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CONTINUING EDUCATION

Ethical Dilemmas in Today’s Nuclear Medicine

and Radiology Practice*
Bruce J. Barron, MD, MHA1; and E. Edmund Kim, MD2
1Department of Radiology, Division of Nuclear Medicine, University of Texas–Houston Medical School, Houston, Texas;

and 2Department of Radiology, Division of Nuclear Medicine, M.D. Anderson Cancer Center, University of Texas Health Science
Center, Houston, Texas

Throughout history, societies have developed their own codes

of ethics, including those pertaining to the practice of medicine.
T he disciplines of nuclear medicine and radiology are
experiencing the most rapid evolution of change. These
In the United States, physicians have adopted a set of ethics
changes, including the rapid technologic developments, new
based on religious values and historical teachings. We, as phy-
sicians, have been presented several codes of ethics, including
molecular models for disease processes, and new opportu-
the American Medical Association Code of Ethics and the Amer- nities and constraints in the economic practice of imaging,
ican College of Radiology Code of Ethics. Over time, we have have given the radiologic community numerous areas in
learned to appropriately apply these codes to our daily practice. which the basic principles of medical ethics are being tested
With the advent of new technologies in imaging, we may lose and challenged. Antenatal imaging has given us the oppor-
sight as to the transfer of these principles to reflect current tunity to selectively perform fetal therapy. The introduction
conditions. Recent history has shown a trend of new technology of stem cell technology has given us new opportunities to
leading to potential misuse of this technology and further lead-
treat disease and potentially select the characteristics of our
ing to stricter governmental regulations. It is the purpose of this
review to give guidelines for dealing with new technologies,
progeny. New adaptations of Stark legislation and the con-
such as PET imaging, and we describe a radiologist’s ethical cept of block leasing and other ingenious means to circum-
responsibility in a doctor–patient relationship. A historical review vent anti-kickback laws have thrown some of the radiologic
of medical ethics will lead to discussions about various issues community into a different light. The numerous codes of
affecting radiologists and nuclear physicians. To be sure, not all medical ethics have not changed much, but our adherence to
ethical situations are black and white, and therefore there are them appears to be waning. The practice of nuclear medi-
many gray areas. The opinions expressed in this article are cine and radiology includes imaging, patient management,
those of the authors and are based on extension of already
therapy, and research.
established rules of ethical conduct.
In each of these areas, there are ethical issues guiding our
Key Words: medical ethics; PET; nuclear medicine; radiology
performance and decision making. The purpose of this
J Nucl Med 2003; 44:1818 –1826 review is to demonstrate several scenarios in which ethical
decision making plays a vital part. To understand the indi-
vidual scenarios, one must be acquainted with the history of
medical ethics and the basic principles underlying the var-
May the love of my art motivate me at all times, may neither ious codes of ethics.
avarice or miserliness, nor thirst for glory or a great reputation Understanding these principles will enable us to derive
engage my mind; for enemies of truth and philanthropy could ethics-based solutions to common problems in the nuclear
easily deceive me, and make me forget my lofty aim of doing medicine or radiology practice.
good. . . . Endow me with strength of heart and mind, to serve the
rich and poor, the good and the wicked, friend and foe and that I HISTORY OF MEDICAL ETHICS
may never see in the patient anything else but a fellow in pain. . . .
The first references for the admonition of physicians to
Maimonides 12th Century
heal their patients can be found in the Bible. In approxi-
mately 400 B.C., Hippocrates, the Father of Medicine, de-
Received Jan. 21, 2003; revision accepted Jul. 18, 2003.
veloped the Oath of Medical Ethics for physicians to follow.
For correspondence or reprints contact: Bruce J. Barron, MD, MHA, De- Among the key elements of this oath, physicians are told to
partment of Radiology, Division of Nuclear Medicine, The University of Texas
Medical School, 6431 Fannin, Suite 2.132, Houston, TX 77030.
honor their instructors in the medical arts, practice for
E-mail: [email protected] healthy benefit, give no deadly medicines, abstain from
* NOTE: FOR CE CREDIT, YOU CAN ACCESS THIS ACTIVITY THROUGH
THE SNM WEB SITE (http://www.snm.org/education/ce_online.html)
mischief and corruption, and maintain confidentiality with
THROUGH NOVEMBER 2004. their patients. The Jewish Talmud has numerous references

