Moral Principles and Medical Practice: The Role of Patient Autonomy in the Extensive Use

of Radiological Services
Author(s): B. Hofmann and K. B. Lysdahl
Source: Journal of Medical Ethics, Vol. 34, No. 6 (Jun., 2008), pp. 446-449
Published by: BMJ
Stable URL: http://www.jstor.org/stable/27720107
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1 University College of Gj0vik,
Faculty of Health Care and
Nursing, Gj0vik, Norway;
2 University College of Oslo,
Faculty of Health Sciences and
Section for Medical Ethics,
Faculty of Medicine, University
of Oslo, Norway
Correspondence to:
BJ0IT1 Hofmann, Section for
Medical Ethics, Faculty of
Medicine, University of Oslo, PO
Box 1130, Blindem N-0318,
Oslo, Norway;
b.m.hofmann@medisin.uio.no
Received 27 September 2006
Revised 6 February 2007
Accepted 13 February 2007
Moral principles and medical practice: the role of
patient autonomy in the extensive use of radiological
services
B Hofmann,1'2 K B Lysdahl2
ABSTRACT use of radiological examinations. Does increased
There has been a significant increase in the use of respect for patients' autonomy change the use of
radiological services in the past 30 years. There are many radiological services? There is little empirical
reasons for this, but one has received little attention: the knowledge about this, and in order to answer this
increased role of patient autonomy in healthcare. Patients question we need to know why and how patient
autonomy can have an influence. Therefore we
demand x rays, CT scans, MRI, and positron emission
tomography scans. The key question in this article is how have investigated how patient autonomy is rele
a moral principle, such as respect for patient autonomy, vant to the increased use of radiological services.
can influence the extension of radiological services. A We do this by reviewing the literature in radi
ology?that is, literature concerning the extension
literature review reveals how patient autonomy is
acknowledged in radiology, and how it is used both to of radiological services where patient autonomy is
explain and to justify the increase in radiological frequently referred to as a relevant factor.
examinations. Furthermore, it also shows how the It is, of course, not surprising if moral principles
premises favouring patients' exercise of their autonomy that regulate how healthcare services are offered
(for example, through legislation) influence the
are not always present, which makes patient autonomy
subject to adverse side effects and even abuse. Patient extension of a healthcare service. However, what is
autonomy can be used to reduce the professionals' not obvious is whether the extension of radiologi
responsibility for radiological examinations (by avoiding cal services results from the good intentions behind
complaints and lawsuits), to increase the popularity of the the moral principle of autonomy or from other, less
profession (by giving the people what they want), to overt, intentions.
increase the income of the professionals or their
institutions, and to promote professional activity. Patient THE CONTEXT OF PATIENT AUTONOMY
autonomy intended to reduce paternalism, to legitimise
At the outset of the inquiry, it is important to
otherwise morally unjustifiable actions (such as exposure
acknowledge that the role and effects of the
to radiation), and to protect patients, can easily be used principle of patient autonomy depend on the
as a moral means for opposite ends. These adverse
context. They may depend on the mode of
effects are not peculiar to radiology. However, they referral?for example, whether the examination is
emerge particularly clearly in explanations and justifica requested by the patient, is by referral from a
tions of the substantial increase in radiological services, general practitioner, or is by self-referral of a
as well as in debates on overuse of radiological services. physician.
Moreover, the idea of patient autonomy can be
relevant both as an explanation of why there is
The number of radiological examinations has extended use of radiological services and as. a
increased substantially over time.1-3 Annual utilisa justification of why this is right. Correspondingly,
tion is increasing typically by 5-11% in developed an analysis of the role of patient autonomy will
countries, and the appetite for images is charac depend on the concept of autonomy?for example,
terised as bottomless1.4 5 There are many reasons whether it is viewed as a (consumer) right, a moral
for this increase. New technology, physician self principle, or a cognitive capacity. Whether the
referral, altered reimbursement systems, increasing patients actually are autonomous (as commonly
patient demands, commercial liability office-based understood) in situations where their autonomy is
imaging by untrained personnel, professional inse used as an explanation or justification is also
curity and increased fear of lawsuits, to mention relevant to the role of autonomy?for example, is
only a few. autonomy used as a moral device to legitimise
Many of these aspects have been discussed otherwise unwarranted actions?
extensively in the literature. One aspect that has Hence, patient autonomy can be relevant to the
received undeservedly little attention is how moral extended use of radiological services in a number of
principles, such as patient autonomy, influence the ways. As our aim is to investigate how it can
'The estimated level of unnecessary examinations is reported to be
influence the extension of radiological examina
between 10% and 40% in industrialised countries,6-11 and it is argued
tions, we do not restrict the investigation to one
that increased medical imaging does not result in better healthcare specific context. Patient autonomy can influence
outcomes.1213 Although overuse of radiological examination is the extension of radiological examinations both by
morally relevant, it is relevant here only with respect to highlighting intent and as a desirable side effect. Both aspects
the role of patient autonomy in the increase of radiological are acknowledged in the literature, and both
examinations.
deserve scrutiny.
