Those who practice EBR strive to continuously review and appraise the state of knowledge in radiology; while the process 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. We can similarly train ourselves to critically review and appraise ethical facts, and, in this sense, the practice of ethics may be conceived as a natural extension of the EBR process.
Is Ethics a Form of Knowledge That Can Be Acquired?
This question goes back to Plato and is still pertinent today. If ethics is knowledge, it can be acquired through inquiry. Because Socrates insisted that he never taught, but helped a man to see the truth through his own eyes, this learning process is compatible with an autonomous adjustment to new roles and situations. Compare this with the authoritative quality of the doctrines of some religions. Such a contrast epitomizes the need to move toward a practice guided by reason rather than by authority, whether we are looking at the scientific or the moral justification of clinical actions. "The floating of other men's opinions in our brain makes us not one jot the more knowing, though they happen to be true" (25). Such a bottom-up approach emphasizes the practitioner's active commitment to a decentralized, autonomous reflection internal to his practice, as opposed to passive obedience to a top-down, centralized norm externally imposed on him or his practice (17,26).
Here we must say a few words about rules and codes. Moral principles have often been put in terms of what is required by duty, which is perhaps an outdated conception reminiscent of divine law that is poorly adjusted to our multicultural and secular world. Of course, professional codes must be respected, but they do not provide the kind of material necessary to enliven a professional life. Too much emphasis on rules at the cost of empathy and care has also been perceived as a historical, masculine bias. We may feel justified in attributing some supremacy to strong principles, acquired the hard way after historical horrors and formulated in salient texts, such as the Belmont report (12). But professional codes often specify rules of etiquette that may sometimes oversimplify moral requirements. Practitioners may mistakenly suppose that they satisfy all relevant moral requirements if they obediently follow the rules, just as many people believe that they discharge their moral obligations when they meet all legal requirements. We believe professional norms may sometimes do more to protect the profession's interests than to initiate a moral reflection on the effects of our actions on patients; that professional norms are sometimes a diversion can be substantiated by reading some of the guidelines published by medical journals that claim to be the official voice of specialized associations.
A decentralized bottom-up approach is likely to heighten awareness of moral issues in everyday practice, to defuse the fears that the EBR philosophy dictates clinical actions on the basis of authority, and to promote certain values essential to the patient-physician relationship, such as freedom and autonomy, perhaps to the detriment of uniformity or standardization. "Decentralized" also means "local" and "practical" and, hopefully, "alive and well."
Theory versus Practice
Our emphasis on practice does not imply that the study of theory is useless. Relevant theories in biomedical circles are utilitarianism, Kantianism, communitarianism, liberal individualism, and the ethics of care that respectively emphasize consequences of actions, obligations, social values, individual rights, and emotional relationships (27). A certain depth of reflection can be gained by studying and comparing theories. Deficiencies and excesses can be found in all theories, but their study helps to expand moral horizons and trains one in the logic of evaluating consequences related to the selection of a paramount principle. Moral theories also expose the analogy between scientific and ethical cognitive processes, both of which are constructed on clarity, coherence, comprehensiveness, simplicity, explanatory and justificatory power, and practicability.
The ethics of the practice of radiology can be considered within the sphere of applied ethics. A deliberate inquiry into specific problems and a policy of practicing decision making that consciously recognizes moral constraints may be more appealing to people of action, such as physicians, than an abstract morality of principles. One characteristic feature of applied ethics is a greater attention to context, as well as a propensity to recognize psychologic, sociologic, historical, and cultural issues as issues relevant to practice. Perhaps the common feature of all fields qualified as applied ethics is a concern for specific or individual dilemmas. But if ethics is restricted in scope to the enunciation of conflicts peculiar to a specialty and to consensual thinking or recommendations regarding these conflicts, the reflection will be limited to a few individuals, which offers little potential to promote a richer, more conscious practice to the majority and little hope to keep pervasive excesses in check. In our view, ethical thinking, just as critical thinking, could be practiced so regularly as to become natural. While ethical subjects that attract public interest (euthanasia, genetics, reproduction) are for the most part outside the practice of radiology, one only has to remain alert to discover in his immediate environment a wide variety of matters pertinent to a morally concerned physician.
As in most fields of applied ethics, there is a confrontation of particular, individual dilemmas with universalness. This tension, often crystallized in the question "What if everyone did that?" introduces the tension between the individual and his group.
The Individual and the Group
The obedient radiologist who attempts to satisfy all moral rules of the groups he belongs to soon finds himself confronted with moral conflicts. Should he work for the welfare of the specialty, the institution, the service, the group, the referring physician, or the patient?