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to proper behavior of physicians and the need to do what- physicians and eventually developed into the first code of
ever is within one’s means to treat their patients. One would ethics adopted by the American Medical Association.
think that this oath alone should suffice in giving physicians The Code of Ethics was established in 1846. Particular
a road map toward ethical behavior. However, as physicians items that pertain to the practice of nuclear medicine and
began to stray from these moral codes, other more tightly radiology include: honesty, competency, duty to report
ethical codes developed. Maimonides, a Jewish scholar and fraud or deception, continued education, and consultation
physician to the Sultan of Egypt, developed the Oath of with other physicians. The heinous crimes against mankind
Maimonides. This oath places this physician as God’s em- perpetrated during the Holocaust resulted in the Nuremberg
issary to heal mankind. One of the pertinent statements is Code being introduced in 1947. To effectively prosecute
cited at the beginning of this review. Other cultures and those involved in the atrocities, a code of normal, moral
religions espoused various elements of medical ethics. For behavior had to be established to be used as a benchmark. It
example, Buddhism, born in India over 2,540 y ago, em- was against this code that Nazi doctors’ actions were com-
phasizes that the root cause of suffering lies within one’s pared. The major thrust of this code was participation in
mind. To obtain freedom from suffering, one must develop research and what proper research should consist of. Basic
the right view and practice the right action. The Sanskrit principles of research, such as informed consent, necessity
word “Shila,” or ethics, means the right way of living (1). of benefit for society, protection from injury, and qualifica-
The Buddhist aim of eliminating suffering in a compassion- tion of investigators, were established as part of this code.
ate way coincides with the objectives of medicine, and The Declaration of Geneva in 1948 adopted by the World
Buddhist clergy have been involved in care of the sick for Medical Association empowered physicians to practice in
over 2,000 y (2). Buddhism’s holistic beliefs parallel other
accordance with the laws of humanity and to respect human
branches of Indian medicine such as Aayervedic medicine.
life from conception. A newer version of this code was
The Muslim religion has also developed its own set of ethics
presented in 1964 as the Declaration of Helsinki. It was later
based on the teachings of the Qur’an. There appears to be a
revised in 2000, and key to this version was the statement
division of opinion with one group, educated and more
that “the well-being of the human subject takes precedence
modern, accepting tenets that serve science and humanity.
of those interests of science and society.” In this version,
An opposing faction is more scholarly and knowledgeable
ethics committees are urged to monitor clinical research
about Islam, but less so of medical sciences. One major
trials, and conflicts of interest are addressed. The Belmont
concept in the Qur’an is, “It is not fitting for believer, man
or woman, when a matter has been decided by G-d and His Report was presented in 1976. This provided ethical prin-
Prophet, to have any option about the decision” (3). Islam ciples and guidelines for the protection of human subjects of
fundamentally does not believe in prolonging life, as every- research. Basic ethical principles were applied to the con-
one has a predetermined life span. Whereas heroic efforts duct of medical research. The basic ethical principles dis-
for the terminally ill are discouraged, heroic measures at the cussed in this report were:
beginning of life, such as for premature babies, are encour-
1. Respect for persons: This provides 2 moral require-
aged (4). There is a separate Oath of a Muslim Physician
ments: the requirement to acknowledge autonomy and the
that was put in place in 1977. This has several similarities to
requirement to protect those with diminished autonomy.
the Oath of Maimonides and mandates caring for rich or
2. Beneficence: People are treated in an ethical manner
poor and people of their faith and those not. One other
by respecting their decisions, protecting them from
culture, the Chinese, has a very long history of medical
harm, and making efforts to secure their well-being.
ethics based on the principles of Confucianism. The core of
this principle is loving people. Believers felt that practicing 3. Justice: This mandates scrutiny of the selection pro-
medicine was a means to save people by love. A physician cess to ensure that there is a fair distribution over all
of the Tang Dynasty, Simaio Sun, emphasized “People’s classes and to prevent some classes, such as minor-
lives worth more than gold.” In medicine, benevolence ities, from being systematically selected.
means causing no harm to people and Confucianism re-
quired doctors to be cautious in the course of diagnosis and Application of these principles led to the consideration of
treatment to avoid mistakes or harm. The Canon of Medi- informed consent, risk– benefit assessment, and the selec-
cine also forbids the medical profession from taking benefit tion of subjects for research.
of temptations like sex and money (5). The practical aspects of medical ethics should not be
Although the various codes of ethics in China, India, and learned on the fly after initiating one’s practice of nuclear
the Middle East have been around for quite some time, it medicine and radiology. For a host of reasons, the teaching
took physicians in America a longer time to develop ethical of ethics should begin long before. Some medical schools
standards. have developed excellent programs to teach ethics. The
Sir Thomas Percival published a code in the 18th century. process of learning to be ethical does not involve a list of
This code of medical ethics was adopted by many American things that one should or should not do. It is an evolution of

