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For personal use only; all rights reserved

Perspective

Morality, Ethics, and Radiologists Responsibilities

John David Armstrong Ill

T he goal
briefly
of this
address
discussion
the matter
is to
of eth-
moral views or the moral
reflects on theirjustification,
values
or compares
of others,
them
or all the reasons
possible answers
we can think
in order
of for and against
to find the answer
ics and critical thinking and then with rival attitudes, to that extent we are all most likely to be true; and formulation of an
to ask, and attempt to answer, three questions moral philosophers [2]. argument or an assertion that something is so
on the relationship between ethics and radi- Ethics is one of several branches of philoso- (or not so), with supporting reasons that are
ology: Why is medicine a moral endeavor? phy and essentially asks the question, What is relevant, coherent, and compelling. Addition-
How do ethics inform medical decision mak- moral? or How do we tell what is good? ally, critical thinking has several dispositional
ing? What are a radiologists ethical respon- The other major questions that philosophy elements; that is, a critical thinker needs to ap-
sibilities in a relationship? As one reflects on asks are What do we know? (theory of proach issues with a critical spirit or disposi-
these questions, it is apparent that contained knowledge or epistemology) and What ex- tion. These include a desire to understand the
within every medical discussion and decision ists? (metaphysics). The subject matter of issues as clearly as possible; a desire to evalu-
is an ethical dimension because the process philosophy is questions, which have several ate all positions fairly, without giving preferen-
entails the values of the participants to the characteristics: Philosophic questions have an- tial treatment to ones preexisting beliefs; a
discussion; moreover, each decision may swers, but the answers remain in dispute; willingness to suspend judgment whenever we
profoundly influence other persons, groups, philosophic questions cannot be settled by sci- discover that we have no evidence for accept-
and relationships, not party to the discussion, ence, common sense, or faith; and philosophic ing one view or argument instead of another
in myriad and complex ways. Our challenge questions are of considerable intellectual inter- [3]; a willingness to engage in reflection re-
is to examine ourselves and our actions in the est to thoughtful human beings and have been quiring serious, unhurried, and thoughtful con-
context of our role as professional caregivers so since antiquity [3]. sideration of an issue, an argument, or a point
and to participate in dialogue with colleagues Philosophy may be regarded as the inquisi- of view; a willingness to participate in inter-
and patients about the nature of the good. tor of the most basic beliefs in all areas of personal dialogue with others such that all
thought, including science, common sense, re- voices are heard and conflicts can be processed
ligion, and philosophy itself. Philosophers use and perhaps resolved; and a willingness to en-
Ethics and Critical Thinking the methodology of critical thinking to reach gage ones own moral imagination to get be-
One may ask, Does one have to be a phi- the most plausible answers to questions that yond ones boundaries, consider other possible
losopher to think about these issues? To be a cannot be answered conclusively. Critical worlds or perspectives, and perhaps change
philosopher, in my view, involves striving after thinking entails several cognitive elements [3]: oneself or ones views.
wisdom, not necessarily possessing it. The examination and criticism of the beliefs of ev-
word wisdom is used here to cover sustained eryone, including ones own moral intuitions
intellectual inquiry in any area, the understand- and beliefs; careful attention to the meaning of Three Questions
ing and practice of morality, the cultivation of words, questions, and issues so that one is Three questions are raised for several rea-
such enlightened opinions and attitudes as lead clear about what is being said; logical outlin- sons. First, it may not be apparent that con-
to human flourishing [lj. It has been said that ing of all the possible approaches to the issue mined within every medical decision exists an
insofar as one thinks critically about ones own in question; comprehensive consideration of ethical dimension of similar or greater weight

Received August31, 1998; accepted after revision February 10, 1999.

1The Program in Health Care Ethics,Humanities, and Law, Box B137, University of Colorado Health Sciences Center, Denver, CO 80262. Address correspondence to J. 0. Armstrong II.