446 J Med Ethics 2008;34:446-449. doi: 10.1136/jme.2006.019307
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AUTONOMY IN HEALTHCARE
Standard roles of patient autonomy in healthcare in general are
said to be
to respect a basic human right of self-determination or
promoting a fundamental human value
to legitimise otherwise unwarranted interventions (such as
exposure to radiation)
to protect the individual against encroachment (by requiring
voluntary informed consent)
to support the public's trust in the healthcare system (for
example, through informed consent)
to promote rational decisions (by increasing patients'
understanding)
to increase transparency in the physician-patient relation
ship and to reduce paternalism.14
It is quite clear that patient autonomy plays such roles within
radiological services and that this influences the use of health
services. However, as the review of the radiological literature
shows, the role of autonomy may also depart from these ideal
intentions.
SELF-DETERMINATION AS A LEGITIMISING HUMAN RIGHT
One obvious explanation for the extension of radiological
services is that it is a result of increased self-determination.
Patients have become more educated and demanding with
respect to healthcare services. Groups with higher socioeco
nomic and educational status take the lead; they "... use
services more readily and demand more elective services ...7;.15
From the patients' perspective, access to healthcare services is
conceived of as a "human right": "More and more often
patients perceive CT and MRI scans as something they are
entitled to."16 They may feel neglected if the professionals refuse
to give them an examination.17 The public requests greater
availability of radiological services.18
Correspondingly, it can be argued that measures to reduce
uncertainty are more prevalent in ("risk-free") diagnostics than
in treatment. Hence, the idea that it is better to be safe than
sorry may be stronger in diagnostics. This coincides with a
general increase in people's need for security, safety and control.
Besides, it has been argued that professionals meet patients'
demands because there are "no strong professional or legal
sanctions against unnecessary X-ray."19 Moreover, competition
over patients (and turf wars) may make professionals more
sensitive to patients' requests.
Hence, there are many reasons why professionals are
inclined to respect patients' autonomy when they ask for
radiological examinations. This can help to explain the
increase in use of radiological services. Respect for patients'
autonomy is used both to explain the phenomenon and to
justify it. As one person put it, "We have to respect patients'
autonomy and give them what they want".20 It is claimed
that a "liberal" attitude to utilisation of radiology is a modern
response to changes in society. To respond in compliance with
patients' requests and demands for radiology is a result of a
d?mocratisation process, also reflected in legislation (patients'
rights acts).21
Hence, a general shift in justification for radiological
examinations, from paternalism to respect for patient auton
omy, can lead to and explain the increased use of examinations.
However, although partly correct, this is an idealisation
and oversimplification of the role of the moral principle of
autonomy.
J Med Ethics 2008;34:446-449. doi:10.1136/jme.2006.019307 447
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Clinical ethics
AUTONOMY: FROM "WASTE OF TIME" TO A LEGAL
REQUIREMENT
Historically, radiologists have argued that concern for autonomy
is unnecessary or "a waste of time77, and that informing patients
about examinations in order to promote their autonomous
decisions would result in ''wholesale refusal of patients to
undergo the procedures77.22 Hence, a paternalistic attitude appears
to have been prominent in radiology, as in other specialties.
However, as it was documented that patients did not refuse
procedures after being informed,22 and that patients were more
inquiring and informed than expected,23 it was argued that
informing patients about complications would make them
anxious and apprehensive and thus worsen the outcome.23
However, once the requirement for informed consent meant
that patient autonomy was "imposed by law77,24 the argument
based on beneficence lost its prominence.
AUTONOMY, INDIVIDUALISM AND CONSUMERISM
Just as in healthcare in general, radiologists are subject to
stronger notions of individualism and liberalism than before.