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experiences and practical solutions that make teaching of CODE OF ETHICS

medical ethics effective. Richard Gunderman, in his article The 2001–2002 ACR Code of Ethics contains principles
about teaching ethics as part of the radiology residency of ethics, rules of ethics, and disciplinary procedures. The
curriculum, mentions 7 reasons for doing so (6). There is a following is a summary of the principles of ethics.
concern that the fractionation occurring in the field of radi-
ology will diminish common denominators between the Principles of Ethics
imaging modalities. Medical ethics is one way to unify The Principles of Ethics summarized below form the first
concerns of a multimodality department. The 7 major rea- part of the Code of Ethics of the ACR. Diverse ethical
sons are: systems have 5 ethical categories in common: the morally
imperative, the morally commendable, the morally neutral,
1. Prevention of misconduct. Nuclear physicians or ra- the morally odious, and the morally proscribed (8). The
diologists are not immune to ethical pitfalls, includ- principles described below serve as goals for exemplary
ing tampering with medical records, fraudulent bill- professional conduct, hopefully placing physicians in the
ing, financial misconduct, substance abuse, and first 2 categories above.
incompetence. Programs should avoid equating ethic 1. Render service with full respect for human dignity.
with legal issues. 2. Continual improvement in medical knowledge.
2. Explicit ethical issues such as informed consent, 3. Be aware of limitations and seek appropriate consul-
patient confidentiality, and informing patients di- tations.
rectly about their imaging results. 4. Safeguard against those physicians deficient in moral
3. Teaching ethics can help protect and promote the character.
stature of nuclear medicine and radiology. 5. Radiologists’ responsibilities extend to society in
4. Ethics foster achievement of professional excellence. general.
5. Promotes sense of professional aspiration. 6. Radiologists may not reveal confidences entrusted to
6. A good teacher can help trainees recognize and seek them or deficiencies in character unless to protect
those career aspects of their careers. welfare of the individual or the community.
7. Ethics is vital to enable trainees to situate their pro- 7. Decision to render a service by a radiologist is a
fessional lives into their personal ones. matter of the individual physician and patient choice.
8. Bond between radiologists and radiation oncologists
A. Everette James Jr. discussed several aspects of the should not be used for personal advantage.
impact of technology on the medical practice (7). The rapid Rules of Ethics
advance of imaging devices has caused legislators to put The Rules of Ethics summarized below are the second
restrictions on technology use. This was accomplished by part of the ACR Code of Ethics. These standards are re-
the requirement for certificates of need, the introduction of quired of everyone and are a directive of specific minimal
diagnosis-related groups (DRGs), the physician’s role as standards of professional conduct.
gatekeeper, and other programs to restructure the practice of
medicine. Practice guidelines and outcomes evaluations 1. Consultative opinion on radiographs or scans re-
were other methods designed to slow down the use of gardless of origin.
technology. As always, government agencies have reduced 2. It is proper for a radiation oncologist to provide
reimbursement for imaging procedures and most recently consultative opinion regarding cancer or other dis-
have slashed reimbursement for outpatient imaging proce- orders.
dures (7). As the level of technology increased, the need for 3. Radiologist should be accepted as a member of the
staff.
training or retraining in the new modalities has put a strain
4. Referral to site of self-interest is not in the patient’s
on both teaching programs and practicing nuclear physi-
best interest. Improper influence on professional
cians and radiologists. With the new constraints placed on
judgment should make effort to restructure the own-
physicians, becoming “functionally literate” in the new ar- ership of the facility.
eas has become difficult. In addition, at the same time, 5. Mutual respect of other members of the health care
lawyers have increased their awareness of these develop- team. No harassment or discrimination.
ments and have increased their litigation resulting from 6. Whatever lawful contractual arrangements with the
errors and pitfalls of these new methods. health care system are deemed desirable and nec-
The American College of Radiology (ACR) has pub- essary, ensure that the system of health care deliv-
lished a set of ethical guidelines for those who practice ery in which they practice does not unduly influence
radiology specialties. For the purposes of this article, the the selection and performance of appropriate avail-
term “radiologist” should also extend to include the nuclear able imaging studies or therapeutic procedures.
medicine physician or the radiation oncologist. 7. No agreement that prohibits medically necessary