AJR 1999;173:279-284 0361-803X/99/1732-279 American Roentgen Ray Society

AJR:173, August 1999 279

 Armstrong

because every decision is considered in the ous, praiseworthy ought, and blamewor- because there is a logical inconsistency [5]. For
context of the values of the individuals in the thy [6]. The philosophic literature on the example, if a radiologist overrides a patients
process together with the values intrinsic to nature of morality analyzes three criteria of the wishes and coerces that patient to accept a pro-
medicine, institutions, and communities. Sec- moral; although unresolved questions about cedure, when in relevantly similar circum-
ond, in the course of our working profes- the nature of morality remain, we can learn stances one would respect the patients wishes
sional lives, we concentrate on the succession much about what morality is, and what it is and not do the procedure, then the radiologist is
of daily tasks that consume our time and en- not, by examining these three criteria [6]. being logically inconsistent unless one can con-
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ergy, with little remaining opportunity at the According to the first criterion of the vincingly make the argument that the patients
end of the day to reflect on who we are, what moral, a judgment, principle, or ideal is circumstances are not relevantly similar.
we do, or what we have contributed. Third, moral only if a person, or a society, accepts it It follows from universalizability that if I say
we may make assumptions about patients, as supremely authoritative or overriding as a thatl oughtto do a certain thing to a certain per-
colleagues, and the policies and procedures in guide to action. Put another way, this crite- son, I am committed to the view that the very
our hospital or clinic without seriously inter- rion says that to be moral, a judgment or same thing ought to be done to me were I in ex-
rogating ourselves or each other about the na- principle or action must have priority over actly that persons situation [5]; that is, ifl with-
tare of things and the way they are or could other values in our lives; it must override hold consent for a procedure from a patient, I
be. Additionally, we may not be systematic in other values [5, 6]. To treat a value or princi- contradict myself unless I agree that informed
our thinking about ethical concerns, or we ple as overriding is to let it always override consent be withheld from me.
may find that we have insufficient skills to other values or principles when they are in Third, and finally, some philosophers have
justify what we believe to be a right act. Fi- conflict. For example, we regard not causing argued that a criterion of morality must nec-
nally, we may be reluctant to disagree with suffering of another person as an overriding essarily have some direct reference to human
each other about substantive and important is- value. As physicians, we regard the allevia- flourishing-that it consider the welfare of
sues in our practice or initiate discussion with tion of suffering as an overriding value in our others. This condition excludes judgments,
each other about these disagreements. The professional endeavor. principles, or ideals pertaining exclusively to
questions asked in the following discussion It is clear, however, that unless this condi- personal benefit and thus accords with com-
provide a context for reflection. This discus- tion of overridingness is combined with mon usage of the term morality [6]. Many
sion draws significantly from philosophic other conditions, it permits almost anything recognizable virtues in medicine, such as
value theory. to count as moral if a person, or a society, is truth telling, compassion, trust, and justice,
committed to its overriding pursuit. If, for are clearly related to the welfare of other per-
example, one asks what value appears to be sons and could be referred to as other-regard-
Why Is Medicine a Moral Endeavor? overriding in the current debate about health ing virtues.
The answer to this question begins with rae- care reform in the United States, in a medical Why then is medicine a moral endeavor?
ognition that physician responsibilities are system or nonsystem that has virtually Medicine is based on health as a primary
grounded in the special nature of illness as a adopted a market model, one might conclude value and the restoration from illness to
human experience-the vulnerability and suf- that profit making has achieved moral status; health as a relational good; that is, healing
fering of a fellow person [4]. We physicians that is to say that some may regard profit as arises within the context of a human relation-
have a social mandate to engage in a trust rela- overriding other values in medicine. It is dif- ship [4]. The primary value in medicine is
tionship with our suffering fellow persons and ficult to hold that the criterion of overriding- the obligation of healers to serve the good of
to ameliorate suffering and promote healing. ness is either a necessary or a sufficient their patients, and the good is the patient-
As physician radiologists, we participate in condition for morality. It is also difficult to physician relationship, in which healing is
this process. Why is this a moral endeavor? say that moral considerations must override the ideal. This relational good in medicine
The concept of what is considered moral all other considerations in competition with can be construed as an overriding societal
seems ambiguous and has a spectrum of them [6]. value. What is universalizable here is that
uses. We are often faced with moral ques- A second, and widely accepted, criterion for physicians fulfill their obligations to serve
tions, some more tormenting than others, that moraljudgments, principles, and ideals is uni- the good of their patients and that fulfillment
generally require that we do some thinking versalizability [5, 6]. According to this crite- of obligation should apply in a similar way
about them. We can do this thinking well or non, moral considerations should apply in a to all persons similarly situated. Finally,
badly. It is the task of moral philosophy to similar way to all persons situated in relevantly medicine is intrinsically focused on the wel-
help us do our thinking better [5]. Each of us similar circumstances. Immanuel Kant, an fare of others, where suffering is amelio-
has what might be called moral intuitions 18th-century German moral philosopher, pro- rated, healing is promoted, and restoring
that may be backed up by powerful moral posed an imperative: Act only on that maxim health promotes human flourishing.
feeling; however, we need to have a greater through which you can at the same time will
understanding of concepts and logical prop- that it should become a universal law [61-for
erties of moral language and we need to de- example, not causing another to suffer. The How Do Ethics Inform Medical
velop critical thinking skills [61. concept of universa.lizahility can be explained Decision Making?
Morality is concerned with many forms of in various ways, but it comes to this: If one Ethics can be considered a sustained intel-
belief about right and wrong human conduct. makes different moral judgments about situa- lectual inquiry about the nature of the right
These normative beliefs are expressed through tions that one admits to be identical in their de- or the good [I]. As an inquiry, ethics seek to
such general terms as good, bad virtu- scriptive properties, one contradicts oneself avoid force or authority, dogma, rules, regu-

