Chapter 2

2 Principles of Beneficence and Nonmaleficence

A person may cause evil to others not only by his actions, but by his inaction, and in either case he is justly accountable to them for the injury.

JOHN STUART MILL

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

beneficence

medical negligence

negligence

nonmaleficence

principle of double effect

reasonable care

res ipsa loquitur

standard of care

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.

Terri L. Fauber, EdD, RT(R)(M), Radiography Program Director

VCU Medical Center Richmond, Virginia

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.

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.

Discussion question

• In what various ways do law, custom, relationship, and contract interact in this scenario?

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.

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:

PRINCIPLE OF DOUBLE EFFECT

A person may perform an act that has evil effects or risk such effects as long as four certain 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:

•Are alternatives with less evil consequences available? Might another procedure produce the same diagnosis with less pain? For example, might magnetic resonance imaging (MRI) be used instead of mammography?

•What are the levels of good intended and evil risked? What will be gained from the procedure? For example, can a contrast media fluoroscopic examination of a first-trimester pregnant woman be justified?

•What is the probability that the good or evil intended will be achieved, and what action and influence do the health care team and patient have? What gains to the patient are possible, and will the imaging specialist have to convince the patient or surrogate that the patient should undergo the procedure?

BENEFICENCE

The term beneficence may encompass many aspects of goodness, promoting good action and preventing evil or harm. Beneficence requires the action of an imaging professional to do good or prevent harm. For example, a patient scheduled for an invasive imaging examination may have determined that he or she does not wish to risk the possibility of the complications resulting from the procedure. The imaging professional may then have to share these concerns with the radiologist and speak on behalf of the patient. A clear definition of nonmaleficence, or the avoidance of evil, may therefore aid in the critical consideration of beneficence.

BENEFICENCE

Performance of good acts.

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.

NONMALEFICENCE

The avoidance of evil.

Table 2-1 Differences between Nonmaleficence and Beneficence

Nonmaleficence

Beneficence

Goal is to do no harm

Goal is to do good

Achieved through passive omission

Achieved through active process

Primary responsibility of the health care provider

Secondary in importance to nonmaleficence

From Creasia J, Parker B: Conceptual foundations of professional nursing practice, ed 2, St Louis, 1996, Mosby.

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:

1.What is the patient's medical problem (what brings the patient to the imaging department)? History? Diagnosis? Prognosis?

2.Is the problem acute? Chronic? Emergent? Reversible? How will this affect the imaging procedure?

3.What are the goals of the treatment or imaging procedure?

4.What are the probabilities of a successful imaging exam?

5.What are the plans in case of therapeutic failure or the inability to complete the exam?

6.In sum, how can this patient benefit by the medical and imaging care? How can the imaging professional avoid harm to the patient?

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).

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.

Discussion question

• Was the injustice active, that is, did the first or second imaging professional deliberately not shield the patient and ask about possible pregnancy? Or was the injustice an unintentional error of omission resulting from the confusion caused by the first technologist's leaving to attend to accident victims in the emergency room?

Discussion

If the case is decided in court, the ruling may be affected by whether the injustice was a result of active intent or passive omission. The obligation not to harm is the strongest motivator in medicine, but the avoidance of evil is also essential.

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.

CONTRACTUAL AGREEMENTS

Verbal and written contractual agreements help provide patient autonomy. Patients requiring imaging services enter into contractual agreements when they agree to enter a hospital and undergo a series of diagnostic imaging studies. Usually such contracts take the form of blanket statements of informed consent. They are general agreements; other processes of informed consent may be required as specific procedures are scheduled. The processes of informed consent and the procedures employed in providing it are discussed at length in Chapter 4.

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.

Discussion questions

• In a situation such as this, how does the imaging professional reconcile issues of “to do good” and “to do no harm”?

• Has the imaging professional actually done harm by participating in the diagnostic examination?

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.

Discussion questions

• Can the student “do no harm”?

• What has to be considered in regard to risk, harm, and benefit for the child?

• How should this problem be handled?

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.

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.

PATIENT'S ROLE

Patients participate in protecting their own good and avoiding their own harm by gathering information about the imaging procedure they will be undergoing. If the patient is unable to understand this information, a surrogate should be appointed to guarantee that appropriate informed consent is given, which will lead to the avoidance of harm and the doing of good. If in doubt about a procedure, the patient or surrogate should seek a second opinion.

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.

STANDARD OF CARE

The degree of skill or care practiced by a reasonable professional practicing in the same field.