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care or requires care at substandard levels. Radiol- integrity are seen in the framework of human rights law.
ogists should advocate cost-effective studies. The principles manifest the concern for protection of human
8. Should speedily respond to patients’ inquiries re- rights in biomedicine (11).
garding fees or financial incentive. No division of
Autonomy
radiology fees directly or by subterfuge (block leas-
By definition, the term “autonomy” means self-governing
ing).
and is associated with the freedom of the individual and also
9. Nonpartisan, scientifically correct expert testimony;
wishes for his or her future life. Autonomy also implies
no compensation dependent on outcome.
other basic characteristics, such as rationality, individuality,
10. Research reported with integrity.
independence, and moral responsibility. The term also im-
11. Should not claim as intellectual property that which
plies the capacity for individuals to make their own deci-
is not theirs.
sions about his or her own life, and thus the concept of
12. No untruthful or misleading advertising.
informed consent is a very vital one. Quoting the authors,
Disciplinary Procedures “An autonomous action means 1) freedom, 2) authenticity,
By virtue of the adopted rules and principles, the Board of 3) deliberation, and 4) moral reflection.” One area of con-
Chancellors may censure, suspend, or expel for due cause. flict occurs when dealing with before-birth and after-death
Disciplinary process is established and defined. issues, such as organ donation. In these cases, the concept of
John Armstrong discussed ethical conflicts in the context autonomy does not apply. Similarly, incompetent patients
of the humanity versus technology conflict (9). When a and minors do not have autonomy in the general sense.
patient becomes ill, he or she suffers a loss of humanity and
Human Dignity
becomes very exploitable. The duty of physicians is to
“The principle of human dignity signifies that the human
honor the patient’s humanity and develop a beneficent phy-
beings have a special position that places them over the
sician–patient relationship.
natural and biological position in nature. Human beings are
New technologies have taken a central role in patient
assigned a dignity that determines their value and position
care. The radiologist is an integral member of the patient’s
in the world.” The concepts of human dignity have been key
care team. The patient develops a relationship with the
issues in both Judaism and Christianity. This devout con-
radiologist. The range of the relationship is from a patient
cept of human life poses difficulties when discussing right-
who respects the radiologist, and may even remember his
to-life issues. The French jurist Noėlle Lenoir stated that the
name, to one in which the patient is merely an abstract
aim of bioethics and biolaw is to protect what is human—
entity. The author presents a spectrum of 7 levels of sepa-
that is, the human dignity in the technologic development
ration between the patient and the radiologist on which we
(12).
all can be found (9).
The advent of teleradiology has presented new ethical Integrity
dilemmas, and new HIPA (Health Insurance Portability and Integrity is closely connected with autonomy and dignity
Accountability Act) regulations have been developed to and concerns the integrity of the human person and person-
protect the patient’s confidentiality. Ashcroft and Goddard ality. “The human body and its parts form a sphere of
discuss several ethical issues regarding teleradiology (10). integrity that is supposed to be treated with special care and
Among these are confidentiality, security, access to a con- comprehension” (13). In this context, integrity implies the
trol of information, competence, the patient–physician rela- right to life and the right to decide about one’s own death.
tionship, interprofessional relationships, and clinicoradio-
Vulnerability
logic meetings. Mutual commitments need to be made by
This principle is considered an underlying concept in the
both parties involved, the agency transmitting the images,
ethical and legal debate about bioethical questions. It is a
and the radiologists who are interpreting them (10). Many
concept that is more difficult to comprehend. The French
radiologists are now performing “nighthawking” services
philosopher Emmanuel Le’vinas has described this concept
from abroad—for example, Australia, France, or Israel. A
as the “foundation for understanding human condition.” The
new set of rules will probably be established to regulate
human being is vulnerable and must be protected when
such practices.
confronted with possible intervention by others (E. Kim,
oral communication, June 2002).
PRINCIPLES OF MEDICAL ETHICS When we think about the term “ethics” in medicine, many
There are several basic principles inherent in almost of us have different connotations. Recently, the significance
every code of ethics written. The principles revolve around of this term has been exemplified in articles published in
the patient’s rights with regard to their body during illness weekly magazines. The thrusts of these articles concern
and even during healthy times. The principles include au- current topics of interest—namely, human cloning and ge-
tonomy, dignity, integrity, and vulnerability. The principles netic research. When physicians involved in the imaging
help to create a solid foundation for protection of human specialties are asked about ethics, many think about proper
beings. Rendtorff states that the principles of autonomy and billing and behavior in the presence of a patient. Ethics in

