Legal and Ethical Considerations in Sonography

Legal Aspects of Safe Practice of Sonography in Australia

  • Legal Aspects:
    • Awareness of laws relating to healthcare delivery is the best protection for sonographers.
    • This awareness is inherent in the professional scope of practice.
    • Legal consequences highlight the need for professional accountability.
    • Ensures respect for patients' rights and promotes high-quality care by reducing errors, misdiagnoses, or inappropriate procedures.

Medico-Legal Issues

  • "Medicolegal" refers to the intersection of medical practice and the law.
  • It involves the legal responsibilities and obligations of healthcare professionals, including compliance with regulations, professional standards, and laws that govern medical care and patient rights.
  • For sonographers, medicolegal issues encompass areas such as negligence, duty of care, informed consent, and patient confidentiality.

Torts

  • Most legal cases brought against sonographers are tort actions.
  • "A tort is a wrongful act which one person commits against another and for which the law provides a remedy."
  • Types of Torts:
    • Intentional: Assault, battery, invasion of privacy, and false imprisonment.
    • Unintentional: Negligence.

Negligence

  • Negligence occurs when a negligent act or omission by a medical professional results in harm to the patient.
  • The injured patient must prove four things:
    • Duty of care
    • Breach
    • Harm
    • Causation

Elements of Negligence

  • Duty of Care: Has the person doing the action reached the required standard of care?
  • Breach: Failure to meet that duty of care.
  • Harm: An injury has occurred.
  • Causation: Event must be the cause of the injury.

Causation - Burden of Proof

  • Usually falls on the patient (plaintiff) to prove harm occurred due to the event.
  • Burden of proof shifts to the defendant when the evidence proves res ipsa loquitur (the thing speaks for itself).
    • E.g., If a medical instrument is left inside a patient after surgery.
    • There will not be any proof in patient notes that “Dr X left scissors in the patient” but clearly that would not happen in normal circumstances, so the burden falls on the Dr to prove the injury sustained was not a result of their negligence.

Examples of When a Sonographer May Be Liable

  • Intentional Torts:
    • Physically molesting a patient.
    • Continuing to scan a patient when consent has been withdrawn.
  • Unintentional Torts:
    • Letting a patient fall when in your care, causing injury.
    • Revealing confidential information about the contents of the examination or disclosing any information that has adverse effects on the patient.
    • Giving the patient or accompanying Dr a wrong diagnosis.
    • Not obtaining consent correctly.

Liability and Vicarious Liability

  • Liability: Legal responsibility for the consequences of one’s actions.
  • Vicarious Liability: Legal principle in which an individual or entity (such as an employer) is held responsible for the actions or omissions of another person (such as an employee) within the scope of their employment or duties.

Vicarious Liability

  • Sonographers are normally employed in private practices or public hospitals.
  • Employers have vicarious liability (take responsibility) for an employee’s wrongful acts.
  • If a sonographer does something wrong, it is normally the employer or hospital that is responsible as long as the sonographer was acting within the scope of employment.
  • Theory of respondeat superior (let the master answer).

Vicarious Liability - Implications for Sonographers

  • Important to follow department protocols and policies and maintain a high standard of care.
  • Always operate within your professional scope of practice.
  • The individual sonographer may also face disciplinary or legal action depending on the nature of the negligence.

Codes of Conduct

  • Codes of conduct establish professional ethical standards and guidelines for appropriate behavior for sonographers to follow.
  • Sonographers in Australia adhere to multiple codes – ASA, ASUM, National Code of Conduct.
  • We protect ourselves by following codes of conduct, and the law takes these into consideration.

National Code of Conduct for Health Care Workers

  • Aimed at unregistered healthcare workers.
  • Addresses risks posed by incompetent, impaired, or exploitative workers.
  • Code-regulation regimes already operating in NSW, South Australia, and Queensland.

ASA Code of Conduct

  • The ASA Code of Conduct is as a professional guide for sonographers to ensure ethical, legal, and professional responsibilities are met.
  • By adhering to these principles, sonographers:
    • Reduce the risk of legal liability.
    • Uphold patient safety and trust.
    • Maintain high standards of professional practice.
  • ASA Code aligns with broader legal frameworks such as the National Code of Conduct for Health Care Workers, privacy laws, and duty of care principles.

Protecting Against Legal Action

  • Insurance:
    • Protection against legal claims.
    • Employer should have appropriate insurance policies for staff.
    • Have your own insurance.
    • Professional body (ASA) provides cover against professional indemnity and public liability.
  • Ensure you have a written or electronic request.
  • Do not perform scans or procedures for which you have not been trained – stay within your scope of practice.
  • Scan only for a clinical reason.
  • Use a chaperone if necessary.
  • Ensure the patient understands the procedure and has given informed consent.
  • Make sure equipment is adequate and you are using it as intended.
  • Know and follow departmental protocols.
  • Know how long you have for a scan.
  • Always record images containing diagnostic content and the area of interest.
  • Stay in control of the ultrasound room.
  • Document any findings, noting any technical difficulties encountered, unusual patient behavior, or incidents that occurred.
  • Beware of common pitfalls resulting from incomplete preps, artifacts, etc.
  • Self-regulation: Personal conduct, ongoing education, know your limitations.