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 or other regional accreditation agencies with similar standards must be met for graduates to be recognized by the American Registry of Radiologic Technologists (ARRT). ARRT recognition, as well as state licensure, is generally a requirement for reimbursement by Medicare, Medicaid, and many private insurers. In fact, the Consumer Assurance of Radiologic Excellence Act, introduced in the U.S. Congress in February 2006 (as it had been in some form, with the support of the imaging professionals, in each Congressional session since 1999), would require medical imaging and radiation therapy professionals to have state licensing in order to receive federal payments for these services.6

Imaging professionals must maintain knowledge of the current standard of care. This becomes particularly important as an imaging professional's time out of the educational program increases. The radiologic sciences are changing rapidly. Professionals in these fields have an obligation to update their knowledge and remain current. Attending appropriate continuing education programs and reading professional publications are ways to keep abreast of the current standard of care. Every patient receiving imaging services is entitled to expect the same level of care as the standard of care recognized by the law.

Additional Sources of Standards

In addition to the professional standard of care to which imaging professionals are held, other standards apply that come from a variety of sources. One source is institutional and departmental policies and procedures. If written guidelines exist, professionals need to be aware of them and follow them. Liability can be found based on the failure to follow the written policies of the institution. An example is a claim of negligence in credentialing against an Illinois hospital, which resulted in a $7.7 million award after a podiatrist negligently performed surgery.7 The hospital failed to follow their own bylaws in granting privileges to the podiatrist when he did not meet their criteria.

Federal and state statutes also create standards that must be followed. The prime example is HIPAA, which is discussed in Chapter 5, but others are also discussed throughout the book. These guidelines should be conveyed from the employer to health care professionals, who must follow them to avoid liability. Another source of standards is the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has provided guidelines governing almost every aspect of hospital operation. A facility must follow JCAHO guidelines to be accredited and therefore eligible for payments by the federal government and other insurance sources.

National Patient Safety Goals

On May 25, 2005, JCAHO approved the 2006 National Patient Safety Goals (Box 2-1). Almost every one of these goals has a place in the imaging profession. Examples include the following:

•Patient identification

•Communication among caregivers

•Medication safety (with regard to contrast media, radiopharmaceuticals, and other medications used in the imaging department)

•Elimination of wrong site, wrong patient, wrong procedure surgery (this goal was designed for surgeries, but the principles apply to imaging, particularly digital radiography, since marking of orientation is sometimes done after exposure, although this is not recommended)

•Reduction in the risk of health care–associated infections

•Reduction in the risk of patients' falls

•Encouragement of the active involvement of patient care as a patient safety strategy

Box 2-1 National Patient Safety Goals

Goal 1

Improve the accuracy of patient identification.

Goal 2

Improve the effectiveness of communication among caregivers.

Goal 3

Improve the safety of using medications.

Goal 4

Eliminate “wrong site, wrong patient, wrong procedure” surgery.

Goal 5

[Goal was retired in 2006]

Goal 6

Improve the effectiveness of clinical alarm systems.

Goal 7

Reduce the risk of health care–associated infections.

Goal 8

Accurately and completely reconcile medications across the continuum of care.

Goal 9

Reduce the risk of patient harm resulting from falls.

Goal 10

Reduce the risk of influenza and pneumococcal disease in institutionalized older adults.

Goal 11

Reduce the risk of surgical fires.

Goal 12

Implement applicable National Patient Safety Goals and associated requirements at the component and practitioner site levels [Networks].

Goal 13

Define and communicate the means for patients to report concerns about safety and encourage them to do so [Assisted Living, Disease-Specific Care, Home Care, Laboratory].

Goal 14

Prevent health care–associated pressure ulcers (decubitus ulcers).

From Joint Commission on Accreditation of Healthcare Organizations: Facts about 2006 National Patient Safety Goals, Oakbrook Terrace, Ill, 2006, Author.

NEGLIGENCE

Negligence is an unintentional tort resulting from actions not intended to do harm. It occurs in situations in which a duty to use reasonable care is owed to another person and an injury results from a failure to use reasonable care. Reasonable care is the degree of care a reasonable person, similarly situated, would use. Reasonable care may be determined by the applicable standard of care, by statute, or by previous judicial decisions, called precedents.8 If a duty is not performed with reasonable care, liability may be imposed.

NEGLIGENCE

An unintentional tort involving duty, breach of duty, injury, and causation.

REASONABLE CARE

The degree of care a reasonable person, similarly situated, would use.