280 AJR:173, August 1999

 Morality, Ethics, and Radiologists Responsibilities

lations, bureaucracy, and ignorance [7]. It is brief characterization of an extreme parental- crisis. Indeed, the patient is vulnerable and re-
not the case that force or authority are neces- ist view. We physicians understand parental- mains the focus of care; however, engagement
sarily wrong, it is that authority and force ism because we have a long tradition that holds the view that illness is also a subjective
stop inquiry. Like medical decision making, holds that caregivers make the decision for experience for both the patient and the care-
ethics require the rigorous process of gather- the patients good. The primary value in a pa- giver. The best thinking in this model is done
ing all relevant information to formulate an rentalist view is the patients well-being, as collaboratively. Engagement recognizes the in-
the caregiver terconnectedness and interdependence be-
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argument-an argument with sound, coher- understands it; on this view the
ent, consistent supporting reasons. Ethics re- physician assumes the moral authority to en- tween patient and care provider. There is a
quire toleration of disagreements between force his or her professional view and over- mutual thinking-through, with a focus on un-
parties to decision making; disagreements rides patient autonomy [7]. derstanding whether or not decision making is
are inevitable and reasonable people dis- What beliefs underlie an extreme parental- the goal. In the engagement model of relation-
agree. We respect the right to hold a different ist view? The beliefs are that patients are ill, ship, the patient is an active participant in the
view. What carries the weight in ethical dcci- afraid, and vulnerable; thus, patients are not dialogue and patient vulnerability is never
sion making is the power of an argument; in competent to participate in decision making overpowered. In fact, the goal of the relation-
that sense, opinions are irrelevant because for themselves; thus, consent is irrelevant. ship is to restructure a world of meaning for
opinion is typically partial to one or another This view holds that the best decisions are patient and professional [7]. It may require that
view and argument requires consideration of rational and objective and that we profes- the patient and physician continually renegoti-
competing views [5]. Importantly, dialogue sionals have a duty to help; we are there to ate the relationship and readdress the same is-
with involved persons in decision making is provide what is needed, to take charge. Fi- sues over and over again, seeking the sort of
both desirable and necessary to obtain any nally, one may argue that society has charged clarification and understanding that facilitate
and all relevant information. physicians with the authority to make these good decision making.
Ethical conflicts arise when different values decisions on a parentalist view. A critique of
are given to available choices or alternatives. this extreme parentalist view would conclude
1pical ethical conflicts include the choice be- that it represents unilateral decision making What Are Radiologists Ethical
tween good and evil, and its rarely that sim- that does not value listening to patients about Responsibilities?
pie; the choice between better and worse; and, their perspective of their own good. If one examines the scope and nature of
the most difficult ethical conflict, the choice Second, an extreme view of autonomy will radiologists ethical responsibilities, one may
between two goods that are mutually exclu- be characterized. The current focus on respect- conclude that we physicians who do radio-
sive, where the decision for one good is a deci- ing patient autonomy has arisen in recent logy variously separate or uncouple our-