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the field of nuclear medicine extend way beyond the simpler tions. By doing so, we expose the patient to the risk of the
ideas we learned in medical school. It encompasses, for new medication, or even placebo, not working. Do we want
example, which study we do on a patient, how we modify a to expose our patient to an increased risk for fracture?
study, how we conduct clinical trials, the handling of con- Ethical Dilemma. This scenario violates the patient’s
fidential information, the marketing of services, referral right to know the consequences and risks. It is very difficult
patterns, billing patterns, and correlative recommendations. to ask a patient to stop a medication that appears to be
The purpose of this article is to provide a historical per- working. In this particular scenario, the physician hounded
spective of medical ethics in practice and research and to the patient to sign the consent. The patient was not told that
identify potential conflicts in our clinical or research nuclear discontinuing the medicine may be harmful or that he or she
medicine practices. may receive a placebo. However, when the patient asked the
Ethics consultations are now available in 93% of hospi- doctor what his financial involvement was, he stopped both-
tals in the United States (8). It is a service offered by an ering the patient.
individual, group, or team of consultants to help patients, Suggested Resolution. Many trials require the patient to
family members, surrogates, or health care providers under- stop taking existing medication, often before the trial be-
stand and discuss “value-laden issues” between physicians gins. Studies involving emerging therapies often require no
and patients or surrogates, between patients and surrogates, other chemotherapy to be given during the trial. For a cancer
and among medical professionals. This is a problem-solving patient in whom chemotherapy was not working, the trial
activity and not something in abstract form and is part of may be a viable option. Patients have a right to know the
ongoing relationships and services of those responsible for physician’s financial interest in a trial and, more impor-
decision making. The objectives of these consultations are tantly, the potential consequences of medication stoppage or
to facilitate communication, mediate and negotiate conflicts, placebo. Some trials simply cannot be run with concurrent
identify ethical options, provide ethical justification, recom- medications. In these cases, an educated participant can
mend strategies, confirm or challenge viewpoints, interpret make a decision based on his or her perception of risk
institutional policy, provide education resources, and assist versus benefit.
with emotional and spiritual support. Many patients needing
to make serious decisions may want spiritual support and Scenario 2
this consultation service can help facilitate this. The goals of A patient with newly diagnosed colon cancer calls your
this “ethical consult team” are to promote ethical resolution, office and wants to get a PET scan before surgery. You
establish comfortable and respectable communication, help advise her to ask her colorectal surgeon to request the study.
those who may have ethical uncertainties, and help institu- The patient informs you that the doctor refused to order the
tions to recognize certain patterns of ethical problems. Al- test. Your curiosity gets to you and you call the surgeon to
though this consult approach is more geared for serious ask him why he didn’t want to order the scan. After getting
therapeutic decisions, an occasional patient may question vague comments, you ask him point blank. He admits that
the need for diagnostic or therapeutic procedures, especially he is afraid to order the study because it may cause a delay
when one of these is part of an investigative protocol. In in the patient’s surgery. This translates into “I may lose the
particular, cancer patients are more prone to question the case if we find extensive disease.” You have your answer.
need for certain procedures and the timing of follow-up Now what do you do?
diagnostic imaging. Ethical Dilemma. Unfortunately, this scenario has be-
To reinforce integration of ethical principles into every- come increasingly more common. A patient in our medical
day practice, we present several scenarios to establish some center was denied a preoperative PET scan by the colorectal
potential issues that may arise in a nuclear medicine prac- surgeon and widespread disease was noted at surgery. A
tice: postsurgical PET scan revealed numerous unresected lymph
nodes. The patient is in a bind. He or she has done home-
work on the Internet and knows that PET is clearly useful.
ETHICAL CASES Another patient was denied a brain PET scan to evaluate for
Scenario 1 active tumor versus radiation changes. The neurosurgeon
You are approached by a drug company that has an did not want to send the patient to a competing hospital that
investigational drug to treat osteoporosis. It is a drug that is ran the PET scanner. During a complicated neurosurgical
injected daily for 1 mo. Volunteer patients with proven procedure, it was determined that there was only scar tissue.
osteoporosis would be asked to withhold their osteoporosis What should have been done was to call the physicians and
medications for 6 mo during the trial. Bone mineral density reinforce the utility of doing PET both presurgically and
(BMD) studies would be performed at various intervals. during follow-up.
This seems like a simple trial. When we analyze this further, Suggested Resolution. When the issue of “lost surgeries”
we see that we are asking a potential patient with a BMD 2.5 comes up, we often discuss increased confidence of the
SDs below the peak bone mass, and currently improving on patient, significant potential cost savings, and even other
his or her medication, to stop taking the existing medica- possible surgical procedures, such as radiofrequency abla-

