Principles of Beneficence and Nonmaleficence

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Principles of Beneficence and Nonmaleficence




Learning Objectives


After completing this chapter, the reader will be able to perform the following:


• Distinguish between beneficence and nonmaleficence.


• Identify the four conditions used to assess the proportionality of good and evil in an action.


• Demonstrate an ability to make appropriate decisions by applying the principles of beneficence and nonmaleficence.


• Identify medical indicators involved in imaging.


• State the imaging professional’s role in doing good and avoiding evil.


• Provide patients with the knowledge necessary to ensure their participation in decision making.


• Identify and define the legal concept of standard of care.


• List the many sources of standards of care.


• Define negligence, medical negligence, and res ipsa loquitur.


• Identify methods to decrease risk, including documentation, technical detail issues, radiation protection, and safety.


• Identify and justify which information is appropriate and inappropriate for documentation.



Key Terms




Professional Profile



The ethical and legal issues that face radiographers take on new dimensions as technologic advances are made. Issues of patient confidentiality have become a greater concern in my practice as a radiographer and educator because of changing methods of communication. Today radiographers have access to more personal information that has the potential to do harm, and we must be cautious in how and when we communicate about our patients’ health and personal status. Just because I have access to patients’ medical records, that does not mean I have permission to read their private information. As a patient myself, I view the confidentiality statement as a contract ensuring that my information is private and confidential. It is my responsibility to provide the same level of assurance to patients. The use of electronic transmission of confidential information requires me to be mindful of the profession’s code of ethics and my moral and legal obligation to protect each patient’s and student’s right to privacy.


Students and patients make assumptions about the ethical standards that guide my practice. Because I bring earned credentials to my job, they believe I will treat them fairly, ethically, and within the standards of practice. This is a level of expectation I wish not to disappoint.


Advancements in radiographic equipment have created an environment in which it may seem that the technology can select and administer the radiation and that, as long as the images are of diagnostic quality, the amount of radiation exposure to patients is incidental. Students and radiographers must be more diligent than ever in selecting radiation exposure techniques to maintain the “as low as reasonably achievable” (ALARA) principle. Radiographic imaging is a major contributor to patients’ radiation exposure, and the use of medical imaging for diagnosis and treatment continues to increase.


When computed radiography was introduced into our radiology department, we were not knowledgeable about this technology and how it would affect our exposure techniques. Because we focus on producing high-quality radiographs, the use of more radiation exposure than needed could easily become a routine. As a radiographer, I have a moral and ethical obligation to understand the new equipment, use it properly, and limit the amount of radiation exposure during procedures. Attending educational seminars makes me more knowledgeable, and consciously thinking about the radiation exposures selected improves my ability to produce high-quality radiographs at reasonably low exposures.


Taking professional responsibility for each patient, including the quality of procedures, privacy, confidentiality, and limits on radiation exposure, must be foremost in my daily activity as an imaging professional. As an important member of the team, the radiographer plays a critical role in setting and maintaining high ethical and legal standards for health care.




ETHICAL ISSUES


Health care decision-making processes require the consideration of all aspects of a problem. When the health care team and patient must decide whether to proceed with an invasive imaging procedure or drastic surgery, the team must intend good for the patient. Moreover, they must consider whether this good outweighs the risks of evil consequences.


Two integral components of decision making in medical ethics are beneficence, or the performance of good acts, and nonmaleficence, or the avoidance of evil. These two definitions may sound similar, but a closer examination reveals distinctions between the two.


This chapter explores beneficence and nonmaleficence and the ways they relate to the roles of the imaging professional and patient. It also considers justice and patient autonomy and the ways in which pursuit of those values may conflict with the ideals of beneficence and nonmaleficence.


Society expects health care professionals to “do good” and thus aid patients. This has long been an expectation of health care professionals; indeed, the Hippocratic Oath begins with the exhortation, “First, do no harm.”