sion not to do the other [8]. For example, the decades in response to a long history of paren- selves from patient-centered responsibilities.
classic dilemma that caregivers face is, on one talism. Respect for personal autonomy holds In the context of modern medicines empha-
hand, to respect the freedom of decision mak- that the patient has a right of self-determina- sis and reliance on high technology, to what
ing for a patient and, on the other hand, to pre- tion and that a person has a right not to be in- extent do we radiologists think of ourselves
serve or save life. As radiologic physicians, we terfered with. An extreme view of autonomy as physicians and reflect on our responsibil-
could experience this conflict when an acutely holds that patients are fully competent to make ity in a patient-physician relationship?
traumatized patient refuses a diagnostic exam- their own decisions and that a professionals A model of radiology practice, proposed in
ination and we override the patients wishes role is simply to provide information. What the context of radiologists perceptions and ex-
and perform the examination, perhaps with beliefs underlie an autonomous model of care? pectations for relationship, illustrates the
sufficient justification. They are that patients can make rational, delib- extent to which we radiologists separate our-
Another important point about the nature of erative decisions and that objectivity remains selves from patients [2]. At one end of the
ethical decision making is related to our sense the best form of decision making. The profes- spectrum, the radiologist is physically and psy-
of comfort with certain decisions and our sional provides objective information and chosocially close to the patient and family and
moral intuitions about them. We may ask our- facts, and the social mandate on this view is to engaged in dialogue about the imaging study
selves or others if we are comfortable with a empower patient decision making. A critique in the context of the patients illness and anxi-
particular decision. Being comfortable, how- of this extreme view of autonomy would likely eties such as during mammography, sonogra-
ever, cannot ensure a good decision. We may characterize it as health care on demand, or phy, or diagnostic or therapeutic intervention.
claim to be comfortable with a decision that cafeteria medicine, wherein the caregivers At the other extreme, the radiologist seeks no
cannot later be justified on critical reflection. role is to satisfy the customer much like a relationship with the patient, family, or pri-
Alternatively, one may be very uncomfortable salesperson-it is a kind of consumerism. In mary care provider and is satisfied to commu-
acting on a good decision, such as respecting a fact, it is parentalism turned on its head, and it nicate with descriptive computer-generated
patients informed choice to refuse treatment may be an example of patient abandonment by reports. The patient is perceived as an abstract
or a diagnostic procedure or deciding to with- the professional [7]. entity, an object in the marketplace. The pa-
draw a patients life support. Third, a model that seeks to balance these tient is no longer an end but a means; the end
Three major ethical theories are appropri- two extremes will be briefly explained-a may be material success or personal power for
ate in this discussion of patient-physician re- model that could be called engagement. En- the physician [2].
lationships and ethical decision making [7]. gagement is essentially an ethical perspective Eric J. Cassell offers thoughtful and defini-
First is paternalism, or its gender-neutral that views illness as threatening to ones world tive discussion about the complex concepts of
equivalent, parentalism. The following is a of meaning, where a patient is in existential what it means to be a person and what it means