Negligence requires a duty, a breach of that duty, injury, and causation. For example, if a driver falls asleep at the wheel, crosses the center line, strikes another car, and injures its driver, the driver has been negligent. Statutes and precedents have established that all drivers have a duty to share the road reasonably with other drivers. The driver who fell asleep and crossed the center line was not acting reasonably. The other driver's injuries were a direct result of the first driver's failure to act reasonably. The driver who crossed the center line was negligent and is liable for damages.

Medical Negligence

A special relationship exists between health care providers and patients. This special relationship entails a duty on the part of the health care professional to provide patients with reasonable care. Whether reasonable care is provided is determined by the standard of care for whatever is done to the patient. A health care provider's failure to follow the appropriate standard of care is therefore a special type of negligence called medical negligence. This type of negligence is sometimes referred to under the general term medical malpractice.

MEDICAL NEGLIGENCE

A breach of the health care provider's duty to follow the applicable standard of care, which results in harm to the patient.

A medical imaging professional owes a duty to the patient to ensure that procedures are performed according to the applicable standard of care. That standard of care requires the imaging professional to follow accepted guidelines for the procedure. A deviation from those guidelines that causes harm to a patient may form the basis for a judgment of liability. Although variations exist between jurisdictions, generally a plaintiff must provide evidence establishing an applicable standard of care, demonstrate that the standard has been violated, and prove a causal relationship between the violation and the alleged harm.9

The applicable standard of care is generally established through the testimony of a medical expert practicing in the same field as the defendant. A plaintiff must offer proof that the defendant breached this legally required standard of care and thus was negligent. Expert testimony is needed to establish both the proper standard of care and a failure by the defendant to conform to that standard.10 An expert witness may not be required in a medical malpractice suit, however, when the facts to be decided are such that a layperson can understand them and determine the question of fact without the aid of an expert witness.11

If a lawsuit proceeds to trial, the imaging professional may have an opportunity to provide his or her personal recollections of the events. Written documentation, however, is extremely important; attorneys, judges, and juries may take the position that if an event was not documented, it did not happen. An example is a case in Nevada when a hospital was sued for an alleged near fall from a gurney in the imaging department, allegedly resulting in a broken hip. The jury returned a verdict for the defense, based on the fact that the incident was never documented in the medical record.12 The patient care documentation was complete and detailed, and therefore the lack of documentation of this alleged event led the jury to believe that since this event was not documented, it did not occur.

Medical imaging professionals have an obligation to perform examinations in a manner consistent with policies and procedures, never vary from accepted standards of care, and provide appropriate documentation. These and other methods to decrease risk are discussed thoroughly later in this chapter.

The legal doctrine of res ipsa loquitur (Latin for “the thing speaks for itself”) may have a significant impact on medical malpractice cases. It is applicable in situations in which a particular injury would not have occurred in the absence of negligence and is often used as a basis for lawsuits arising when sponges or instruments are left in a patient after surgery.

RES IPSA LOQUITUR

Latin term meaning “the thing speaks for itself.” It is a legal concept invoked in situations in which a particular injury could not have occurred in the absence of negligence.

When res ipsa loquitur is claimed as the basis for a lawsuit, all parties involved in the procedure are defendants because obviously at least one of them was negligent. Therefore they all must try to prove that they were not negligent. The doctrine may apply to many situations in the medical imaging practice. For example, a confused elderly patient left alone on a cart in the hall after a procedure may fall and suffer a broken hip. The fall and injury would not have happened if the patient had not been left alone in the hall without being appropriately restrained. Therefore all health care professionals who worked with the patient, including the imaging professionals, may be called on to prove absence of negligence. Expert testimony may be used to prove that the standard of care was violated. If a clear breach of duty is evident to a layperson after the presentation of the facts of the case, however, expert testimony may not even be needed.

METHODS TO DECREASE RISK

Documentation

The type of information to be documented (see Appendix B) and incorporated into the medical record is a crucial consideration for medical professionals. From the risk management perspective, the medical record is the most important element in preventing and minimizing adverse consequences of malpractice suits. The record will serve as the basis for the defense of the suit. Poorly maintained, incomplete, inaccurate, illegible, or altered records create questions as to the treatment given the patient and may be used to show liability. Proper documentation creates a medical record that accurately and completely reflects the patient's care and can be used to correlate the facts related by witnesses. From a legal perspective, certain information is mandated by statutes, regulations, and institutional requirements. The Code of Ethics adopted by the ASRT13 and ARRT14 requires that the radiologic technologist act as an agent through observation and communication to obtain pertinent information that will aid in the diagnosis and treatment of the patient. JCAHO regulations require that pertinent patient histories be taken before all procedures performed in the medical imaging sciences.15 Departmental policies generally mandate that this information be recorded on every patient record, which becomes a part of the patient's medical record. (See Appendix B for a sample patient data sheet and incident report.)

