*Radiologic Technologist, Hillsboro, Oregon.
Address correspondence to: Susan Castanette, RT(R)(BD), 2459 SE Tualatin Valley Highway, PMB 433, Hillsboro, OR 97123. E-mail: firstname.lastname@example.org.
Disclosure Statement: Ms Castanette reports having no significant financial or advisory relationships with corporate organizations related to this activity.
Ethics encompasses a variety of issues that all medical professionals, including medical imaging technologists, must ultimately tackle. When considering ethics, medical imaging professionals need to take into account their responsibilities to patients, colleagues, employers, the imaging profession, and themselves. This article will review these responsibilities with respect to medical imaging and the challenges that imaging technologists may face in approaching their work from the perspective of sound ethics.
Those of us in medical imaging rarely have to deal with serious ethical issues, such as end of life decisions, organ donation, do not resuscitate orders, and other strictly ethical issues. However, our attitudes, actions, and decisions in even the most minor aspects of daily practice can greatly affect patient care. Clinicians and hospital staff sometimes encounter ethics on a corporate level. For instance, Tuality Community Hospital developed 6 "Standards for Success" that are used during the hiring process, during yearly reviews, and in other areas of the hospital's management. As a result of these standards, employees are held accountable to model Integrity, Compassion, Quality, Commitment, Fiscal Responsibility, and Customer Satisfaction in the workplace. This article will review basic ethics concepts that are pertinent to the field of medical imaging and will discuss the ethical treatment of patients, colleagues, employers, the medical imaging profession as a whole, and, just as importantly, the ethical responsibilities that medical imaging technologists should have in their treatment of themselves.
Established Codes of Ethics
Every branch of the medical profession, including the medical imaging field, has its own code of ethics, and one can drill down to the ethical aspects of routine patient care in radiologic imaging. The American Registry of Radiologic Technologists (ARRT) has developed a Standard of Ethics document,1 and the ARRT and American Society of Radiologic Technologists (ASRT) have jointly developed the Radiologic Technologists Code of Ethics, which includes the following mandates2:
In addition, the ASRT has also developed a Radiation Therapist Code of Ethics3:
The Code of Ethics documents and practice standards for all areas of medical imaging are available through the ASRT Web site (http://www.asrt.org/).
Basic Medical Ethics Concepts
Four basic concepts are in play when considering medical ethics: beneficence, non-maleficence, respect for patient autonomy, and justice. Each concept is described below.
Beneficence is a duty to promote good, to act in the best interest of the patient, and to act in the best interest of society. One can consider beneficence as an active aspect of ethical consideration, representing not just what we think, but what we do in daily practice.
Non-maleficence is a duty to do no harm to patients or society. Although all physicians take a Hippocratic oath that holds them to this idea of doing no harm, not all medical schools use the same Hippocratic oath. Here are some surprising facts: 100% of current oaths pledge a commitment to patients, but only 43% vow to be accountable for their actions, and only 3% prohibit sexual contact with patients.4 The American Medical Association ethics division does not endorse any version of the Hippocratic Oath.5 Meanwhile, the British Medical Association has worked to develop a modern Hippocratic oath.6
Respect for Patient Autonomy
Clinicians must demonstrate a respect for patient autonomy, in that they have a duty to protect the patient's ability to make informed decisions about his or her medical care.
Justice comes into play in medical ethics because clinicians have a duty to be fair to the community as a whole, and to protect and promote the fair distribution of healthcare resources. However, this is often beyond the realm of the normal responsibility of medical imaging personnel because we have little control over insurance limitations, state covered health plans, Occupational Safety and Health Administration or Workman's Compensation cases, or other routine opportunities to make decisions that affect our wider community.