AJR:173, August 1999 281

 Armstrong

to suffer [9]. He persuasively argues that post- possible consequences of each action, such as fessor of economics at Harvard University,
modern medicine reduces the suffering of performing the examination, modifying the stated, What we must seek in these matters
persons to diseases of bodies. Radiologists examination in some important way, delaying is reasonably evident. It is the use of plain
necessarily reduce bodies to images of the the study until more information is available, language to express the clear truth. We can
body, thereby giving appropriate attention to offering an alternative study, or not performing take pleasure from the discomfort the truth
excellence in image acquisition and interpreta- the requested examination. so often evokes. In the context of the fore-
tion. Accepting that images are a necessary The context of this decision process in- going discussion on the elements of morality,
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condition for the practice of radiology-the ra- cludes a heightened awareness about cost and the clear truth is that the physician held the
diologists raison d#{234}tre-one must be cau- various potentially coercive forces that influ- view that his interests overrode other values
tious about the extent to which radiologists ence an examination in a particular patient: ra- and considered his authority absolute; using
consider images in isolation. Considering im- diologists interests, a referring physicians Kants maxim to inquire about the universal-
ages in isolation, as ends in themselves, may demands, an insurance carriers policy, or a izability of the physicians acts, one would
give rise to misconstruing them as having no managed care organization mandate, for exam- likely answer that the consequences of such
representational connection whatever to the pie. The radiologist, within either a fee-for-ser- acts are antithetical to a shared understand-
suffering person represented therein. The per- vice or a capitated arrangement, must balance ing of a professionals obligations to pa-
ception that no connection exists between the conflicting interests with every decision to per- tients. Finally, how is the welfare of others
person of the patient and the persons images form the requested imaging study. If a physi- nurtured by these attitudes and behaviors?
may therefore provide a radiologist with justi- cians primary goal is to benefit the patient, A physician radiologist is essentially a
fication that no patient-physician relationship then serving the radiologists or any other in- steward of costly, sophisticated, high-tech,
exists. This is to suggest that images are a nec- terest is necessarily a secondary goal. Several scarce resources to be used judiciously for
essary, but not sufficient, condition for radiolo- important questions arise. Does a potentially persons likely to benefit from use of such re-
gists responsibilities and that images are also adverse effect on a radiologists income justify sources. It follows that a radiologist, together
a means-a means to the end that patient ben- the performance of a marginally indicated ex- with the referring physician and patient, par-
efit is the focus of our professional endeavor. amination? Whose interest is being served ticipates fully in assessing the appropriate-
On reflection, a radiologist has a broad with the performance ofa marginally indicated ness of a proposed imaging examination.
range of ethical responsibilities to the patient or inappropriate examination? What reasons This assessment is based upon a well-formu-
represented in images. As one examines the provide support for an argument thatjustifies a lated argument regarding the likelihood and
concept of what it is to be a radiologic physi- physicians decision to serve his or her own in- magnitude of proposed benefit for the patient
cian, each step in the process of discharging terests over those of the patient? Is the argu- balanced against all foreseeable costs. This
ones responsibilities is directly focused on ment persuasive? argument is a paradigm different from per-
patient well-being. An examination of these A practicing physician stood in a radiology forming an examination as ordered or any at-
responsibilities reveals that a referring physi- reading room, addressing several diagnostic ra- tempt by a radiologist to justify a marginally
cians request for an imaging examination diologists, insisting that a patient receive an im- indicated or inappropriate examination or
initiates the process, and the radiologists re- aging examination immediately. Further, he procedure because it is not harmful to the pa-
sponsibility is fulfilled when the findings, demanded that he receive a percentage ofthe in- tient. Thus, the radiologist and referring phy-
and the significance of the patients imaging come generated by the examination because he sician share the role of patient advocate for
data, are communicated to and understood was in a position of influence to make the in- an informed patient in the engagement model
by the referring physician. The complex con- come possible for the radiologist. Damn it! he of the patient-physician relationship.
cept of our responsibility in a relationship said, This is my patient and I want a piece of
entails the following seven elements, briefly the action (Armstrong JD II, personal observa- Informed Consent Process
summarized here [10]. tion). This physician held a view that his role in Second, we reflect on the extent to which
the patient-physician relationship was one of we radiologists participate in the process of
Appropriateness of the Imaging Examination patient ownership, that he alone understood the consent with patients. As the ethical and le-
First, we reflect on our participation in de- patients good and held exclusive authority to gal basis of trust between patient and physi-
termining the appropriateness of an examina- dictate the appropriate imaging examination, cian, the consent process is grounded in the
tion for patients referred for imaging studies. and that a kickback was rightful recompense for engagement model of the patient-physician
This determination could include participation his referral. These demands, spoken with emo- relationship. This process includes the re-
in a broad-based consensus panel with the cre- tional force, do not constitute a persuasive argu- quirement that radiologists understand the
ation of critical pathways or practice guide- ment and, in my view, require a thoughtful, elements of informed consent [12]. The first
lines (e.g., American College of Radiology unemotional, and principled response. The ex- of these elements is disclosure of a core set
guidelines for determining appropriate imag- amination was marginally indicated and not of information to a patient, including facts
ing in a particular patient context). Assessing performed; however, although one may bejusti- that patients usually consider important in
the appropriateness of an examination ideally fiably critical of the physicians morally repre- deciding whether to consent to or refuse the
challenges us to listen to the patients story; hensible acts, one must at the same time reflect proposed examination, information that the
engage in discussion and perhaps argument on and be self-critical about the extent to which physician deems material, the physicians
with the referring physician; question the indi- one could use patients to serve ones own ends. recommendation, the purpose of seeking
cations for the requested examination; reflect In a different context but appropriate here, consent, and the nature and limits of consent
on the patients circumstances; and analyze the John Kenneth Galbraith [11], emeritus pro- as an authorization. The second element of