Other than the basic information mandated by statutory, regulatory, ethical, and institutional requirements, no steadfast rules govern the documentation of additional information in the medical imaging sciences. An examination of the purposes of documentation, however, may help the imaging professional make decisions regarding the inclusion of additional patient information.

High-quality patient care in the imaging sciences, particularly accurate diagnosis in diagnostic procedures and correct application of therapeutic radiography, depends largely on the interpreting physician's receiving pertinent information about the patient. The imaging professional must communicate with the patient, observe the patient, and interpret responses and observations. This process helps the professional formulate the patient's pertinent history. Often judgments regarding examinations to be performed and specific positioning to be used are based on the patient's history. Moreover, the interpreting physician may not be able to analyze images correctly or make accurate diagnoses without the information contained in an accurate and pertinent patient history.

Imaging Scenario

An imaging professional and a radiologist perform an arteriogram to evaluate peripheral vascular disease of the right leg. Significant narrowing is found, and a stent is placed to open the artery. Almost 2 years later a lawsuit is filed alleging that the arteriogram and stent placement were improperly performed. The specific allegation is that the stent placement was incorrect and caused further deterioration of the leg and foot to the point at which the patient had constant pain in his leg and was barely able to walk. The imaging professional is told that she is likely to be deposed, and the hospital's legal department gives her a set of questions she will probably be asked to answer under oath:

How much do you remember about the procedure?

Did you document the procedure?

How thorough was your documentation?

Did you document the stent placement and location?

Did you document any patient complaints at the time?

Did you document any report of patient status at the conclusion of the examination indicating the patient had no complaints?

Did you document your observations on a form that became a permanent record along with the patient's images?

Did the images you took include the stent placement site and the area of diagnostic interest?

Is documentation available to prove that the risks of the procedure were explained to the patient and that the patient understood?

Even the information necessary to ensure that the correct procedure is performed properly and interpreted accurately may not be adequate to protect health care professionals and the medical facility from liability. Thus imaging professionals must consider ways to obtain enough information to minimize the litigation risks.

As the scenario above indicates, remembering all the details of the particular procedure performed is extremely difficult. Written and radiographic documentation is a great aid in the defense of an unfounded medical negligence case. Imaging professionals have the opportunity and obligation to document thoroughly and thus avoid or minimize the effects of unfounded medical negligence claims (Box 2-2).

Patient Data Sheet

A uniform patient data sheet or computerized form should be developed for use in each facility (Box 2-3). Input from the department administrator, risk manager, physicians, and legal counsel in the drafting of this form is advisable.

Box 2-2 Documentation Basics

Never alter or falsify a record. You will lose all credibility if alteration or falsification of records is discovered.

If you make an error, draw a line through it and write “error.” Never use correction fluid or put a sticker over an error. Others must be able to see clearly the information you have changed in order for you to maintain credibility.

Know and adhere to your department's policies and guidelines. They help define expectations of reasonable care in your facility and may be evaluated in a lawsuit to determine whether your actions complied.

Document clearly and in chronologic order. If comments are necessary, make them in chronologic order. Do not leave blanks to fill in later. Blank spaces give the impression that the documentation was altered or sanitized. All corrections, late entries, entries made out of time sequence, and addenda should be clearly marked as such in the record and should be dated and timed on the day they are written and signed.

Do not document irrelevant details.

Provide objective, factual information. Avoid subjective, conclusory terms such as well, good, fine, and normal.

Document all instances of patient noncompliance or refusal of recommended treatment.

Sign your legal name and title and always make your documentation legible. Illegible writing can only hurt you if litigation results.

Keep records in a safe place and respect confidentiality. The maintenance of patient confidentiality is a duty of each member of the health care team. Documentation in a medical imaging department carries the same obligation of patient confidentiality as does the information in the patient's chart.

Use incident reports to report unusual circumstances. Do not refer to incident reports in routine documentation. The incident report is for use in quality assurance and risk management to improve patient care. Acknowledgment of it in routine documentation may change it from a patient care improvement tool to a discoverable document in a lawsuit.

Modified from McMullen P, Philipsen N: Charting basics 101, Nurs Connect 6(3):62, 1993; and Creasia JL, Parker B: Conceptual foundations of professional nursing practice: charting basics, St Louis, 1996, Mosby.