Ethics

  • Ethics begins where the law ends.
  • It is a system of moral principles that uphold values and judgments in the practice of medicine.
  • In general terms, includes concepts that:
    • we do no harm
    • promote best interests of the patient
    • patient makes their own decisions.
    • all patients are treated equally
  • Every medical specialty has its own code of ethics.

Ethical Responsibilities for Sonographers

  • Communication
  • Compassion and Respect
  • Unbiased Treatment
  • Patient privacy
  • Patient safety
  • Collegial responsibility
  • Continuing education
  • Responsibility to employers
  • Responsibility to self
  • Responsibility to the profession

Basic Ethical Theories

  • Philosophical frameworks of thought that provide a deeper understanding of morality and explain why certain actions are right or wrong.
  • Deontology: is the study of duty, moral obligation, and taking the right action. Actions are right or wrong regardless of the consequences.
  • Teleology: is the study of evidence of the design and purpose of nature. An act is right if it brings a good outcome with the least number of bad consequences.
  • Sonographers use both theories depending on patient and situation.

Ethical Principles

  • Ethical principles are fundamental guidelines or rules that help healthcare professionals determine right and wrong in specific situations.
  • They provide a framework for decisions on courses of action in practice, ensuring that moral standards are upheld.
  • Principles:
    1. Nonmaleficence
    2. Beneficence
    3. Autonomy
    4. Justice

1. Nonmaleficence

  • Nonmaleficence is the principle to “do no harm” and emphasizes minimizing harm to the patient during treatment or diagnosis.
  • In practice, it involves sonographers:
    • Obtaining appropriate education and clinical skills to ensure examinations are performed competently and safely.
    • Being accountable for and participating in regular assessment and review of protocols, equipment, procedures, and results to ensure that patients are not harmed by outdated procedures or poorly functioning equipment.
    • Practicing emergency procedures and striving to ensure patient safety in all procedures and circumstances.
    • Refraining from substance abuse or any activity that may alter their judgment or ability to provide safe and effective patient care.
    • Performing all examinations with ALARA - as ultrasound energy poses a theoretical risk to the patient, the principle of nonmaleficence requires sonographers to keep energy exposure as low as reasonably possible, to achieve desired results.
    • Reading current medical literature to stay abreast of new developments related to patient safety.

2. Beneficence

  • Beneficence involves acting in the best interest of the patient, promoting their health and well-being to ensure a positive outcome. It goes beyond the ethical principle of avoiding harm (nonmaleficence) and seeks to find what benefits the patient the most rather than simply avoiding harm to them.
    • ensures there is a greater balance of ‘goods’ over ‘harms’
    • requires clinical justifications for interventions
  • In practice:
    • Beneficence is like nonmaleficence and also requires competency, knowledge, and excellent sonographic skills to ensure that patient receives greatest benefit from examination.
    • Beneficence encourages sonographers to go beyond minimum standard protocol and extend the examination if appropriate to obtain the most accurate possible diagnosis.

Beneficence and Nonmaleficence

  • Beneficence focuses on actively doing good and providing benefit.
  • Nonmaleficence focuses on avoiding harm and minimizing risks.
  • In healthcare, beneficence and nonmaleficence often work together.
  • For example, transvaginal scan of the pelvis.

3. Autonomy

  • Autonomy is the right to self-determination, respecting a patient's right to make their own healthcare decisions. Sonographers also have an obligation to protect and advocate for individuals with diminished capacity to make decisions (e.g., minors, cognitively impaired patients).
  • The patient’s values, beliefs, and preferences and perspectives should be respected and upheld equally alongside the clinician’s perspective on patient’s interests.
  • Avoid interfering with the patient’s ability to express and implement their preferences unless necessary.
  • When there is uncertainty about the clinical benefits or risks of ultrasound, patients must be informed to allow them to make their own choices about managing the uncertainty in line with their preferences.
  • In practice:
    • Informed consent is autonomy-based right of the patient, and we, as sonographers, have autonomy-based obligations regarding the informed consent process.
    • Informed consent includes providing
      • information about what sonography examinations can and cannot detect,
      • sensitivity and rates of false-negatives and false-positives of sonography
      • techniques employed
      • the difficult and sometimes uncertain interpretation of sonographic images.

Beneficence and Autonomy

  • May have to balance ethical principles when a health professional’s duty of beneficence may suggest one course of action and the patient may choose another.
  • In these cases, beneficence must be balanced by respect for the person’s autonomy.
  • For example, balancing the diagnostic benefit of a transvaginal vs the patient’s right to decline on personal preference or values.

4. Justice

  • Justice deals with the concept of fairness in healthcare, ensuring that all patients have equal access to treatment and care without discrimination.
  • In practice, sonographers should strive to ensure:
    • translators are used when necessary to provide adequate and appropriate communication with all patients.
    • disabled patients have access to reasonable accommodations and pathways and that obese patients have comfortable chairs, gowns, and stretchers.
    • children, adults, and geriatric patients alike feel equally welcome and cared for within the ultrasound room.
    • there is standardization of protocols.
    • men and women with similar symptoms should receive similar tests and interventions
  • The principle of justice implies that healthcare professionals should act in accordance with the best interests of the community.
  • If a group is denied services or asked to assume an undue burden to obtain care provided to others, justice is not being served.

Summary

  • Understanding medicolegal and ethical considerations equips sonographers to provide safe, legal, and ethical care while protecting themselves from professional and legal risks.
  • These concepts are foundational to professional practice, ensuring patient rights, safety, and trust remain central to the role of the sonographer.