282 AJR:173, August 1999

 Morality, Ethics, and Radiologists Responsibilities

informed consent is comprehension of perti- Additional important questions relate to tive, milieu is perpetuated. Can one openly
nent information about the examination and when additional information about the pa- address ones own and others mistakes in
alternative choices, as well as the nature and tient should be sought, what specific ques- such a way that an opportunity for learning is
consequences of ones actions. The third is tion the radiologist is expected to answer provided, thus minimizing the likelihood that
voluntariness of consent, emphasizing a per- through the intended study, what the radiolo- the mistake will be repeated? Does ones
sons independence from others manipula- gists level of certainty is about a particular working milieu allow mistakes to be shared
finding clinical colleagues and patients when
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tive and coercive influences. The fourth is and its significance, through which with
determining the patients decisional capacity process a final decision should be reached, appropriate? To learn from mistakes is a
(competency, determined by the court, is the and which specific wording should be used sine qua non in ethics, as it is in any human
legal designation) and securing an appropri- to spell out findings, their significance, and a endeavor [14].
ate surrogate decision maker in the event that recommendation for action.
a physician determines that a patient lacks Continuous Quality Improvement

the capacity for medical decision making (a Communication with Patients and Physicians Seventh, and finally, we reflect on the
patient should not automatically be deemed Fifth, and of critical importance, is the question How is it possible to continuously
to lack decisional capacity when the patient communication of information to physicians improve the quality of patient care? An-
disagrees with a physicians recommenda- and patients. Communication begins with a swering this question requires that we learn
tion, nor is it ethically appropriate to override dialogue focused on whether the requested to systematically examine the processes
an informed patient when the patient refuses examination is appropriate for a patient and through which we accomplish our mission in
the proposed examination). The fifth element may entail answering the patients questions radiology. Systems of health care delivery,
is empowerment of a patient to consent or about indications for the proposed examina- like any system, are essentially designed to
withhold consent, called informed refusal, tion and discussing the results of an imaging provide precisely the outcomes that they pro-
for an imaging examination. Consent is a pro- study with a patient or family [13]. More- vide. Admirable intentions and motives, hard
cess requiring conversation with a patient- over, communication includes the requirement work, and continuous learning do not change
perhaps several conversations-and a signed that referring physicians receive information in systems that provide services to patients and
consent form does not constitute consent but a timely manner and that the referring physi- in which we function as providers of care.
merely evidence of consent. cian understand the importance, relevance, Systems improve and become more sensi-
urgency, and possible consequences of the tive to patient needs if, and only if, participants
Patient Protection findings, together with further requirements in systems join together to systematically ex-
Third, we radiologists are responsible for for patient evaluation or treatment. Commu- amine the processes through which service is
protecting patients and their interests during nication is ideal in face-to-face consultation provided [ 15]. This examination requires that
the course of an imaging examination or inter- combining the patients images with other key indicators of quality be identified and that
ventional procedure. This concept includes pertinent patient-based data. the processes responsible for providing quality
considerations of patient safety and comfort, care be understood, measured, and systemati-
examination timeliness, preparedness for Continuous Learning cally changed. Moreover, any changes initiated
emergent resuscitative care, and patient fol- Sixth, we seek to answer the question What must measurably improve and sustain quality.
low-up. Adequate management of pain and have I learned in this process? The question of Such examinations include being rigorously
amelioration of suffering during interven- whether one has learned or gained new knowl- accountable to ones peers, with measures of
tional procedures using sufficient analgesia edge from a process is fundamental to being a performance; determining how service to pa-
and conscious sedation constitute fundamental professional. Learning requires critical thinking tients and consultation for physicians is pro-
responsibilities of the radiologic physician. about the question, particularly a willingness to vided; and measuring the imaging contribution
Protection of patients also entails protection be self-critical, and acknowledging ones limits to certain patient outcomes. Finally, one must
from inappropriate examinations or proce- and the limits of ones methods. Acquisition of answer the question of how one integrates what
dures and protection from impaired or incom- knowledge is often stimulated by examination is learned into earlier stages ofthe process such
petent care providers; thus, participation in ofones own mistakes. Despite ones best mien- that ones professional contribution is continu-
peer review is critical to the process of protect- tions or the care with which one systematically ously improved.
ing patient interests in an imaging department. examines images or performs procedures, errors
are inevitable. Particularlytroublesome are the Summary
Image Interpretation errors that result in patient harm. How one re- The goal of this discussion was to address
Fourth, the radiologist is responsible for the sponds to mistakes, of any magnitude, is in sig- the matter and methodology of ethics and
complex processes of acquisition, analysis, nificant part determined by the institutional critical thinking and to ask several questions
and interpretation of a wide variety of medical ethical milieu and the attitudes of ones col- about the relationship between ethics and ra-
images. This process of providing excellence leagues about acknowledging errors. diology. Questions about the nature of the
in image interpretation includes, but is not lim- Acknowledging ones mistakes vividly re- moral and how ethics inform decision mak-
ited to, monitoring image quality and monitor- flects ones willingness to accept responsibil- ing raise our awareness and may provide
ing individual and group performance with ity for being fallible. If errors are hidden or new understanding about moral thinking.
respect to errors of interpretation, specifically covered up in fear of embarrassment or legal #{149}
Why is medicine a moral endeavor?
errors of search, detection, and recognition, to- exposure, opportunities for continued learn- Overridingness, universalizability, and other-
gether with other aspects of peer review. ing are lost and the secretive, perhaps puni- regarding virtues were discussed.