Box 2-3 Items to be Included in the Patient Data Sheet

Basic patient identification information

Pertinent patient history

Answers to questions regarding pregnancy and last menstrual period

Signature line

Time of patient arrival and departure

Name of technologist performing examination

Comment section

Generally the form should include basic patient identification information, questions to assess for pregnancy, and pertinent patient history. A signature line for the patient and a line to note the time the patient arrived in and departed from the medical imaging department may also be included. In addition, the form may indicate the imaging technologist who performed the examination and provide space for additional comments. This comment section should be used to note and explain any variance from written procedure such as the patient's refusal or inability to cooperate during part or all of the examination. If data are collected in a computer, a comment section should be available on the computerized form or an alternative method should be available to document any variance from standard procedure. If computerized patient data documentation is used, an alternate system must be in place for the inevitable “computer-down” situations. The patient data sheet should be part of the permanent patient record.

Every page of a patient's record should be clearly labeled with the patient's name and medical record number. Electronic systems should require a password, and if paper records are used, these should be hospital-approved forms only and should be written only with pen, never pencil. Associated records, such as films, reports, requisitions, contrast forms, consent forms, and any other documents used in the imaging department, must also be labeled with the patient's name and medical record number and the time and date the action took place.

Inappropriate Documentation

Because proper documentation is so crucial, the imaging technologist must understand what type of information is inappropriate for documentation and the reason for this determination. Because medical records are business documents, they must reflect only factual information regarding patients and their care and treatment. Documentation of personal opinions or derogatory statements regarding the patient is inappropriate and may result in liability for the imaging professional, medical facility, or both. Mention of the preparation of an incident report should never be included in the medical record. An objective description of the incident should be reported in the medical record along with follow-up information.

Incident Reporting

The incident report is a valuable risk management tool. It allows the hospital to immediately investigate the circumstances of the incident and, if necessary, institute corrective action to prevent similar future occurrences. Although procedures may vary by facility, health care facilities generally require incident reports on occurrences involving patients and visitors that have resulted or may result in hospital liability or patient dissatisfaction. Examples include sudden deaths; falls; drug, contrast, and radiopharmaceutical errors and reactions; injuries caused by faulty equipment; injuries to employees or visitors; threats of legal action; and unexplained requests from attorneys for medical records. Department heads and supervisors are usually responsible for filing incident reports, but imaging professionals should know the procedures in their facilities before the need arises, as well as what circumstances necessitate the filing of an incident report.

Incident reports are generally directed to the risk manager, who investigates as necessary. The risk manager also informs appropriate administrative and medical staff and, if necessary, the facility's insurer. The incident report is a valuable tool because it allows compilation of data to identify problem areas and thus prevent future errors and injuries. Incident reporting should not be done on the patient data sheet. Instead, the incident reporting procedures set up by the facility's risk management department should be followed. The reasons for this are twofold:

1.The risk management department has put specific incident reporting procedures in place because the incident report is a valuable tool for assessing risk and tracking problems in a facility. The ultimate goal of such reports is to improve patient care.

2.From a legal perspective, the patient chart, including all imaging department documentation, is discoverable in a lawsuit. Incident reports generally fall into a different category and may not be as easily discoverable. However, acknowledgment of an incident report in routine documentation may make it more easily discoverable.

Documentation of the Introduction of Intravenous Contrast Material and Radiopharmaceuticals

Any procedure performed in an imaging department that involves the intravenous (IV) administration of contrast material carries with it the risk of allergic reaction. Although these reactions may range from mild, such as an itchy nose, to severe, such as anaphylactic shock, the risk is great enough to mandate extensive documentation.

Procedures involving the introduction of contrast material or radiopharmaceuticals present special documentation needs. Forms for documenting the type of material administered during the examination and other important information are very useful. A standardized form with spaces for each piece of information makes the regular recording of this information much more likely (Box 2-4). A form is useful, however, only if it is properly and consistently used. Imaging professionals performing risky procedures have a responsibility to ensure such proper and consistent documentation.

A form for documenting procedures involving injection of contrast medium or radiopharmaceuticals should include a place for allergies to be noted. For risk management purposes a notation should always be entered in that space, such as “NKA” (no known allergies) if the patient denies having allergies. Strict adherence to this requirement ensures that the question is asked and answered every time IV contrast material is administered. The form should include a space for recording that informed consent was obtained and the proper documentation is in the patient chart.