Although many aspects of medical ethics are beyond the scope of the imaging professional, there are daily opportunities to provide services that reflect sound ethical practice. Ethics can be approached from a variety of perspectives, and we find ourselves responsible for the ethical treatment of our patients, our colleagues, our employer, our profession, and ourselves as individuals. Medical imaging technologists should keep these issues in mind in their daily practice and interactions with patients, keeping in mind how our responsibilities to these different parties may impact patient care.
Ethical Responsibility to Our Patients
High Quality Examinations
When patients enter the clinic, hospital, urgent care setting, emergency department, or other medical facility, they assume and expect that everyone they encounter during the visit is a skilled professional. When imaging examinations are ordered, they have a right to the highest quality examination that the imaging technologist can provide. Imaging technologists should respect the fact that the imaging examination is a major factor in the patient's diagnosis and can therefore, substantially affect subsequent medical care. Imaging technologists are human and, similar to any other medical technologist, their work can be affected by fatigue, long shifts, and internal politics. Despite these potential distractions, we have to always remember our responsibility to the patient. Although our images do not always have to qualify for Merrill's, we should always strive to deliver the best quality images for the sake of a patient's care.
The medical imaging technologist is usually the one associate within the imaging department who will have the most contact with the patient and the most opportunity for communication. The radiographer, sonographer, mammographer, computed tomography (CT) technologist, magnetic resonance imaging (MRI) technologist, nuclear medicine technologist, and radiation therapist are the professionals who talk to the patients, touch them, position them for the examination, and give them an explanation of what to expect during the procedure. Often, the radiologist has no physical contact with the patient, and therefore, medical imaging technologists are a vital link between the patient and the radiologist. Our communication with the patient is of the highest importance. It is our duty to take enough clinical history to provide the radiologist with the necessary information to contribute to an accurate diagnosis. For instance, a medical imaging technologist may encounter an order for a chest X ray that just gives a clinical reason as "pain." However, when asking the patient about his or her pain, the patient reveals additional symptoms, such as shortness of breath, heart palpitations, or other symptoms that can affect diagnosis and the urgency of treatment. It is the responsibility of the medical imaging technologist to capture relevant patient information and contribute to the report sent to the radiologist. The ASRT Code of Ethics recognizes this important role, stating, "the Radiologic Technologist acts as an agent through observation and communication to obtain pertinent information for the physician to aid in the diagnosis and treatment of the patient."2
The other side of the issue of communication is our effectiveness in relaying information to the patient. When physicians refer a patient for imaging studies, they sometimes explain very little about the actual procedure that they have ordered. For instance, a physician may tell the patient that he requires an "X ray" while neglecting to explain that it is a small bowel follow through procedure that will take at least 2 to 3 hours. Furthermore, patients may be unprepared for the claustrophobia of the MRI table, the repeat visits required to film the nuclear medicine examination, the compression on their first mammogram, and the other myriad discomforts and inconveniences inherent in medical imaging.
Adequate communication and diagnostic care may not only improve patient comfort and satisfaction, but may also reduce the risk of substantial complications or accidental death. In fact, the 2008 Joint Commission Resources (JCR) has identified communication and patient assessment as the 2 top factors contributing to sentinel events, which are defined by the JCR as events that have "resulted in an unanticipated death or major permanent loss of function—not related to the natural course of the patient's illness or underlying condition."7 In other words, patient deaths during hospitalization due to an acute myocardial infarction or terminal cancer are not considered sentinel events. Meanwhile, death or permanent impairment due to an allergic reaction to a drug that was administered during a routine hospital admission because someone responsible for the patient's care neglected to notice the drug allergies listed in the chart would be characterized as a sentinel event. Obviously, communication plays a critical part in preventing these events.
Compassion and Respect
As medical professionals, we are required to treat all patients with the same level of compassion and respect. This starts with listening to them—really giving them the time to tell us about how much pain they are in, what their current state of fear may be, how confused they are about what is happening. Regarding pain level, many facilities use standardized pain scales that help patients rate their pain for both adults (Figure 1)8 and children (Figure 2).9 Medical imaging technologists also can ask simple questions, such as, ‘How recent was your surgery? Is there a way we can move you that would be less painful? Has the pain medication taken effect yet?" Even though we should inform the patient that we are unable to make the examination entirely pain free, we can still communicate that we care and are making our best effort to alleviate the patient's pain.