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tion. We have not won this battle, and continued patient regard to disclosure of findings directly to patients. Ninety-
diligence will be needed. Most patients are reluctant to one percent of their patients surveyed wished to have the
make a suggestion to someone held in such high esteem as results presented to them by the radiologist, if the results
their surgeon. However, the Internet has made many pa- were normal. Eighty-seven percent would like the radiolo-
tients PET savvy. gist to tell them of abnormal results. Similar patient attitudes
were described by Levitsky et al. (15), by Vallely and
Scenario 3
Manton Mills (16), and by Song et al. (17), who reported
You have just installed your state-of-the-art PET scanner.
that radiologists are generally reluctant to convey informa-
You remember an interesting case you had seen involving
tion to patients regardless of results. One half of the radi-
an 18 y old with fever of unknown origin (FUO). A gallium
ologists surveyed believed that the patient should be re-
scan was not contributory. A recent journal article talked
ferred to his or her physician to discuss the results.
about using 18F-FDG PET to look for infections. You are
Suggested Resolution. The ethical considerations are ob-
excited. Do you call the referring physician and offer to
vious. Discussing results alone with the patient does not
perform a PET scan?
portray the possibility of other diagnoses. The patient’s
Ethical Dilemma. Several articles have shown the utility
physician can put the results in perspective. Giving a patient
of PET scanning in patients with FUO. However, under the
an interpretation before they leave your department can
present allowable indications, this use may be considered as
often spur the radiologist into making a hasty, erroneous
clinical research. The other issue is lack of reimbursement.
reading. This should be avoided at all costs. One could tell
Although the use of oncologic PET imaging has been
stretched to include unusual tumors, the nuclear medicine the patient that it takes awhile to adequately review the
community has not yet sanctioned 18F-FDG PET for routine images and correlative images. There has been at least 1
clinical evaluation of FUO. episode of a radiologist being sued for failure to divulge
Suggested Resolution. Under the physician practice-of- results to a patient. In this case, the patient had an abnormal
medicine concept, a nuclear physician would be allowed, on chest radiograph as a preemployment screen in perspective
an individual basis, to use an approved radiotracer for a with the patient’s clinical findings and history. The court
nonapproved indication. Under the guise of consultation, ruled that by not informing the patient, the radiologist
physicians frequently will call the referring physician to ask caused a delay in diagnosis (18). In our institutions, physi-
about changing the type of study. For example, if a diabetic cians do not give reports directly to the patient. The patient
with a foot ulcer were referred for a bone scan, we often is told that a report will be conveyed to or discussed with the
would call the referring physician and ask permission to referring physician and when that report can be expected.
switch to a tagged white blood cell study. Similarly, one All too often, physician’s offices give the patient a copy of
may ask the referring physician to switch from a gallium his or her report without any discussion. This should also be
scan to an 18F-FDG scan in a patient with lymphoma. Many avoided.
times these decisions are based on reimbursement or lack of Scenario 5
thereof. The patient needs to know about the potential You are reviewing a PET scan on a patient with colon
economic consequences of insurance coverage denial if cancer. The patient has a large intensely hot lesion in the
performing an out-of-indication examination. liver, consistent with metastasis. However, the patient also
Scenario 4 had an MRI scan of the liver that was interpreted as “classic
Mrs. C had a bone scan performed in your department. for hemangioma” according to your colleague. Most hem-
She had a biopsy positive for breast cancer and was sent for angiomas, in our experience, have no increased FDG me-
a bone scan. Before she leaves, Mrs. C would like a report tabolism. This patient had been followed with serial CT and
from the radiologist. She is not due to see her doctor for 2 MRI scans and the lesion was getting bigger. Several hem-
more weeks. What do you do? angiomas in other parts of the liver had no FDG uptake.
Ethical Dilemma. This scenario is a common occurrence. How do you discuss this situation with your associate?
As a resident, one of us was faced with a similar situation. Ethical Dilemma.With the increased specificity of PET
The patient had a history of treated breast cancer and the imaging in cancer, scenarios like this are becoming more
follow-up bone scan demonstrated a solitary lesion in her common. Many “CT misses” are due to the technology
lumbar spine. She demanded a report before she left the differences between the 2 modalities or to CT “blind spots.”
department. My attending told her she had a bone lesion that However, PET has shown that things often thought to be
could be a metastasis and that he would call the doctor to normal on CT can harbor metabolically active disease.
tell him of their conversation. On the way out of the hos- Some of our referring physicians have been disappointed
pital, the patient dropped dead from a heart attack. The with the CT scan interpretations and have started ordering
autopsy findings demonstrated Paget’s disease of the spine the PET scan first so that directed CT scanning can be
without metastatic disease. Though this case may be the performed. Getting back to our situation, the evidence
extreme, patients process result data differently than their pointed toward metastasis, although occasionally hemangi-
physicians. Schreiber (14) reviewed patient preferences in omas do take up FDG. Metastasis was confirmed. It is

