On completion of this chapter, you should be able to:
Identify multiple sources of moral beliefs in a pluralistic society
Differentiate morality from ethics
Describe the application of nonmaleficence, beneficence, justice, veracity, and autonomy in various settings where sonographic examinations are performed
Define the principle of beneficence in clinical ethics
Define the principle of respect for autonomy in clinical ethics
Identify beneficence-based obligations to the fetal patient
Identify ethical issues in competence and referral in sonography examinations
Identify ethical issues in routine obstetric sonography screening
Identify ethical issues in disclosure of results in sonographic examinations
Identify ethical issues in the confidentiality of findings
Ethical codes are important regulators in health care. Patient trust is built on the expectation that health care professionals will follow established ethical principles and guidelines. Medical ethics promotes excellence and protects patients by encouraging practitioners to reflect on, communicate, and demonstrate optimal care.
Sonographers have ethical responsibilities to their patients and colleagues. The principles of nonmaleficence, beneficence, autonomy, respect for persons, veracity and integrity, and justice must be implemented in the sonography laboratory to ensure ethical practice. Sonographers who regularly participate in ethical discussions and discourse within their environment may best meet these requirements. The Society of Diagnostic Medical Sonography (SDMS) has adopted a code of ethics for sonographers. This code includes elements consistent with principles of nonmaleficence, beneficence, autonomy, veracity, justice, and confidentiality.
Morality and ethics defined
Ethics is defined as systematic reflection on and analysis of morality. Morality concerns right and wrong conduct (what we ought or ought not to do) and good and bad character (the kinds of persons we should become and the virtues we should cultivate in doing so). Morality reflects duties and values. Freedom and autonomy are integral to morality because they allow values to be expressed. All aspects of morality, duties, values, and rights are of importance in the clinical ethics of sonography practice.
In a pluralistic, multicultural society such as the United States, moral beliefs and behaviors vary widely. Morality is learned through personal experiences and family traditions, and from normative behavior within communities, ethnic and racial groups, or geographic regions. Religions disagree about conduct and character, and religious ethics provides an inadequate foundation for professional ethics in a culturally diverse society. National identity and history also contribute to beliefs, as do the laws of the states and the federal government. These many sources of moral beliefs can sometimes cause conflict. Health care providers with good intentions may disagree among themselves or with patients on moral directions. When these disagreements are discussed and analyzed, a collaborative and ethical resolution of the conflict can be achieved. It is this type of discussion, reflection, and discourse on morality that constitutes ethics.
Whereas morality has to do with the protection of cherished values, ethics is a discipline of study that seeks to articulate clear, consistent, coherent, and practical guidelines for conduct and character. Ethics tries to answer the key question, “What is good?” To be applicable to a medical context such as sonography, ethics must transcend moral pluralism by offering an approach with minimal ties to any substantive prior belief about moral conduct and character. This is what philosophical ethics attempts to do because it requires only a commitment to the results of rational discourse in which all substantive commitments about what morality ought to be are open to question. Every such substantive moral claim requires intellectual justification in the form of rigorous ethical analysis and argument. Philosophical ethics therefore properly serves as the foundation for medical ethics, especially in an international context.
History of medical ethics
Medical ethics has evolved since the beginning of civilization, when health care knowledge was shared orally and healers exemplified a community’s moral code. Prince Hammurabi of Babylon recorded the responsibilities of health care providers in 1727 bc, and early Hindu writers at about the same time cautioned healers to treat patients with respect, gentleness, and dignity. Fundamental principles of Western medical ethics were first recorded in ancient Greece in about the 5th century bc. Hippocrates cautioned his students, “primum non nocere,” which famously means, “First, do no harm.” In ethics, this is known as the ethical principle of nonmaleficence. Hippocrates’ teachings emphasize choosing treatment based on knowledge that would best benefit patients, treating patients as one would treat family members, upholding confidentiality, and practicing personal piety.
Ethical norms, elements, and principles were refined through the centuries. Thomas Percival (1740–1805) wrote a treatise that substantially changed medical ethics. Previously, a patient was someone who paid for treatment, but Percival redefined patient as anyone needing care. He also foresaw a team approach in health care and public health. Percival emphasized patient care provided by all professionals and ordered competitive or professional interests as secondary to the needs of the patient.
Modern medical ethics was codified after the Nuremberg trials, which judged the atrocities done in medical experimentation by Nazi doctors. The judges in the Nuremberg trial issued a verdict that included a section on permissible human experimentation. That section, which became known as the Nuremberg code, was incorporated into regulatory policy in the United States. The same protections were adopted internationally and published within the Helsinki report in 1964. The Nuremberg code emphasized individual rights and autonomy and has become a key element of modern ethics.