This trend appears to have influenced the concept and position
of patients7 autonomy in general.25-27 Furthermore, it is argued
that the individualistic interpretation of patient autonomy
reduces the patient-doctor relationship "to that of client and
technician77.28 Radiologists, because their interaction with
patients often is brief and episodic, may be particularly receptive
to the role of service provider. Hence, the consumer model
appears to play an important role in radiology, as in other parts
of healthcare.9
Strong consumer rights and radiological services conceived of
as easy, painless and risk free may have contributed to
entrenchment of the individual consumer model. However,
the practice in radiology differs from that in a traditional
consumer model, as most patients do not themselves pay for
imaging services. Nevertheless, it appears that patients behave
more like consumers than before, providers describe their
activity as "production77, and reimbursement systems encourage
competition?making the relationship between radiologist and
the patient more like that between a customer and a service
provider in a market.
Corresponding to the general trend of individual consumer
ism, which could explain part of the increase in use of
radiological services, consumerism is also used as a way to
justify and promote a liberal practice with respect to examina
tion decisions. Professionals supporting self-referrals by patients
"advocate patient autonomy and unrestrained imaging77.29 It is
argued that there is no difference in principle between letting
patients order examinations themselves and doing examinations
requested by clinicians (whose referrals radiologists hardly ever
question), and since we allow people to decide more serious
medical matters, such as abortion, it is hard to argue that they
should not decide on matters of radiological services.30
In mixed healthcare systems (such as the Norwegian system),
representatives of market-based medical services tend to promote
the individual-consumer aspect of patient autonomy more
vigorously than their colleagues in public healthcare.21 This, of
course, corresponds with the fact that consumer ideology (still) is
more forceful in private than in public healthcare. It also
corresponds with studies showing that private radiological
institutions contribute to the increase in examinations31 (includ
ing those for which medical justification is controversial).
Hence, a liberal, consumer-based conception of patient
autonomy is used both to explain and to justify the extended
use of radiological services: "We give them what they rightly
 Clinical ethics
demand!" However, the justification strongly depends on true
premises: that patients are autonomous. If the premises are not
clear or true, so-called autonomy may have some adverse side
effects.
AMBIGUOUS PREMISES FOR AUTONOMY
The general concerns about whether the premises for autonomy
are true appear to be relevant in radiological services?that is,
whether patients have sufficient understanding of the health
care service they require. Patients' sources of knowledge are not
always neutral, balanced or evidence based:32 33 radiological
services often do not provide sufficient information10 34 and
involved risks are "understated with the intention to reassure
patients".10 There is also a question of patients' comprehension
of information when it is provided.35 Their understanding may
not be exhaustive with respect to diagnostic accuracy,
complications and outcome.
The prerequisite deliberative capacity for autonomy is
questioned in radiology as in healthcare in general.29 36 37 Even
healthy (asymptomatic) people might be in a state of anxiety,
due to fear of potential disease. Besides, in radiology "the harm
patients fear most is the harm caused by unwise choice. And
exactly because patients are afraid of choosing foolishly they
delegate decisions",36 or, more generally, patients may decide to
have an examination in order to avoid "anticipated decision
regret".38 patient that this is what is happening, it undermines the
Additionally, patients may be under substantial pressure? premises for their autonomous choice (because of a lack of
from family members, professionals or marketing forces? understanding).
reducing the voluntariness of their decision. Another influence
reducing real autonomy is the belief in technology and progress.
The notion that "you should take advantage of everything that
modern medicine can offer"36 appears to be particularly promi
nent with respect to radiology. It may be counter-intuitive to
people that information such as that provided by a radiological
examination might not be useful to them.36 The fascination with
the capability of radiology, especially the high-tech procedures,
provides an imperative towards examinations. Correspondingly,
it is argued that personal autonomy is threatened because
radiology indirectly undermines people's ability to assess their
own health, and that they must undergo imaging tests in order to
know whether they are healthy or not.39
Moreover, people's perception of risk related to radiological
services is low, if acknowledged at all. Accordingly, one could
argue that it is unlikely that patients would refuse an examination
when one is offered or available. General notions, such as "to
know is better than not to know", "hi-tech is better than lo-tech
(or no-tech)", "more choice is better than less",40 and a general
belief in progress can undermine (consumer) autonomy, in
healthcare in particular and in commerce in general.
Hence, with reference to the radiological literature it appears
that the basic premises for autonomy are not always met.