Psychologically, the moral imperative is characterized by an act of volition (choices we make), accompanied by the feeling of obligation. Thus, it would appear justified for everyone to set up his own moral directives. How, then, is harmonization possible? Adaptation to goals of others is the essence of social education. The egoist soon discovers that he fares better when he cooperates. But the morally serious practitioner will not necessarily compromise. Much as he is willing to learn from the group, he is prepared to steer the group in the direction of his own choices. The friction between volitions becomes the propelling force of ethical development. "Mutual adjustments of moral valuations occur in the pursuit of activities: we act, reflect about results of our action, talk to others about it, and act again, this time in what we regard as a better way" (28). This approach seems compatible with an awakening of the moral dimensions of a professional life and a more active, personal involvement of the practitioner in ethical concerns of his group.
What Should I Do?
Most would acknowledge that in the practice of their medical profession, they are authorized to commit on a human being actions that are otherwise universal taboos, such as intrusion into one's privacy and physical integrity. This exceptional relationship between the physician and the patient entails responsibilities. The patient expects competence and trustworthiness in exchange for granting these outstanding privileges. This is beyond moral theories. The most self-centered professional must recognize that without respect of the "terms of contract," his services will no longer be desired. The development and preservation of technical and scientific competence have been the main focus of training programs and continuing educational efforts. We believe the trustworthy element of the contract has, in comparison, been somewhat neglected.
To summarize what we have said so far: We are looking for a decentralized, autonomous, practical, and rational method to enhance the moral dimensions of the practice of radiology that is applicable and adaptable to a wide array of rapidly evolving practices, without resorting to a specific normative set of guidelines or principles imposed by authority.
Rational deliberation is crucial in many aspects of ethical development. Most volitions are entailed by other, more fundamental, aims that we set for ourselves. The process of learning the beliefs behind our volitions, of clarification of our desires or motives, of assigning weights to our values, of balancing principles that seem to contradict themselves, and of judging how appropriate are the means to an end is a cognitive process that can be learned by reflection and practice (29).
For the general expansion of the ethical dimension of one's practice, one may start by the identification of persons and structures that are part of one's professional life and the attempt to decide to whom one's loyalty could be directed and what would be the consequences. The process should be exhaustive and should include a systematic review of motives and of extraneous values such as money, advancements, control, and power, which are factors that may warp fundamental aims of care. Personal work may continue by introspection on focal virtues that are classically associated with health care, such as compassion, discernment, trustworthiness, integrity, conscience, and conscientiousness. How pertinent do we feel these virtues are to our practice, and can they be manifested and exercised in our daily work?
One does not need to choose a formal ethical theory. An approach inspired from prima facie (at first sight) principles may be appropriate to our goals and leaves sufficient freedom for autonomous reflection (30). Hence, one may clarify the set of principles (such as respect for autonomy, nonmaleficence, beneficence, and justice) that one feels are crucial to one's practice (27). Open discussions with colleagues of various experiences, ages, sexes, cultural backgrounds, and specialties, looking for differences, but hopefully identifying constant or common grounds, are likely to enlighten moral consciousness and deliberation. A canvas for reflection, discussion, and deliberation can be constructed to help deal with specific conflictual situations. Such a possible scheme (Figure) is meant to be illustrative. Others could be selected, but all need validation of their value in practice.
|
|
THE GOOD PRACTICE OF SCIENCE AND ETHICS IN RADIOLOGY |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
Our approach is in keeping with the practice of EBR and is founded on a scientific attitude to be strived for at the level of the individual. Our quest for good practice should be continuous and tireless. Keeping opinions and dogmas at a distance; believing in progress while promoting healthy skepticism; remaining humble, realistic, and critical of the power of medicine; requesting validation; applying rigor and authenticity to our inquiries; searching for the undesirable as well as the useful consequences of our actions; and distrusting old customs as well as new fashions are powerful instruments for facing the dangers of the health care jungle of modern times.
|
ACKNOWLEDGMENTS |
|---|
|
FOOTNOTES |
|---|
Abbreviations: EBR = evidence-based radiology
Authors stated no financial relationship to disclose.
|
References |
|---|
|
TOPABSTRACTINTRODUCTIONBACKGROUNDEVIDENCE-BASED PRACTICE: SCIENCE...SEARCH FOR A METHOD...THE GOOD PRACTICE OF...References |
|---|
This article has been cited by other articles:
|
|
 |
|
  J. B. Kruskal, B. Siewert, S. W. Anderson, R. L. Eisenberg, and J. Sosna Managing an Acute Adverse Event in a Radiology Department RadioGraphics, September 1, 2008; 28(5): 1237 - 1250. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
| RADIOLOGY | RADIOGRAPHICS | RSNA JOURNALS ONLINE |
