Since the turn of the 21st century, and the emergence of a global knowledge sharing practice based in medicine, the increased attention to practitioner ethics has created an interdisciplinary focus on informed consent practice (Showalter). In most healthcare contexts, this topic is further refracted through the lens of medical malpractice liability and tortious negligence lawsuits (Hoey). Some countries also sustain social policies that may actually pose risk to patients; as in the case of fetal sex inquiries under China’s one child policy.
The importance of informed consent as a rule and as an ethical obligation to a duty to a reasonable standard care in administration speaks to debates within the field of radiology centered on palliative care, and on fetal screening practices. The inference that the two patient scenarios both involve third-party intervener consent is complicated by the fact that the latter always includes the pregnant mother whereas terminal treatment may or may not include another party.
Informed Consent in Palliative Care Settings
Unlike the United States, where physician “duty to a reasonable standard of care” is focused on “reasonability” of patient decision, in the Canadian radiology practice setting, where medical teams are charged with diagnosis of a palliative care patient, “reasonability” falls back on the practitioner (CMPA, Showalter). In Canada, there are four (4) informed consent rules to forewarning, Table 1.
For instance, if it is discerned that certain psychological or other harm to the patient may be the result of forewarning of secondary consequences, no obligation by the physician is present in Canada. Omission may ensue to “protect” the patient from additional suffering (i.e. extreme morbidity or mortality by bleeding to death) (CMPA).
In both North American healthcare environments, competency of patients is also a factor in the discretion of informed consent practice. While informed consent to treatment is an obligation of radiologists, where a third-party guardian or intervener is involved, forewarning may be limited to the discretion of the latter party rather than the patient.
Research on palliative care in the European radiology practice setting is also distinct from that of North America. In an investigation into Greek palliative care team practices, Mystakidou found that practitioners “do not always cover the needs of these patients and their families since palliative care is not yet recognized as a distinctive and autonomous part of their health care” (Mystakidou).
Ethical dilemmas arising in response to care of terminally ill patients more often than not result in “withholding the truth” suggests, Mystakidou in spite of the fact that there is a growing awareness of informed consent obligation in Greece (Mystakidou). Notwithstanding competency issues, the general practice of “informing the relatives before the patient” is contrary to what Greek medical ethics sustain as “confidentiality of the doctor–patient consultation” (Mystakidou).
Ethical Dilemmas in Ultrasound Scanning
Much like the ethical dilemmas found in informed consent practices with palliative care patients in Canada and Greece, and especially those under third-party supervision, the circumstance of autonomy-based right to fetal sex inquiry by pregnant women poses challenges to medical ethical principles outside of the West. While ethical respect for the principle of autonomous patient decision in their own treatment is normally accepted prima facie, in practices settings such as China where a one child policy has been in effect for a number of decades, the obligation to pregnant women can be overruled by other obligations.
Consistent with Canada’s informed consent rules in regard to ‘reasonability’ in physician decision to forewarn palliative care patients, the basis for exercise of autonomy and its prioritization in by Chinese radiology professionals, may be “justifiably be restricted to prevent serious social harm” to both the mother and unborn child (Chervenak & McCullough).
Still, there is ample evidence that parental consent to ultra-sound radiology of the fetus is recommended for detection of malformation, and that this is a globally recognized method of screening for risk. The use of color Doppler, 3-D and 4-D scanning ultra-sound to detect the presence of anomalies and their undesirable effects on the fetus makes this technique highly valuable for early reporting of congenital conditions or transmission (i.e. genetics, diabetes, etc) that would otherwise go unnoticed due to lack of symptoms (Malhotra, Rao, Malhotra & Malhotra).
In practice settings where termination is an option for pregnant women whom are faced with the birth of a severely handicapped infant, “diagnosis of such conditions during pregnancy can give the couple the option” if untreatable, open neural tube defects or cardiac defects are present (Malhotra, Rao, Malhotra & Malhotra). The limits of fetal medicine, some argue, place an emphasis on prenatal anomaly scanning as the best possible approach to ensuring that a fetus is healthy enough to sustain birth.
Conclusion
In Surbonne’s "Truth Telling to the Patient." the distance between informed consent and patient confidence may not be entirely covered by institutional procedures. Radiologists aware of patient mistrust face important challenges in practitioner-patient synergy, not to mention institutional liability. Recommendation to additional evidence based practice research on therapeutic misconception matters and ethical complications in informed consent is widely advised.
Bibliography
Canadian Medical Protection Association (CMPA), 2013.
Chervenak, FA & McCullough, LB. “Sex determination by ultrasound: ethical challenges of sex ratio imbalances and invidious discrimination”. Ultrasound Obstet Gynecol Vol 34 (2009), pp. 245–246.
Hoey, J. “The CMA's Health Information Privacy Code: Does it go too far?”. CMAJ: Canadian Medical Association Journal 20 October 1998, pp. 953-954.
“How do the Courts determine standard of care?”. Canadian Medical Protection Association (CMPA), 2010.
Malhotra, Narendra, Rao, JP, Malhotra, J, Malhotra, N. “Ultrasound for Screening Fetal Malformations—Has 3-D Made a Difference?. South Asian Federation of Obstetrics and Gynecology, Vol 2 No. 2, January-April (2010), pp. 7-10.
Mystakidou, Kyriaki. “Interdisciplinary working: a Greek perspective”. Palliative Medicine Vo. 15 (2001), pp. 67–68.
Showalter, J.S. The Law of Healthcare Administration. Health Administration Press, Chicago, 2008.
Surbonne, Antonelle "Truth Telling to the Patient." Health Care Ethics in Canada, pp. 50-54.