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imperative that the discrepancy be brought to the radiolo- Scenario 7

gist’s attention. The nuances of PET imaging are changing A major equipment manufacturer wants to take you and
the way we define findings on a CT scan. If the radiologist your associates out to dinner at the next Radiological Soci-
is made aware of how PET can distinguish various abnor- ety of North America meeting. It just so happens that your
malities, he or she is less likely to make the same mistake hospital is looking at the picture archiving and communi-
again. It is important not to point a finger at a particular cation system package. Do you agree to be picked up in a
radiologist. It is not uncommon for PET to demonstrate limousine and be wined and dined?
focal uptake for no apparent reason. Ethical Dilemma. This is a very difficult issue to tackle.
Suggested Resolution. When notified in a polite, dignified Although such events occur in almost every industry, the
way, the radiologist will become aware of this discrepancy medical profession is excessively scrutinized for conflicts of
and hopefully will affect future interpretations. Whether or interest or other issues that may give the impression of
not the radiologist amends the report has also caused some impropriety. These issues need to be addressed on an indi-
concern. One radiologist said that by doing so, he would vidual basis. When a detail person delivers some samples
lose the confidence of his referring physician. On the con- and a pen, he is hoping you will prescribe his pharmaceu-
trary, referring physicians may be impressed with surveil- tical product. Obviously, you are under no obligation to do
lance and correlation of reports. It is also not uncommon for so. In the medical imaging business, imaging equipment
the radiologist to call to let us know that what was seen on manufacturers will do almost anything to get their equip-
the PET scan was a more benign process, such as athero- ment into your department. Once an affirmative decision is
sclerosis of a vessel. Although we routinely have the CT or made, that company can usually be assured of a longer-term
MRI scans available at the time of dictation, good commu- relationship.
nication with the radiologist is imperative. We also relate Suggested Resolution. Several highly visible radiologists
confirmed findings to the radiologist as positive feedback. and nuclear medicine physicians have gotten labels based
on their relationships with these companies. For example,
Scenario 6 Dr. X is known as a General Electric person or Dr. Y is a
One occurrence that is a nuclear medicine physician’s Philips person. We believe that dealings with equipment
nightmare is a misadministration. For example, a patient companies should be at arm’s length and one should avoid
referred for a bone scan inadvertently is injected with 99mTc- any perception of more than a business relationship. Atten-
diethylenetriamine pentaacetic acid. What do you tell the tion should be paid to the individual institution’s conflict of
patient? The doctor? interest policies. Some have a “no gifts” policy and employ-
Ethical Dilemma. For some misadministrations, manda- ees made be dismissed for violating it. There appear to be
tory reporting to a state or federal agency and the referring more controls in government agencies, such as state- and
physician is necessary. The question of whether or not to tell county-run hospitals. In addition, “consulting fees” paid to
the patient is a difficult one. Some state laws say that if the various employees make dealing at arm’s distance impos-
patient’s condition would be worsened by knowing of a sible. This is especially concerning when that person has
misadministration, such disclosure may not be necessary. decision-making powers related to contracts and equipment
We have found honesty is the best policy. purchases.
Suggested Resolution. According to the book To Err Is
Human: Building a Safer Health System (19), there are Scenario 8
between 44,000 and 98,000 deaths per year in U.S. hospitals You have opened your PET imaging center and have built
attributed to medical errors. Many errors, including misad- up a nice practice. One day, a major referring physician lets
ministration and therapeutic errors, can be prevented by you know he is no longer going to send you patients. He has
designing systems that make it hard for people to do the signed a block lease arrangement with a new imaging center
wrong thing and easy for people to do the right thing. For down the street.
example, a workable checklist system for identifying the Ethical Dilemma. Under this relationship, which is not
patient and preparing and labeling a dose would help to specific to PET, a party such as an oncology group buys
prevent misadministration errors. An error is defined as blocks of imaging time, usually 100 h per block. The time
failure of a planned action to be completed as intended or is paid for by a bank draft, whether or not a patient is
the wrong use of a plan to achieve an aim. The goal is to imaged. In return, the oncology group buys the scan at
reduce errors classified as preventable adverse events, those wholesale and sells it back to the patient at near retail.
injuries by medical management rather than the disease Groups usually try to give the patient a slight discount to
itself. “legitimize” this type of arrangement. Although there is a
In our case, in the very least, the patient’s referring very detailed legal structure for such entities, not all centers
physician needs to be made aware of the misadministration. follow the guidelines. Ethically, this can be viewed as a
Notation should be made of any such conversation. In glorified kickback scheme. However, under current laws
addition, solutions to prevent a reoccurrence should be put related to PET imaging, these contracts are generally con-
in place. sidered legal entities.