Medical imaging technologists should also keep in mind that although the examinations that we perform are familiar to us, the patient may be experiencing this type of test for the first time. We need to practice with a conscious awareness of the patient's potential state of fear or confusion. Patients may be afraid of their own diagnosis, expecting the worst. They may have had a relative or friend who died of the same disease, someone who had a negative experience in our facility, or just a general fear of the unknown. We can assist patients by clearly explaining what is going to happen during the test, providing a realistic estimate of how long the procedure may take, and giving them professional and calming answers to their questions and concerns. This is where we can practice the third basic concept of medical ethics, protecting the patient's right to make informed decisions about his or her medical care.
Some patients may also have physical or emotional challenges that we need to respect. Is the patient weak, hard of hearing, or developmentally challenged? It is the duty of all caregivers, including the medical imaging technologist, to take all of these possibilities into account, and to treat the patient according to his or her own abilities. We also must consider both cultural issues and family member expectations. Often, our ability to provide effective communication, patience, and respect toward the families of our patients is what they remember most. Furthermore, these aspects of care can promote health and healing while providing a more positive experience for our patients. In addressing important cultural issues in medical care, staff education on cultural competency is now prevalent, but should be geared toward the specific population demographics served by the institution to be truly valuable.
Every medical facility and many state laws incorporate nondiscrimination policies that are reflected in ethics codes. Most codes are designed to ensure that all patients are treated with equal care, compassion, and skill. The ASRT Code of Ethics #3 states, "The radiologic technologist delivers patient care and service unrestricted by concerns of personal attributes or the nature of the disease or illness, and without discrimination on the basis of sex, race, creed, religion, or socioeconomic status."2 Although most medical professionals are well aware of the "big issues" of non-discrimination, healthcare providers should still be careful and examine actions and motives on a deeper level, recognizing factors that could potentially result in the treatment of one patient with less compassion or respect than another. Whatever the source of an underlying prejudice or reluctance to engage with the patient, imaging technologists need to remember their ultimate responsibility to provide unbiased care. Every patient deserves the best examination possible. As such, all medical professionals need to move beyond bias and treat all patients with equal respect and care.
Right to Refuse Medical Treatment
Patients always have a right to know what treatment they are about to receive, and refuse this treatment if that is their choice. This can be an area where medical imaging technologists have to walk a fine line. To act in the best interest of the patient, the technologist should give the patient as much information as possible, communicate how important the diagnosis might be, and urge the patient to consider carefully any possible diagnostic or treatment alternatives. Although we can sometimes help patients move beyond their fears or concerns and agree to an examination, we should still understand that no means no when it comes to the refusal of medical care.
Right to Radiation Protection
Radiography programs teach the principles of "as low as reasonably achievable" in delivering diagnostic services, with the 3 key aspects of radiation protection being time, shielding, and distance. State rules regarding radiation protection vary, but Oregon has clear Administrative Rules about gonadal shielding, holding patients during exposures, and tracking the use of fluoroscopy dosages.10 Medical facilities track radiation exposure to ensure compliance with these laws. Tuality Community Hospital's Radiation Safety Committee asks for a quarterly report of fluoro usage, and technologists receive a quarterly report on the percentage of their patients who were properly shielded. All of these practices work toward protecting the patient from excessive radiation, as well as protecting medical imaging personnel.