This good encompasses proper behavior within “law, custom, relationship, and contract.”1 State and federal laws, which presumably have been based on moral and culturally virtuous processes, may give the health care professional defined guidelines within which to do good as society sees matters. For example, society perceives caring for sick people and supplying high-quality imaging services as inherently good. Custom further helps define good behavior based on repeated patterns within the society. Relationships between individuals, individuals and institutions, and individuals and society also contribute to a definition of good within a society. In addition, the contractual process may indicate an individual’s conception of a good act.



IMAGING SCENARIO


A 4-year-old boy with Down syndrome is scheduled for a cardiac catheterization. The completed test shows a defect that will drastically limit his life expectancy if left untreated. The pediatric cardiologist does not recommend surgery because of the child’s low intelligence quotient (IQ).


The child’s parents are afraid their son will outlive them if he has the surgery. A vascular imaging technologist who assisted with the cardiac catheterization is horrified when she finds out the young child will not be operated on because of low IQ and quality-of-life decisions made for the child by others. She wonders whose good the parents and physician are considering and in what way they arrived at such a decision.




PROPORTIONALITY


The avoidance of all evil is impossible. Because of this, society tends to value the utilitarian theory described by philosopher John Stuart Mill in which the ideal is to do the most good for the most people. In the achievement of good, however, people may be subjected to its opposite—harm. For example, chemotherapy may achieve its goal of curing cancer only after causing pain, nausea, and hair loss. Individuals and society therefore need to determine the amount of harm or evil that may be tolerated. To make this determination, society often applies the principle of double effect, which states that a person may perform an act that has evil effects or risk such effects as long as four conditions are met:





1. The action must be good or morally indifferent in itself. For example, a proposed imaging procedure must help the patient or at least not cause harm.


2. The agent must intend only the good effect and not the evil effect. That is, the imaging technologist must intend for the imaging to aid in the health care process, not injure the patient or cause pain.


3. The evil effect cannot be a means to the good effect. This condition may be complicated for the imaging technologist. The patient may believe the imaging procedure to be an evil effect; however, to gain a diagnosis, or good effect, the patient may have to undergo an unpleasant examination.


4. Proportionality must exist between good and evil effects. The good of the procedure must at least balance with the unintended pain or discomfort.


To conform to the principle of proportionality, “the action should not infringe against the good of the individual. There also has to be a proportionate good to justify the risk of an evil consequence.”1 The following questions may be used to define proportionality:





NONMALEFICENCE


Nonmaleficence, or the avoidance of evil, hinges on a system of weighting. Nonmaleficence does not require individual action. It only requires that the imaging professional do no harm. The good desired must outweigh the risk of evil. For example, the performance of a balloon angioplasty offers the patient the great good of opening the coronary artery and enhancing the patient’s quality of life. However, the health care team and patient must consider the risk that plaque will dislodge within the artery and produce myocardial infarction, stroke, or death. The team weighs the possible good and evil outcomes of the procedure by assessing the patient’s physical condition and his or her mental and emotional ability to understand the risk and significance of the possible harm. If the patient is otherwise healthy, the intended good usually outweighs the unintended evil; if the patient already has suffered heart damage or has serious respiratory disease, however, the evil consequences may overshadow the intended good. Both the performance of good and the avoidance of evil benefit the patient. A decision must be made by weighing both good and evil.





DIFFERENCES BETWEEN BENEFICENCE AND NONMALEFICENCE


Beneficence and nonmaleficence differ in the degree of force each possesses. The stronger action of the two is nonmaleficence, or the avoidance of harm; beneficence, or the performance of good, is weaker. Although the interest of imaging professionals is in doing good, they must not cause harm while doing so. This is a vital consideration in the practice of imaging. For example, an elderly patient may have arrived in the imaging department for a thoracic spine image. The patient has a kyphosis and is crippled with degenerative arthritis and finds lying on the table intolerable. The guiding principle in this case may be to do no harm, even at the expense of the patient’s receiving the good of the diagnostic image. Decisions in health care should be made after consideration of both beneficence and nonmaleficence.