Basic principles of medical ethics have been incorporated into research regulations, professional codes, and clinical practices throughout the world. The ethical codes of different professional groups may differ slightly in definition and emphasis, but the basic principles of autonomy, justice, beneficence, nonmaleficence, integrity, and respect for persons are universal.
The Code of Ethics for the Profession of Diagnostic Medical Sonography has been adopted and is maintained by the SDMS.
Principles of medical ethics
The principle of nonmaleficence directs the sonographer to not cause harm. Application of the principle of nonmaleficence requires the sonographer to obtain appropriate education and clinical skills to ensure competence in performing each required examination. Ensuring an appropriate level of competence imposes a rigorous standard of education and continuing education. Problems result when obstetric sonographers do not maintain a baseline level of competence in the techniques and interpretation of sonographic imaging: (1) They may cause unnecessary harm to the pregnant woman or fetal patient, for example, from mistaken impressions of fetal anomalies that in turn lead to unnecessary anxiety or testing; and (2) they may undermine the informed consent process regarding the management of pregnancy by reporting in an incomplete or inaccurate manner to the physician, who in turn reports misinformation to the pregnant woman.
Sonographers need to be accountable for and participate in regular assessment and review of protocols, equipment, procedures, and results to ensure that patients are not harmed by outdated procedures or poorly functioning equipment. Appropriate oversight and approval of protocols by research or hospital committees contribute to patient safety. Protocols and diagnostic criteria should be established by peer review. Sonographers may contribute to the safety of patients by sharing with others and publishing peer-reviewed information about mistakes made or lessons learned.
The sonographer must practice emergency procedures and strive to ensure patient safety in all procedures and circumstances. Sonographers must refrain from substance abuse or any activity that may alter their judgment or ability to provide safe and effective patient care.
Because ultrasound energy poses a theoretical risk to the fetus, the principle of nonmaleficence requires sonographers to perform only medically indicated examinations and to perform all examinations in keeping with ALARA, an energy exposure that is as low as reasonably achievable, to obtain the desired results. Sonographers should not perform obstetric ultrasound examinations for entertainment purposes.
Sonographers need to read the current medical literature to stay abreast of new developments related to patient safety. Sonographers should not perform ultrasound examination without medical benefit.
Protections for patients and subjects based on the ethical principle of nonmaleficence only partially explain what is in the patients’ interests because medicine, and therefore sonography, seeks to benefit patients, not simply to avoid harming them. The use of obstetric ultrasound, like other medical interventions, must be justified by the goal of seeking the greater balance of clinical “goods” over “harms,” not simply avoiding harm to the patient at all cost. This ethical principle is called beneficence and is a more comprehensive basis for ethics in sonography than is nonmaleficence.
Goods and harms are to be defined and balanced from a rigorous clinical perspective. The goods that obstetric sonography should seek for patients include preventing early or premature death (not preventing death at all costs); preventing and managing disease, injury, and handicapping conditions; and alleviating unnecessary pain and suffering. Pain and suffering are unnecessary and therefore represent clinical harms to be avoided when they do not contribute to seeking the good of the beneficence-based clinical judgment. Pain is a physiologic phenomenon involving central nervous system processing of tissue damage. Suffering is a psychological phenomenon involving blocked intentions, plans, and projects. Pain often causes suffering, but one can suffer without being in pain.
The principle of beneficence obligates the obstetric sonographer to seek the greatest benefit in the care of pregnant patients. Beneficence encourages sonographers to go beyond the minimum standard protocol and to seek additional images and information if achievable and in the best interests of patients. Beneficence requires sonographers to focus on small comforts for patients, respecting their privacy and including their family on request. Kindness and attention to small details minimize suffering caused by frustration or anger. Beneficence, like nonmaleficence, requires competency, knowledge, and excellent sonographic skills to ensure that the patient and the fetus receive the greatest benefit from the examination.
Fetal interests in sonography are understood exclusively in terms of beneficence. This principle explains the moral (as distinct from legal) status of the fetus as a patient and generates ethical obligations owed by physicians and sonographers to the fetus. In the technical language of beneficence, the sonographer has beneficence-based obligations to the fetal patient to protect and promote fetal interests and those of the child it will become, as these are understood from a rigorous clinical perspective. The clinical good to be sought for the fetal patient includes prevention of premature death, disease, handicapping conditions, and unnecessary future pain and suffering. It is appropriate therefore to refer to fetuses as patients, except when a patient elects to terminate her pregnancy.
In clinical practice, beneficence may have to be balanced against other ethical principles. A health professional’s duty of beneficence may suggest one course of action and the patient may choose another. In these cases, beneficence must be balanced by respect for a person’s autonomy. The principles of veracity and integrity on occasion may conflict with beneficence when truth-telling will cause undue stress and complications. The principle of justice or fair distribution of benefits may conflict with beneficence for individual patients who need extra resources. Fortunately in most situations, it is in the patients’ best interests to respect their autonomy, to tell the truth, and to distribute benefits justly.
