Nicolas Argy, M.D., J.D. SRPE April 24Th 2019

Nicolas Argy, M.D., J.D. SRPE April 24th 2019

Copyright Nicolas Argy, M.D., J.D. 2011 Goals 1. Define ethics and establish professional mandates of RPE 2. Understand the elements and limits of ethical mandates 3. Understand methods to approach and analyze ethical dilemmas

Copyright Nicolas Argy, M.D., J.D. 2011 Definition of Ethics 1. Dictionary 1. (used with a singular or plural verb) a system of moral principles: the ethics of a culture. 2. the rules of conduct recognized in respect to a particular class of human actions or a particular group, culture, etc.: medical ethics; Christian ethics. 3. moral principles, as of an individual: His ethics forbade betrayal of a confidence. 4. (usually used with a singular verb) that branch of philosophy dealing with values relating to human conduct, with respect to the rightness and wrongness of certain actions and to the goodness and badness of the motives and ends of such actions.

2. Difference between ethical mandate and legal mandate

 Increase number of issues with informed consumer

 Greater emphasis on cost containment

 Greater technology mandate

 Balance of patient, personal, societal values History of Medical Ethics

 Hammurabi

 Hippocrates

 Percival

 Buck v. Bell

Copyright Nicolas Argy, M.D., J.D. 2011 History of Medical Ethics(cont.)  US Supreme Court: Buck v. Bell(No. 292) 143 Va. 310, affirmed. The court held: “The principle that sustains compulsory vaccination is broad enough to cover cutting the Fallopian tubes. Jacobson v. Massachusetts, 197 U.S. 11. Three generations of imbeciles are enough.”  Court cases: Quinlan, Saikewicz Human Social Behavior

1. Custom: based on traditions and culture 2. Etiquette: based on courtesy and acceptable social interaction (Hostile work environment) 3. Ethics: based on professionalism, competence, integrity, fairness, and truth 4. Law: based on codified enforceable rules and regulations statutes 5. Morality: based on spiritual, religious values Theory of Ethics

1. Competing Interests: Individual vs. Societal

A. Personal autonomy vs. greatest good for greatest number

2. Natural Law vs. Moral Relativism

 Beauchamp and Childress, 1978

1. Autonomy

2. Beneficence

3. Non Maleficence

4. Social Justice

1. Autonomy

A. Self determination

B. Free will and accord

C. Information IC decision

D. Respect and dignity Theoretical Medical Ethics(cont.)

2. Beneficence

A. Actions which only benefit the patient (no consideration of third parties or society).

B. Maximum benefits and minimum harm considering overall effect on both subject and society. Theoretical Medical Ethics(cont.)

3. Non Maleficence

A. Primum non nocere

B. Sanctity of life emphasized

C. Risk benefit analysis Theoretical Medical Ethics(cont.) 4. Social Justice

A. Fair distribution of benefits B. Equal shares with distribution of benefits to society C. Transparent non discriminatory accountable principles D. Equitable distribution of burden and benefits Fiduciary Obligation  What is it?

 Inherent in professional relations?

 Is fee for service ethical?

 Is capitation ethical? CBRPA/SRPE Requirements

1. Follow established code of ethics

2. Adhere to state and federal law

3. Seek consultation

4. Provide services within education and training

5. Shall not misrepresent professional status

6. Place service before material gain and avoid COI

 http://www.cbrpa.org/professioninfo/pdf/ScopeofPrac tice.pdf

1. Provide a broad range of radiology services, 2. Assess, evaluate, and manage patients, 3. Administer IV medications or contrast media, 4. Perform fluoroscopic, specialized imaging & invasive procedures under supervision, 5. Evaluate and screen images

Copyright Nicolas Argy, M.D., J.D. 2011 STANDARDS OF PROFESSIONAL PRACTICE 1. PATIENT INFORMATION, ASSESSMENT AND EVALUATION

A. Identify patient, B. Assess pregnancy status, C. Collect information, D. Assess information for best management, E. Conduct physical examination

2. PATIENT EDUCATION AND SECURING INFORMED CONSENT

A. Explain, take questions, confirm understanding, educate and be sensitive to patients needs/background

B. Will cover IC later in lecture for completeness

3. ANALYSIS AND DETERMINATION OF THE APPROPRIATE CLINICAL PATHWAY

A. The most appropriate clinical pathway seeks to optimize patient safety and comfort based on the clinical presentation, patient assessment and analysis of data in the selection of the imaging modality to achieve the optimum diagnostic objective of the examination and in consideration of cost effectiveness.

4. IMPLEMENTATION OF IMAGING EXAMINATION PROCEDURE

A. Quality patient care is provided through the safe and accurate implementation of the appropriate imaging examination procedure.

5. MEDICAL IMAGE EVALUATION

A. Analysis of the imaging procedure results in context with the procedure and the patient’s medical and clinical history is important to determine if the goals of the procedure have been met or if additional imaging procedures are needed.

6. DOCUMENTATION

A. Clear and concise documentation is necessary for continuity of care, accuracy of care and quality assurance.

B. http://www.cbrapa.org/professioninfo/pdf/StandardsofPrac tice.pdf

1. Goals

2. Elements

A. RBA

3. Exceptions

A. Minor, emergency, waiver

4. Paternalism and therapeutic privilege

 https://www.arrt.org/ethics/standardethic.pdf

Copyright Nicolas Argy, M.D., J.D. 2010 ARRT Standards of Ethics 1. Provide high quality 6. Follow standard of care patient care & service. and practice. 2. Deliver care without 7. Act in the best interest of discrimination. patient. 3. Enhance the dignity of 8. Minimize radiation patients. exposure to pt, self, and 4. Maintain professional healthcare members. demeanor. 9. Maintain confidentiality 5. Exercise care, discretion, and privacy. and judgment. 10. Participate in continuing education.

 HIPAA

 Exceptions and duty to disclose A. Public welfare, B. Release, C. Disclosure to other treating physicians, D. Legally required or court ordered, E. Risk to self or others

 Information gathering

A. Medical facts

B. Personal, family, provider values and preferences

C. Competing interests

 82 yo pleasantly demented pt in for aortogram for 4cm AAA

 You observe a colleague doing interventional procedures repeatedly having unusual complications and showing poor judgment regarding when to terminate interventions and get help.

 You work with a radiologists who repeatedly is demeaning, rude and insulting to technologists and clerical staff.

 You come to work and smell what you think is alcohol on a colleagues breath.

 You are obtaining IC for a liver biopsy from the son of a 88 yo with Hep C.

The son says, “My Mom always takes the advice of the doctors and does whatever they recommend.” Example 6  You are getting IC from a 52 yo for a liver biopsy. The patient says she has researched this on the internet and thinks an MRI of the abdomen with diffusion weighted sequences is safer. She is also concerned that she is part of a capitated ACO as part of Obamacare She thinks her doctor recommended the biopsy because it is cheaper than an MRI Summary

Familiarize yourself with the ethical mandates of your professional organizations.

 Professional excellence, evidence based

 CME/teaching

 Collegiality

 Confidentiality

 Financial propriety

 Compassion and kindness

Ethical behavior is maintaining the highest standards of professional and personal excellence.

Aristotle “Excellence is an art won by training and habituation. We do not act rightly because we have virtue or excellence, but we rather have those because we have acted rightly. We are what we repeatedly do. Excellence, then, is not an act but a habit.”

Q & A

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