Although beneficence and nonmaleficence are both important considerations in patient autonomy, they differ in the way they are practiced. Beneficence is an active process, whereas nonmaleficence is passive (Table 2-1). This difference is evident in the scenario on p. 32.




MEDICAL INDICATIONS INVOLVING PRINCIPLES OF BENEFICENCE AND NONMALEFICENCE


Jansen, Siegler, and Winslade2 provide six points to consider when dealing with issues of beneficence and nonmaleficence. With some modifications to suit imaging situations, these are the points:




JUSTICE


For imaging professionals, justice, or the principle of fairness, requires the performance of an appropriate procedure only after informed consent has been granted. Informed consent is permission, usually in writing, given by a patient agreeing to the performance of a procedure. (Issues of informed consent are discussed more fully in Chapter 4.) Conflicts among beneficence, nonmaleficence, and autonomy (the state of independent self-government) may arise during consideration of principles of justice. The general belief in the right to health care brings beneficence and nonmaleficence into conflict with autonomy and justice. Although most people believe that the good of health care should be available to all, health care resources are limited and hard decisions must be made about their allocation. Limited resources reduce the overall quality of care and may lead to less avoidance of evil. When quality of health care is reduced, the patient’s autonomy suffers from loss of freedom of choices. When choices are limited, the obligations of the patient and health care giver may conflict with resources and justice for the patient (Figure 2-1).


image
FIGURE 2-1 The needs of patients and care providers can conflict because of limited resources, making ethical decisions part of a professional’s daily tasks.


IMAGING SCENARIO


A female patient is scheduled for a lumbar spine imaging series. The imaging professional in charge of the examination is interrupted and called to the emergency room to care for victims of a massive accident. Another imaging professional arrives to take over the examination before the initial exposure is taken. When asked if everything is ready, the first technologist says yes and hurries to the emergency room. The second imaging technologist surveys the patient, who is covered with a sheet, introduces himself, and performs the lumbar spine series. The processed images reveal that the woman is in her first trimester of pregnancy. Obviously, an injustice has been done, and a lawsuit may possibly result.




The performance of good and the avoidance of evil often come into conflict when medical indication principles or the proportionality of consequences is judged by the health care provider. The medical indication principle states that, “granted informed consent, the physician should do what is medically indicated such that from a medical point of view, more good than evil will result.”1


The conflict between beneficence and nonmaleficence on the one hand and informed consent and patient autonomy on the other may be explored further by asking how, if the health care professional cannot make quality-of-life decisions concerning patients but must make recommendations concerning good and evil, decision making can lead to patient autonomy. For example, an imaging professional may be asked to give an imaging examination to a neonate in intensive care. The infant has the majority of its organs outside the abdomen, including a massive spina bifida. The imaging professional wonders why the infant’s life is being maintained by artificial methods. This question, however, is an issue for the family. It is not the imaging professional’s responsibility to make quality-of-life decisions for others.




SURROGATE OBLIGATIONS


Surrogate obligations present another area of conflict. The interactions among patient autonomy, beneficence, and nonmaleficence become even more complex in these situations. If the patient is incompetent, either the best interests of the patient or the rational choice principle should be used. The rational choice principle “commands that the surrogate choose what the patient would have chosen when competent and after having considered all available relevant information and the interests of the relevant others.”1 In a determination of the best interests of the patient, the proportionality between good and evil may be different for patient and surrogate; this may interfere with patient autonomy. In this situation the surrogate must consider the patient’s and perhaps significant others’ attitudes regarding good and evil consequences.



IMAGING SCENARIO


A 6-year-old boy arrives in the emergency room (ER) after being found floating face down in the neighbors’ pool. The ER imaging professional is called in to take a portable chest x-ray. The child has been receiving cardiopulmonary resuscitation. No one knows how long he was without oxygen. He is nonresponsive, and the staff continues to work on the child. The radiograph is completed. When the radiographer returns, the child has a heartbeat and is receiving mechanical ventilation. He does not regain consciousness for a month. When he does awaken, he cannot communicate and is believed to have severe brain damage.