In the 21st century, autonomy, or the right to self-determination, has become a key ethical principle. Respect for persons incorporates both respect for the autonomy of individuals and the requirement to protect those with diminished autonomy. Patients, including pregnant women, have their own perspective on their interests, which should be respected as much as the clinician’s perspective on patients’ interests. A patient’s perspective on her interests is shaped by wide-ranging and sometimes idiosyncratic values and beliefs. Autonomy refers to a person’s capacity to formulate, express, and carry out value-based preferences. The ethical principle of respect for autonomy obligates the sonographer to acknowledge the integrity of a patient’s values and beliefs and of her value-based preferences; to avoid interfering with the expression or implementation of these preferences; and, when necessary, to assist in their expression and implementation. This principle generates the autonomy-based obligations of the sonographer.
Informed consent is an autonomy-based right. Each health professional has autonomy-based obligations regarding the informed consent process. This process must include discourse about what sonography examinations can and cannot detect, the sensitivity and frequency of false-negative and false-positive results of the sonography techniques employed, and the difficult and sometimes uncertain interpretation of sonographic images. In the face of medical uncertainty about the clinical good and harm of routine ultrasound, it is obligatory to inform pregnant patients about that uncertainty and to give them the opportunity to make their own choices about how that uncertainty should be managed. In routine examinations, it is also important to inform the woman of the possibility of confronting an anomaly that will lead her to decide whether to terminate the pregnancy or take it to term.
As the protocols and options for gaining medical information regarding potential fetal anomalies increase and risk assessment becomes more individualized, requirements are increased for patient education that is sufficient for informed choice. Genetic counselors, patient educators, sonographers, and physicians often work together to counsel women regarding their options and choices.
The sonographer respects the patient’s autonomy by providing a detailed explanation of the examination, including appropriate choices such as the right to view the screen or to learn the gender of the fetus. Respect for maternal autonomy dictates responding frankly to requests from the pregnant woman for information about the gender of the fetus. As part of the disclosure process, the pregnant woman should be made aware of the uncertainties of ultrasound gender identification. The sonographer can use his or her own experience to help the pregnant woman understand these uncertainties. A second choice that may be presented during obstetric examinations is the choice to view the images. This choice concerns the phenomenon of apparent bonding of pregnant women and their families to the fetus as a result of seeing the sonographic images. Such bonding often enriches pregnancies that will be taken to term, but at other times can complicate decisions to terminate a pregnancy.
A current ethical issue is the nonmedical use of sonography for the videotaping or photography of “baby pictures.” There is nothing intrinsically wrong with the practice if it is a side product of a legitimate ultrasound examination. However, when videotaping or photography is performed to generate revenue, this practice trivializes medical sonography and may result in harm because problems that could be diagnosed may be missed. Dwelling on the fetal profile or face for entertainment purposes is contrary to ALARA and the principle of nonmaleficence. It is the responsibility of sonographers to ensure that women have the information necessary to make informed choices.
It is an autonomy-enhancing strategy for a woman to be allowed to insert a vaginal probe herself to make the experience more comfortable and less threatening. It is also a sonographer’s obligation to respect a patient’s right to refuse a procedure.
Maternal interests are protected and promoted by both autonomy-based and beneficence-based obligations of the sonographer to the pregnant woman. Fetuses are incapable of having their own perspective on their interests because the immaturity of their central nervous system renders them incapable of having the requisite values or beliefs. Thus there can be no autonomy-based obligations to the fetus. The pregnant woman also has beneficence-based obligations to the fetal patient when the pregnancy will be taken to term. She is expected to protect and promote the fetal patient’s interests and those of the child it will become. When a pregnant woman elects to have an abortion, however, these obligations do not exist. A sonographer with moral objections to abortion should keep two things in mind: First, the moral judgment and decision of the pregnant woman to end her pregnancy should not be criticized or commented on in any way; her autonomy demands respect as shown by the sonographer and the physician being neutral to her judgment and decision. Second, the sonographer is free to follow his or her conscience and to withdraw from further involvement with patients who elect abortion. Physicians should as a matter of office policy respect this important matter of individual conscience on the part of the sonographer.
Veracity and integrity
Telling the truth is an ethical practice that most sonographers have been taught from a young age. Yet the vast majority of us on occasion will tell “white lies” in kindness or to escape unwanted consequences. The universal acceptance and even cultural preference in some countries for white lies is evidence of the difficulty involved in adhering to the principle of veracity. Veracity means truthfulness. Integrity means adherence to moral and ethical principles. Integrity is related to the word integrate, meaning “to bring together.” In terms of honesty, integrity means that there is no difference between what you think, what you say, and what you do: They all come together in ethical behavior.