Also, the Alliance for Radiation Safety in Pediatric Imaging has released the Image Gently Initiative that calls attention to important issues in radiation exposure during pediatric imaging.11 This program focuses on CT scanning because of the substantial increase in the modality in recent years and the resulting increase in radiation doses to pediatric patients. CT is fast, provides a wealth of diagnostic information, and is sometimes the best diagnostic choice in a particular clinical situation. Because younger patients are more radiosensitive, it is natural and appropriate that the debate on the relative risks and benefits of imaging modalities begins with our pediatric patients. However, all patients, regardless of age or any other factor, deserve the best imaging examinations with the least possible radiation dose.
HIPAA and Personal Privacy
The Federal Health Insurance Portability and Accountability Act (HIPAA) laws12 initially resulted in many severe measures to ensure patient privacy, but the pendulum has now swung back to a more reasonable approach. Many sound practices are now in place to cover protected health information (PHI). Legally, medical personnel have a right to access PHI for treatment, planning, and operations. PHI can also be shared legally when it relates to a crime or child abuse, or when the patient threatens serious self-harm or harm to someone else. Still there can be times when we are tempted to access information that violates an individual's right to privacy. Under HIPAA guidelines, an employer "must have and apply appropriate sanctions against members of its workforce who fail to comply with privacy policies."12
The medical imaging technologist should be provided with a variety of resources to ensure patient safety. These may include gait belts, walkers, step stools, or may be as simple as the guardrails on the stretcher. We cannot afford even a momentary lapse in our attention to patient safety. Medical imaging technologists should recognize that keeping our patients safe and unhurt also protects us from both physical and legal standpoints.
Ethical Responsibility to Our Colleagues
Regardless of whether professionals work in a small office with 1 or 2 coworkers, or in a large trauma hospital with a staff of a thousand, the way we treat each other shapes the culture of the workplace and has a direct impact on the patient's perception of the facility and the quality of patient care.
Medical professionals have a profound responsibility to treat coworkers with respect and professionalism. It is not necessary to be the best of friends, but too often, staff members expect management to control the work environment and "police" staff interactions, when in fact it is every individual's responsibility. Working together as a team and having positive interactions optimizes patient care. These practices also have a substantial positive impact on employee morale and retention.
Point #10 in the ASRT Code of Ethics states "The radiologic technologist continually strives to improve knowledge and skills by participating in continuing education and professional activities, sharing knowledge with colleagues, and investigating new aspects of professional practice."2 The saying, "It's a good day if you can learn 1 new thing," applies equally to a technologist who graduated 1 month ago, or one who has been in practice for 35 years. All medical professionals should be encouraged to never stop learning and should recognize the potential for new professional interactions from new employees, a traveler, or even a student visiting on a clinical rotation, to demonstrate an entirely new way of accomplishing a good image. We all have something to share and something to learn.
Have Fun in the Workplace
Is having fun an ethical responsibility? Maybe not, but it can make coming to work something that everyone can look forward to. Whether it is the guy who breaks into his "air guitar" routine during the slow times, the prankster who posts funny pictures on the front of your locker, or any other way that we can make each other smile, it adds to our connection with our coworkers. Ultimately, we are not only providing our coworkers and ourselves with a better work environment, but the patients notice the positive (or negative) energy associated with the facility.
Ethical Responsibility to Our Employer
When an employee takes a job with a new employer, he or she is in essence entering into a contract to provide agreed-upon job responsibilities for agreed-upon compensation and benefits. Both parties need to carry out their part of the bargain.
Dependability and Attendance
If one worker out of a group is constantly late or absent, how does that affect the morale and work attitudes of the rest of the team? We all know the answer—there will be griping and mistrust of management because one person gets away with this and the rest of the staff picks up the slack. Medical professionals owe it to themselves and their employer to avoid this kind of tension in the workplace.