Box 2-4 Items to be Included in the Data Sheet for Introduction of Contrast Material and Radiopharmaceuticals

Documentation of the obtaining of informed consent

Allergies

Material used

Amount (volume and radioactivity if using radiopharmaceutical)

Time of administration

Path of administration (oral, IV, through catheter, rectal)

Injection sites

Name of person administering material

Reaction

Time of reaction

Symptoms of reaction

Treatment of reaction

Physician treating

Time and condition on leaving department

The form should include space for documentation of basic information about the material used, including identification, amount used, time administered, path of administration (oral, IV, through catheter, rectal), name of the person administering the material, and injection site or sites.

Documentation of the injection site is important for several reasons. The delivery of high-quality patient care, especially continuity of care, requires this documentation because problems with the injection site may develop. Risk management requires the information because infiltration of contrast material may raise litigation issues. Questions on the form that prompt the entering of required information and spaces for responses are helpful in ensuring adequate documentation.

Space should be provided to note any reaction the patient exhibits to the contrast material. This documentation should include all reactions: nose itching not requiring treatment, hives requiring treatment with diphenhydramine (Benadryl), or full-blown anaphylactic shock reactions. Documentation of reactions should be chronologic and include the symptoms observed, actions taken in response to the reaction, and detailed descriptions of treatments initiated. The condition of the patient on leaving the radiology department and the transfer of care to other health care providers such as the nursing floor or emergency department should also be documented, with signature, date, time, and to whose care the patient was transferred.

As with pharmaceuticals given on the nursing floor, pharmaceuticals given in an imaging department must be charted. Each facility should have a facility-wide system of charting in place. All individuals authorized to record information on patient charts (including imaging professionals) should be educated regarding the charting style, including accepted abbreviations. This will ensure that charting is performed uniformly by all health care providers.

Technical Detail Issues

Correct Film Identification and Care with Films

Although the concept of correctly identifying films and using care in filing films seems second nature, it is worth mentioning as a risk management tool. Liability has been imposed in cases based on the incorrect identification of films and mix-ups of films.

Film identification as to both patient identity and right and left orientation is extremely important and has become more troublesome with the advent of computerized radiography and digital radiography. Films must be correctly identified as to the patient. The imaging professional has the sole responsibility for ensuring that this is done, often by selecting the correct name from a computerized list of patients. The imaging professional is also responsible for ensuring that films are marked correctly for right and left orientation. With the advent of the new technologies, particularly digital radiography, the radiologist has virtually no way to know whether the orientation as to right or left is correct. It is the sole responsibility of the imaging professional to correctly mark digital radiographs, whether before or after exposure. Use of a uniform, consistent system to identify films will help eliminate errors that can lead to litigation in this area.

The mix-up of films is another area in which there is much litigation. This seems particularly important when films are removed from the department, often to be used as a guide during surgery. In Mississippi a $1.4 million verdict was awarded when brain surgery was done on the wrong patient because the MRI was switched with that of another patient.16 A habit of routinely looking at the patient's identification each time the imaging professional views a film will help to prevent mix-ups and decrease risk in this area.

Timely Distribution of Reports

The delay or failure of a report to get to the appropriate physician is a common source of litigation in the radiology arena.17,18 The imaging professional may play a variety of roles in the delivery of information, depending on how the department or facility is structured. In many small facilities and physicians' offices, the imaging professional helps with the process of distributing reports and makes the necessary phone calls regarding positive results to physicians. In almost every facility the radiologist sometimes asks the imaging professional to notify a physician by phone about an abnormal result and the need for further tests. Another issue in this area is the delivery of oral reports to other departments such as the emergency department, the operating room, or intensive care. The most effective way for the imaging professional to decrease risk in this area is documentation. The professional should always record that the report was delivered, to whom it was given, and the time and date and should initial this notation. If an oral report is being delivered, the contents of that report should also be documented in writing. This small step will prove valuable if litigation looms on the horizon.

Radiation Protection

The National Council on Radiation Protection and Measurements (NCRP) establishes policies and procedures regarding radiation exposure based on the phrase “as low as reasonably achievable” (ALARA). The NCRP states, “The primary goal is to keep radiation exposure of the individual well below a level at which adverse effects are likely to be observed during the individual's lifetime. Another objective is to minimize the incidence of genetic effects.”19 When ordering a radiographic procedure, the physician must weigh the benefits to be obtained against the risk of exposure.