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Suggested Resolution. The ACR Code of Ethics specifi- ferences in types of PET scanners. Some, with sodium
cally forbids any relationship that rewards referral patterns. iodide crystals, require only 148-MBq (4 mCi) doses of
Those who have signed such block leasing arrangements 18F-FDG. Scanners can acquire in either 2- or 3-dimensional

typically do not refer Medicare patients under this arrange- mode, and there is much variation in the time it takes to
ment. At this time, these arrangements are under scrutiny perform a whole-body scan. PET/CT can provide the fastest
but do not seem to violate any laws. The concept was throughput.
modeled after the mobile imaging services that sign con- When purchasing a PET camera, one should take all of
tracts with hospitals. If one does enter such a relationship, it the factors into consideration. However, increasing dose to
should be disclosed to the patient. decrease scanning time is not generally acceptable.
Scenario 9 Scenario 11
You just got a call from a referring oncologist. You had You have just purchased the latest and greatest PET/CT
read a PET scan on one of his patients. At the patient’s system. Your business manager wants to capture the costs of
request, he sent the scan to be read at a major academic the CT in addition to the PET scan. You have some reser-
center. You are flabbergasted when he reads you the report, vations. What do you do?
which suggests that the oncologist should send all future Ethical Dilemma. The advent of PET/CT had brought
patients to them because you aren’t doing things right. about several concerns. Though the technology uses state-
Believe it or not, this actually happened. This type of of-the-art CT scanners, only 1 CT protocol is performed on
self-aggrandizement should not be tolerated. Ethics does not each patient. One does not have the option of precontrast,
stop when one dictates a report. The essence of medical
postcontrast, or multiple-phase studies. Some centers do
ethics and business ethics should pervade all aspects of
read and bill for a separate CT scan, when done as part of
patient care.
the PET scan. There have been some concerns as to whether
Ethical Dilemma. The medical record or reports should
nuclear medicine technologists can perform CT scans and
not be used as a means of criticizing others. In this particular
vice versa. Some states have allowed cross-imaging with
case, there was no error in the original dictation. A stan-
additional training.
dardized uptake value of an abdominal lesion was not
Suggested Resolution. Many nuclear physicians are not
reported. The overreading physician used this as an oppor-
certified to interpret CT scans. Therefore, a radiologist may
tunity to generate business for himself.
need to be consulted to read the CT scan. Because of the
Suggested Resolution. If, indeed, there is an error in the
incompleteness of the CT scan when compared with stan-
original dictation, the physician should call the doctor read-
dard protocols, some are reluctant to bill for this study. This
ing the initial scan or the referring physician. The imaging
dilemma is in its evolutionary stage and there are no hard-
report should not be used as a verbal battleground or mar-
and-fast rules. Perhaps, a surcharge for coregistration or CT
keting tool. Additional abnormalities discovered should be
will be developed to simplify the situation.
mentioned without stating that the other doctor erred. Re-
member, that whatever is written in a report, albeit an Conflicts of Interest
overreading, may come back to haunt you if there is any Conflicts of duty result when a physician is responsible to
subsequent litigation. ⬎1 party. For example, a radiologist has an obligation to the
Scenario 10 patient to do the right study and interpret it correctly. He or
You have just purchased a new PET scanner. If you use she has an obligation to the referring physician to interpret
a recommended 555-MBq (15 mCi) dose of 18F-FDG, you and correlate the study in a reasonable amount of time and
can have your patient imaged in 45 min. However, after with a high degree of accuracy. The radiologist also has a
thinking about it, your business manager tells you that by responsibility to the hospital or his partners to generate
increasing the dose to 740 MBq (20 mCi), you could cut out income with which to cover expenses. Generally, this “poly-
2 min per bed stop or up to 15 min per patient. That would loyalty” of the radiologist does not cause any problems.
increase your throughput by at least 1 patient per day. What Problems may occur when an unethical physician is paid
do you do? referral fees for sending patients to the radiologist or when
Ethical Dilemma. Sadly, some centers are putting eco- the hospital does extra imaging or billing that may not be
nomic benefit ahead of patient safety. Although there is no warranted. A more common example occurs when a radi-
doubt that a 740-MBq (20 mCi) dose is relatively safe, ologist or nuclear medicine physician is acting as an agent
unnecessary radiation is being delivered to the patient. In for a pharmaceutical company performing research involv-
Europe, where FDG supply is not as bountiful, scans are ing imaging. The radiologist is beholden to the drug com-
done with a lower dose. Some physicians forget that they pany to do the best imaging per protocol. He or she must
are there for the benefit of the patient. Increasing dose to also protect the patient by understanding the informed con-
improve the bottom line should be viewed with disdain. sent. Sometimes, this is difficult. For example, if we ethi-
Suggested Resolution. Physicians should adhere to dose cally related all concerns to the prospective research subject,
guidelines for all radiopharmaceuticals. There are vast dif- very few would volunteer for such a protocol. We owe it to

MEDICAL ETHICS • Barron and Kim 1825

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CONCLUSION
tember 2, 2003.
Nuclear medicine physicians historically have been and 6. Gunderman RB. Why is ethics needed in the radiology curriculum? Acad Radiol.
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Ethical Dilemmas in Today's Nuclear Medicine and Radiology Practice

Bruce J. Barron and E. Edmund Kim

J Nucl Med. 2003;44:1818-1826.

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