IMAGING SCENARIO


A young boy who has fallen from a tree is brought to the emergency room (ER), and x-rays of his shoulder and humerus are ordered. He is in pain and cannot move his arm. The student radiographer hesitates to move the youngster’s arm because she knows it will cause significant pain. The ER doctor is waiting for the film and is becoming vocal about the time it is taking to complete the exam.




Imaging Professional’s Role


The imaging professional must be aware of the obligations to do good and avoid harm. Every imaging procedure has the potential to harm the patient; invasive procedures, radiation, and equipment malfunction all pose dangers to the patient. Maintaining a high quality of patient care and technologic skills helps ensure that procedures achieve good for the patient, and practicing protective measures aids in the avoidance of harm (Figure 2-2). Each imaging professional must be responsible for daily contact with patients undergoing diagnostic health care procedures.


image
FIGURE 2-2 Safe transport of patients to, from, and within the imaging department is one way of showing both beneficence and nonmaleficence. From Ehrlich RA, Daly J: Patient care in radiography, ed 6, St Louis, 2004, Elsevier.



LEGAL ISSUES


The ethical concepts of beneficence and nonmaleficence may not generally be thought of as connected with legal theories involving health care. However, these concepts—the doing of good and avoidance of harm—are incorporated into the duty of a health professional to do no harm and provide reasonable care to the patient. This section explores the legal concept of standard of care. The reasonable care that is expected is defined and the negative results when less than reasonable care is provided are discussed.




This section provides some methods to ensure that reasonable patient care is provided and litigation risk is decreased. Included in these methods are documentation, technical detail issues, radiation protection, and safety issues.



STANDARD OF CARE


The law provides many parameters for the delivery of imaging services. These parameters have evolved from statutes (laws written and enacted by state or federal legislatures) and court decisions. The most basic legal parameter in health care is the standard of care, which encompasses the obligation of health care professionals to do no harm and their duty to provide reasonable patient care. Each profession establishes standards of care to define the parameters within which that profession is obligated to practice. Standards of care are not limited to the imaging services but exist for all other health care providers in the facility, the physicians, and the facility itself.


The legal standard is the degree of skill or care employed by a reasonable professional practicing in the same field.3 Lack of training or experience is not an excuse for the failure of a health care professional to perform a duty to the patient adequately. For example, imaging professionals working as nuclear medicine technologists are held to the same standard of care as trained and certified nuclear medicine technologists. If the appropriate standard of care is violated, liability may be imposed on both health care professionals and medical facilities.



Professional Standard of Care


Practice standards, educational requirements, and curricula developed for the medical imaging sciences all help to establish the standard of care to which imaging professionals must hold themselves. The practice standards for health care specialists are set forth by that discipline’s national professional organization. Practice standards are important because they are recognized as the authoritative basis of a profession. Specific practice standards exist for each subspecialty of imaging, including cardiovascular-interventional technology, computed tomography, magnetic resonance imaging, mammography, nuclear medicine, radiation therapy, radiography, and sonography.4 These standards may be found on the website of the American Society of Radiologic Technologists (www.asrt.org).


The practice standards may be used to define what radiologic technologists do and how they do it. For example, health care facilities use professional standards to develop job descriptions, departmental policies, and performance appraisals. If there is a question as to whether an activity falls within the professional duties of the radiologic technologist, a radiology manager may consult the practice standards. Practice standards may also be used to hold the radiologic technologist to a certain standard of care. In the case of medical malpractice or negligence, a lawyer may use the practice standards to establish the generally accepted standard of care and show whether the professional met that level of care.4


Standards for accreditation for educational programs in radiologic sciences as defined by the Joint Review Committee on Education in Radiologic Technology (effective January 1997)5

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Feb 27, 2016 | Posted by in GENERAL RADIOLOGY | Comments Off on Principles of Beneficence and Nonmaleficence

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