Because radiation exposure is a risk, an important task for imaging professionals is the use of proper radiation protection to provide high-quality patient care and reduce litigation risk. Radiation protection education is essential in keeping exposures to patients ALARA.19

Methods of radiation protection are use of proper exposure factors, filtration, collimation, and shielding devices. Other methods that can be used to reduce the number of repeat exposures include restraining devices, technique charts, and a quality control program that ensures proper equipment performance. Repeat film analyses and clear policies concerning pregnant patients are also essential to keep radiation exposure ALARA.19

Instruction in radiation protection is part of the curricula of accredited educational facilities and is documented in student records. In addition, many states and medical facilities require continuing education in radiation protection on an established schedule.

Preventive maintenance and calibration performed routinely on equipment ensure that the radiation dose emitted is accurate and appropriate. State and federal agencies also inspect equipment periodically to verify that each piece has been properly maintained and calibrated and meets acceptable standards. Calibration of therapeutic radiation equipment is important and is performed by qualified radiation physicists in accordance with state and federal agencies. Records of all preventive maintenance, calibration, and government inspections should be kept in the department.

Imaging Scenario

A patient comes to the medical imaging department for a chest x-ray for suspected pneumonia. The routine questions regarding pregnancy are asked, and the patient says that she is sure she is not pregnant but does not remember the date of her last menstrual period. On the patient data form, she answers no to the pregnancy question but leaves the last menstrual period space blank. She signs the signature line. Posteroanterior (PA) and lateral chest x-rays are taken. Later the patient finds out that she was approximately 4 weeks pregnant when she underwent radiography. Her obstetrician calls the radiologist, concerned that the woman has had radiography and worried about possible harm to the fetus. The radiologist requests that the imaging technologist pull the films. The films demonstrate the collimation line, which shows that the beam was collimated to approximately ½ inch within all edges of the film. The documentation includes the patient's response to the pregnancy question.

Discussion questions

• Is the radiation dose to the fetus likely to be significant? Why or why not?

• Is the technologist or facility liable for negligently exposing a fetus to ionizing radiation?

• What else could have been done to protect the fetus? Would those measures have limited the risk of litigation?

Quality control and assurance programs are implemented in the imaging department to make certain that patients do not receive unnecessary radiation. These programs include repeated examination analysis, tracking of results, and measures to correct noticed problems. They also ensure that processing equipment is performing correctly and consistently. Consistently following policies and procedures for shielding and collimation helps to protect patients against unnecessary radiation. Pregnancy poses the greatest risk in this area. For this reason an imaging professional should always ask a female patient whether she may be pregnant and question her about the date of her last menstrual period.

If radiography of a pregnant patient is necessary, informed consent should be obtained and additional shielding should always be used. The informed consent procedure must include an explanation by a physician of the risks involved in exposing the fetus to ionizing radiation. This consent must be documented. (For further information about obtaining informed consent, see Chapter 4.)

Imaging professionals and therapeutic technologists must be diligent about radiation protection, both for the patient's benefit and from a risk management standpoint. Litigation arises from exposure issues. Two recent reported cases involved radiation overexposure. In one case a 300-pound man sustained a radiation burn on his lower back after fluoroscopy during a cardiac catheterization. The plaintiff was awarded $300,000.20 The other case involved external beam therapy for anal cancer, which resulted in total fusion of the vagina. The defense denied any deviation from the standard of care, and the jury found for the defense.21

Imaging Scenario

A patient falls on an uneven floor between the emergency and sonography departments. The sonographer tells the patient, “We keep waiting for them to fix that spot. Several other people have fallen, and we keep telling them to fix it.” The sonographer takes the patient to the ultrasound room, performs the study, and returns the patient to the emergency department without relating the incident to anyone or filling out an incident report. The patient had complained only of a little swelling in her ankle.

Discussion questions

• Was the standard of care regarding incident reports followed?

• Were other standards not met?

• Did the statement by the sonographer have any impact on any liability issues?

Discussion

Any statement made regarding previous incidents resulting from the same hazard has a legal impact because such a statement establishes that the facility knew about the hazard and therefore breached its duty by failing to warn of the hazard or remedy it. If the patient was indeed injured in the fall, the facility would be liable for negligence. In addition, the facility would be liable for failing to follow policies and procedures for incident reporting and safety and for violating those standards of care.

Safety

Safety is an important concern in any health care facility, both in the provision of good-quality patient care and in the reduction of litigation risks. Larger facilities generally have comprehensive safety programs that include written policies and procedures regarding handling of hazardous materials, fire and electricity safety, emergency codes, back safety, patient transport and lifting techniques, infection control, occurrence reporting, and loss prevention. Most facilities use risk management guidelines as they develop these policies and procedures. JCAHO guidelines exist for safety programs, and institutional policies and procedures generally follow these guidelines.