AJR:173, August 1999 283

 Armstrong

#{149}
How do ethics inform medical decision and the extent to which we achieve excel- McGraw-Hill, 1982:11-14

making? Ethical theories, including parental- lence in our contribution to patient care; to 7. Gadow S. Existential advocacy: philosophical
foundation of nursing. In: Spicker SF, Gadow 5,
ism, autonomy, and the engagement model, break out of comfortable habits and reflect
eds. Nursing: images and ideals-opening dia-
were discussed. on new, alternative ways of knowing as care-
logue with the humanities. New York: Springer,
#{149}
What are radiologists ethical responsibili- givers; to think about what we are doing in 1980:79-101
ties? Our ethical responsibilities as radiologists medicine and the consequences for the hu- 8. Brody H. Ethical decisions in medicine. East
entail seven briefly described elements: assess- man mind and spirit of our patients, our col- Lansing: Michigan State Univ. Press, 1976:1-27
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ing the appropriateness of the imaging exami- leagues, and ourselves; and to provide a 9. Cassell E. The nature of suffering and the goals of
medicine. New York: Oxford Univ. Press, 1991
nation, participating in the informed consent forum for this important dialogue in our
10. Armstrong JD II, Baum S. Radiologists profes-
process, protecting patient interests, providing practices, residency programs, and continu-
sional relationships: an ethical inquiry (abstr).
excellent image interpretation, communicating ing education curricula. Radiology 1992;185:27
effectively with physicians and patients, seek- 11. Galbraith JK. Free market fraud. The Progressive
ing continued learning, and continuously im- 1999;63:54
References
proving quality. Of these responsibilities, 12. Beauchamp IL, Childress JE Principles of bio-
1. Earle WJ. Introduction to philosophy. New York: medical ethics. New York: Oxford Univ. Press,
competence, loyal concern for the patients McGraw-Hill, 1992:1-4 1994:128-170
well-being, and respect for his or her person 2. Armstrong JD II. Radiology ethics. AiR 1992; 13. Armstrong JD II. Radiologists responses to pa-
provide the basis for trust in the patient-physi- 159:18-20 tients inquiries about results. invest Radio!
cian relationship [2]. if the central paradox in 3. Double R. Beginning philosophy. New York: Ox- 1993;28: 1049-1051
medicine is the tension between self-interest ford Univ. PreSS, 1999:1-4 14. Fletcher JC. On learning from mistakes. J Clin
4. Pellegrino ED, Thomasma DC. For the patients Ethics 1995;6:264-270
and altruism [16], then responsibility to the pa-
good. Oxford, England: Oxford University PreSS, 15. Harrington Hi. Total improvement management:
tient in this trust has the greatest force and
1988:3-10, 37-50 the next generation in performance improvement.
overrides other obligations [4]. 5. Hare M. Moral thinking. Oxford, England: Clar- New York: McGraw-Hill, 1995
Finally, our challenge is to critically ex- endon, 1981:1-24 16. Jonsen A. Watching the doctor. N Engl J Med
amine our and each others professional role 6. Beauchamp IL. Philosophical ethics. New York: 1983;308:153 1-1535

284 AJR:173, August 1999

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