Distractions, Distractions, Distractions
Our world is one of constant communication and stimulation. We are used to being in touch, online, or constantly reachable for our friends and family. Unfortunately, this mindset is just not feasible when working in a busy imaging department. The use of personal cell phones is a huge issue—can we carry them while on duty, answer personal calls, send text messages? Ask yourself, is this how my employer is paying me to spend my time? Some medical offices have instituted policies that restrict cell phone use, and are ultimately respectful of both the patient and the doctor and the time dedicated to health issues. Many hospitals or clinics require patients to turn off or not answer cell phones during appointments. If we expect that of our patients, surely we should hold ourselves to the same standards.
The Internet is another possible distraction. Depending on the policy of your workplace, you may or may not be able to access outside Web sites, personal e-mail, and other potential online distractions. Of course the only time to ethically engage in Internet activity not related to work is during breaks or lunch.
When downtime occurs, those with a good work ethic will look for ways to stay productive. This could mean making sure that rooms stay stocked, paperwork is filed, and interoffice e-mails are addressed. Personal calls and e-mails should be saved for the break time.
Productive Complaints and Positive Contributions
Every workplace has room for improvement, and most of the best suggestions for change come from the frontline workers. A manager can never be aware of all the things that happen during all shifts and relies on staff to communicate workflow problems. Keep in mind that medical imaging technologists who identify a problem should be prepared with possible solutions. There will always be workplace factors that can be an annoyance or hindrance to us doing our jobs, and medical imaging technologists cannot expect that their employer can create the perfect workplace.
Opportunities for improvement may be identified in the work process, the work environment (physical), or the workplace environment (social). Effective changes to the work process might impact the flow of paperwork, staff rotations, or other administrative aspects of the facility. Aspects of the work environment include the physical arrangement of computers, cassette storage, and portable instruments; keeping enough materials, such as positioning accessories, stocked; and making decisions regarding new equipment installations. A good administrator will gather feedback from the patient care staff when planning for these decisions that impact the work environment.
The workplace environment is harder to define. Do we have monthly potlucks to honor the birthdays that month, and who does the work to organize them? Who volunteers to work the extra shift when someone calls in sick for the dreaded graveyard coverage? Which coworkers are always flexible to trade a shift with you so you can see your son's last football game of the season? These seemingly little things are really what contributes to that the sense of teamwork in the workplace sought by all medical professionals.
Ethical Responsibility Toward Self
Although it is important to consider our responsibilities to patients, our colleagues, and our employer, it is just as important to treat ourselves ethically in the workplace.
Physical Health and Safety
Many of the same practices that are followed to keep our patients safe also protect our own safety. Proper ergonomic and body mechanics when moving patients or equipment allow us to work without hurting ourselves and allow us to stay in the field of medical imaging for the length of our desired career. We also can make lifestyle choices, such as not smoking, getting the proper exercise, getting enough sleep, and eating a healthy diet. All of these healthy habits will keep us in shape for our challenging and physical careers in medical imaging.
No one wants to be involved in a legal suit against their employer or themselves. Medical imaging technologists should protect themselves from legal issues by following facility policies, communicating effectively with coworkers and patients, and acting only within the scope of their practice.
Finding the right fit between a person and his or her job is a critical responsibility of both the employer and the employee. Every workplace has a distinctive personality. One technologist who is bored to death in a small clinic may thrive in a busy trauma center, whereas another technologist who is overwhelmed in the busy hospital environment might feel at home in an orthopedic or podiatrist office. We all have our own comfort levels and our own desires for our career. Medical imaging technologists should recognize that they are responsible for finding the workplace that best suits them. Conversely, they also should be willing to recognize the need to move on if the workplace does not fit them.
Ethical Responsibility Toward Our Profession
Medical imaging technologists are daily representatives of the imaging profession as a whole. Consequently, the public may base their judgment of the entire imaging profession based on one experience with one technologist. Therefore, all technologists should recognize their role as ambassadors of the medical imaging field.
Ethical Responsibility Is Always a 2-Way Street
It is important to recognize that in clinical and workplace interactions, all of the relevant parties carry a certain degree of ethical responsibility.