Special attention should be paid to the transporting of patients from wheelchair or cart to the x-ray, MRI, CT, ultrasound, or radiation therapy table. Litigation commonly arises because one technologist attempts to perform the transfer alone when two people are needed. In one recent case, transfer to an MRI table was blamed for brain damage and lumbar spine injury, resulting in a $200,000 judgment,22 and in another the failure to provide a two-person lift to an x-ray table was alleged to cause a leg fracture and eventual death from pneumonia.23

Although smaller facilities may have fewer staff members to provide education regarding safety issues, the same safety standards must be met as those expected of larger facilities. Imaging professionals should know their facility's programs and be familiar with policies and procedures. If a safety issue arises while a patient is in the imaging department, the imaging professional is responsible for knowing the correct action to take. The department should keep records of attendance at safety instruction and in-service meetings.

If imaging professionals do not know whether their facilities offer safety programs, they should find out by asking supervisors until they get an appropriate answer. If no safety program exists, JCAHO guidelines EC1, 1.1-1.9 and EC2, 2.1-2.14 are excellent starting points.15

SUMMARY

• The values of beneficence and nonmaleficence have been respected since the time of the earliest health care providers who tried to provide a good by aiding the sick and injured. These values provide a system of checks and balances for providers and patients to aid in making decisions concerning medical care. To facilitate this decision-making process, the principle of double effect helps weigh the proportionality between good and evil consequences.

• Although both beneficence and nonmaleficence are necessary to patient autonomy, some differences exist between them. Beneficence is active, whereas nonmaleficence is passive; further differences are evident in the importance of the ways they are practiced.

• Conflict may arise between beneficence and nonmaleficence, and this often affects patient autonomy. Conflicts may occur when good intentions have negative consequences. They also may result from friction between the notion that all people deserve good health care and the reality of limited resources, power struggles, quality-of-life decisions, and surrogate obligations.

• By examining the medical indications, including the medical problem, its severity, the goals of the examination, the success probability, options for imaging procedures, and how the patient will benefit from the examination, the imaging professional will gather information needed for problem solving.

• The imaging professional and patient are both responsible for encouraging good and avoiding harm in the imaging process. Continuing education enhances the imaging professional's skills, and obtaining information concerning the procedure aids the patient in appropriate decision making.

• In any pluralistic society, the many interpretations of beneficence and nonmaleficence ensure that patient autonomy remains a source and cause of conflicts. These conflicts must be addressed to provide society with appropriate health care.

• The ethical concepts of beneficence and nonmaleficence, which are integrated into the legal standard of care for health care professionals, define the duty to do no harm and provide reasonable medical care.

• The legal standard of care is the degree of skill or care practiced by a reasonable professional practicing in the same field. The standard of care for imaging professionals is established through practice standards, educational requirements, and curricula developed for imaging professionals. It is an important consideration if negligence is alleged. If the appropriate standard of care is violated, liability may be imposed on both health care professionals and medical facilities.

• Negligence is an unintentional tort resulting from actions not intended to cause harm. For negligence to be proved, a duty to use reasonable care must exist, this duty must be breached, and harm must result from this breach. The existence of a duty and the determination of reasonable care may be established by statutes, previous judicial decisions, or appropriate standards of care.

• Health care providers have a special relationship with patients that involves a duty to follow the appropriate standard of care. If that standard is not followed, liability may ensue for the health care provider and medical facility. This is called medical negligence or medical malpractice. To establish medical negligence, a plaintiff must provide evidence of an applicable standard of care, demonstrate that the standard has been violated, show that an injury occurred, and prove that the injury was caused by the violation of the standard of care.

• Methods to ensure quality patient care and decrease risks include thorough and consistent documentation, attention to technical detail issues, radiation protection, and dedication to safety. Documentation forms are useful tools in ensuring consistent documentation; examples of information to be included on these forms have been provided in this chapter.

• Care must be taken in technical detail issues such as correct film identification with regard to patient identification and proper orientation, tracking of films to avoid mix-ups between films, and timely distribution of reports. Radiation protection must be diligently practiced, and safety issues must be a constant concern.

• The principles of beneficence and nonmaleficence also have an impact on patient consent, informed consent, advance directives, and surrogate decision makers. Legal issues concerning consent and informed consent are discussed in Chapter 4 in the context of patient autonomy. Legal issues regarding advance directives and surrogate decision makers are addressed in Chapter 6 in the context of choices about death and dying.