In medical care, patients properly rely for their protection on the personal and professional integrity of their clinicians. A crucial aspect of that integrity on the part of physicians is willingness to refer to specialists when the limits of their own knowledge are being approached. Integrity should also be one of the fundamental virtues of sonographers and thus a standard for judging professional character. Similar to other virtues, such as self-sacrifice and compassion, integrity directs sonographers to focus primarily on the patient’s interests as a way to blunt mere self-interest. Sonographers must avoid conflicts of interest and situations that exploit others, create unreasonable expectations, or misrepresent information.
Veracity with respect to abilities and limitations is absolutely essential among sonographers. If a practitioner asks a sonographer to perform an examination that he or she is not competent to do, it is essential for the sonographer to be truthful about his or her limitations to protect the patient. A sonographer asked by a patient or a colleague must accurately represent his or her level of competence, education, and credentials.
Premature disclosure of the results of an abnormal sonographic examination raises significant clinical ethical issues for sonographers. Sonographers are justified in disclosing findings of normal anatomy directly to the pregnant woman. When images reveal abnormal findings, sonographers must not act “dumb” or tell the patient that they do not know what they are seeing. Veracity is upheld by telling the patient in a nonalarming way the procedure for diagnosis, that “multiple eyes need to look at some of the images,” and that the physician will determine the results. Disclosure of, and discussion about, abnormal findings by sonographers is inappropriate because it is not in the best interest of the patient. If the disclosure and the discussion are to respect and enhance maternal autonomy and avoid unnecessary psychological harm to the pregnant woman, the discussion should occur in a setting where the alternatives and choices available to manage the pregnancy are presented. Sonographers cannot by training or by experience claim the clinical competence to engage in such discussions. Physicians can and therefore should.
Sonographers must strive to supply patients and colleagues with complete and accurate information. The sonographer’s integrity is an essential safeguard for the patient’s autonomy. At times, the sonographer will need to become an advocate, even a vigorous advocate, for disclosure of information to a patient. In such cases, sonographers must address their concerns not to the patient but to the practitioner involved. Failure to make patient disclosures undermines professional integrity and the moral authority of health care professionals. When the sonographer disagrees with the clinical judgment of his or her supervising physician, professional communication and discussion of the matter need to occur. The best interests of the health care team and the patient are enhanced by such conversations.
Justice is the ethical principle that requires fair distribution of benefits and burdens; an injustice occurs when a benefit to which a person is entitled is withheld, or when a burden is unfairly imposed. Justice means simply that sonographers must strive to treat all patients equally. In practical terms, justice requires that translators be used when necessary to ensure adequate and appropriate communication with all patients. Sonographers should strive to ensure that disabled patients have access to reasonable accommodations and pathways, and that obese patients have comfortable chairs, gowns, and stretchers. Children, adults, and geriatric patients need to feel equally welcome and cared for within the sonography laboratory.
Justice is served when protocols are standardized. Men and women with similar symptoms should receive similar tests and interventions. If a group is denied services or is asked to assume an undue burden to obtain care provided to others, justice is not being served.
Justice and autonomy are the ethical principles that determine the timing of obstetric sonography examinations. The information obtained from a sonogram enhances women’s choices. It is an injustice to provide this information to some women and not to others. It is for this reason that recommendations are made that all women be offered risk assessment for anomalies during the first trimester. Sonography results, such as risk for an abnormality, are relevant to the woman’s decision about whether she will seek an abortion. In pregnancies that will be taken to term, sonography enhances a pregnant woman’s autonomy. The timing of the information is also relevant if anomalies are detected and she does not choose abortion, as she may begin to prepare herself for the decisions that she will confront later regarding management of the anomalies in the intrapartum and postpartum periods. Providing requested information early in pregnancy permits a pregnant woman ample time to deal with psychological and practical issues before she must confront decisions.
The principle of justice implies that health care professionals should act in accordance with the best interest of the community. As health care costs increase, insurance costs skyrocket, and bankruptcy becomes associated with chronic illness, the societal aspects of medical justice are receiving more attention. The traditional focus of medical ethics is the individual patient. In some cases, however, the costs and benefits of treating one patient may place an undue burden on others. An individual ethical focus may be in conflict with a society focus when an individual uses a disproportionate amount of health care without paying for it. This forces others to pay for the service—a burden that society accepts if the service is considered essential. However, as the benefit of the service decreases, as in experimental protocols, or as the cost of the service increases, the conflict grows. If the resources used are not replaced, others may be deprived of similar services. The solution to such conflicts is not clear politically, socially, or ethically. What is clear, however, is that the community aspect of justice will receive more attention in the future. Sonographers can support community interests by performing only medically indicated procedures prescribed by a clinician.