From the patient: We require an honest medical history, respect, and cooperation. Patients who are unhappy or uncomfortable with the need for testing may become belligerent. These patients may engage in offensive verbal language and angry outbursts. If we can maintain our composure and approach these individuals with a professional demeanor, we may be able to control the situation, resulting in a greater degree of respect from the patient and a successful completion of the imaging study.
From our coworkers: We should expect a mirror image of all the traits that we are expected to model. These include respect, sharing of knowledge, and teamwork, among others. Sometimes problems arise when the teamwork is interdepartmental—when we are dealing with nursing staff, office managers, laboratory technicians, or other staff members. In general, respect and cooperation begets respect and cooperation. It may take time, but building rapport with other departments can vastly improve our work experience, as well as the experience of the patients treated through our practice.
From our employers: We enter into a legal agreement with our employers, and their ethical responsibilities are just as great as ours. We have the right to the following expectations:
From our profession: In general, any personal investment in our profession can be returned many times over by providing a livelihood and a career, in addition to meaningful experiences, the opportunity for lifelong learning, and valuable friendships.
As medical imaging technologists, our everyday choices of actions, attitudes and interpersonal communications can have a great impact on patient outcomes. After all, the opportunity to impact patient's lives while realizing a satisfying career is a likely reason behind most technologists' decision to practice in this field. Ultimately, though, we should all remember that our practice is all about the effective delivery of patient care.
Professionals interested in additional information on medical ethics and relevant issues in medical imaging are encouraged to access the following resources:
American Registry of Radiologic Technologists (ARRT®) Standards of Ethics
American Society of Radiologic Technologists (ASRT) Code of Ethics
Image Gently Campaign of the Alliance for Radiation Safety in Pediatric Imaging
1. American Registry of Radiologic Technologists. ARRT® Standards of Ethics. Available at: http://www.arrt.org/ethics/standardethic.pdf. Accessed June 15, 2008.
2. American Society of Radiologic Technologists. ASRT Code of Ethics. Available at: https://www.asrt.org:/content/RTs/CodeofEthics/Code_Of_Ethics.aspx. Accessed June 13, 2008.
3. American Society of Radiologic Technologists. ASRT Radiation Therapist Code of Ethics. Available at: https://www.asrt.org:/media/pdf/rt/rtcodeofethics.pdf. Accessed June 20, 2008.
4. Gersten DJ. The Modern Oath of Hippocrates. Available at: http://www.imagerynet.com/hippo.ama.html. Accessed June 18, 2008.
5. American Medical Association. Frequently asked questions in ethics. Available at: http://www.ama-assn.org/ama/pub/category/5105.html. Accessed June 17, 2008.
6. Berwick D, Hiatt H, Janeway P, Smith R. An ethical code for everybody in health care. BMJ. 1997;315:1633-1634.
7. Joint Commission Resources. Sentinel Event Resources. Available at: http://www.jcrinc.com/29376/. Accessed June 16, 2008.
8. American Geriatrics Society. The management of chronic pain in older persons: AGS Panel on Chronic Pain in Older Persons. J Am Geriatr Soc. 1998;46:635-651.
9. Wong DL, Hockenberry-Eaton M, Wilson D, et al. Wong's Essentials of Pediatric Nursing. 6 ed. St. Louis, MO: Mosby; 2001.
10. Oregon Administrative Rules. Oregon Department of Human Services, Public Health Division. Division 106: X-Rays in the healing arts. Available at: http://arcweb.sos.state.or.us/rules/OARs_300/OAR_333/333_106.html. Accessed June 16, 2008.
11. Alliance for Radiation Safety in Pediatric Imaging. Image gently. Available at: http://www.pedrad.org/associations/5364/ig/. Accessed June 13, 2008.
12. Health Insurance Portability and Accountability Act of 1996. Available at: http://aspe.hhs.gov/admnsimp/pl104191.htm. Accessed June 13, 2008.
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