Therefore, even if an individual-consumer conception of patient
autonomy may seem to be a sound explanation for the
increased use of radiological services, it may not be valid as a
justification if the premises for consumer autonomy are not
met. Furthermore, if general criteria for autonomy are not met,
appealing to persons' autonomy when deciding in favour of
radiological examinations may have adverse effects.
ADVERSE EFFECTS OF PATIENT AUTONOMY
The continued insistence on patient autonomy even though the
premises on which it is based may not be met has been
explained as a way to promote professionals' rather than to
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promote patients7 autonomy.14 41 In particular, patient auton
omy (regarding consent to a radiological procedure) can reduce
the risk of a lawsuit.42 Hence, autonomy may fulfil a protective
role, but to the professionals instead of to patients. Rather than
preventing paternalism, autonomy may become a tool for its
covert promotion.
Furthermore, patient autonomy is used as an argument to
allow controversial procedures, as in CT screening for lung
cancer.20 29 30 It is far from obvious that patients know that these
procedures are controversial.
Correspondingly, patient autonomy may result in a shift in
responsibility in general?that is, in the legal sense in order to
avoid lawsuits, and also in a moral sense. An autonomous
person demanding a particular examination, possibly against
professional advice, gains responsibility. This is an expected
result of reduced paternalism: the paternalist is responsible, the
(radiologist as a) service provider is not.37
Although most professionals set limits on patients7 self
determination?for example, with respect to liposuction for
people with anorexia?they appear to have a different view on
unnecessary (low-risk) radiological examination for reassurance
and to relieve anxiety.43 44 This is not the place to enter into the
interesting debate on therapeutic use of diagnostic radiology.
The point is that there are challenges associated with
transferring the responsibility for professional issues to patients,
both morally and legally. Moreover, if it is not clear to the
The side effect that patients can be made consumers on
demand, forcing them to make decisions beyond their capa
city,32 is also noted in radiology.30 Claiming that "it is for you to
decide77 may go beyond mere respect for autonomy. However,
although this potential side effect has been noticed, there is no
evidence that it is acknowledged by radiologists in general.
Moreover, because the increased use of radiological services
comes at a substantial cost,518 4145 it may result in a reduction of
available resources for other kinds of healthcare. If this results
from increased autonomy, we have a paradox: the increased
autonomy (of patients with regard to radiological services)
reduces the autonomy of other patients?which is contrary to
standard conceptions of autonomy. (The relevance of this is
demonstrated by the great geographical variations in the use of
radiological services.518 31)
PATIENT AUTONOMY AND PROFESSIONAL POWER
So far we have investigated the roles of patient autonomy in
explaining and justifying the extension of radiological services.
Although many of the roles are based on good intentions, some
may have side effects that counter these intentions. We have so
far not argued that anyone promotes autonomy because of
these side effects.
Nevertheless, it is worth asking who could gain from such
side effects of patient autonomy in radiology. Healthcare
professionals could gain by reducing their professional, legal
and moral responsibility (as explained above), by increasing
their professional power (under cover of respecting patients7
autonomy), by having an excuse for pursuing professionally
interesting issues, by increasing the popularity of the profession
(because we give the people what they want), and by increasing
the professional activity or status. Moreover, professionals may
have an economic interest in "respecting patients7 auton
omy77? for example, professionals can come to "rationalize
medical unsound or financially self-interested decisions as
448 J Med Ethics 2008;34:446-449. doi:10.1136/jme.2006.019307

autonomy-respecting decisions".19 Industry could benefit from
the extended use of radiological technology. Healthcare institu
tions could gain economically.46 Hence, although we have no
evidence that patient autonomy is used to covertly suppress or
abuse people or patients, review of the radiological literature
indicates that this is a possibility that should be taken into
account.
AUTONOMY AS AN END AND A MORAL MEANS
Personal autonomy is a well-established moral principle, with
many praiseworthy roles that are widely acknowledged in
radiological literature. However, patient autonomy also has less
overt and appealing functions. It can be used as a protective
device to reduce professional responsibility in general and to
avoid lawsuits in particular. It can be used to promote
professional pecuniary interests and to provide opportunities
to perform certain procedures. These adverse functions are not
peculiar to radiology, but they become particularly clear in
explanations and justifications of the substantial increase in
radiological services and in debates about their overuse. Hence, a
moral end (patient autonomy) can be applied as a moral means
for quite opposite purposes (such as paternalism).
Our analysis is not a valid argument against patient
autonomy: we have only pointed out some of the possible
adverse (opposite) effects, as well as which premises that must
be true if patient autonomy should play legitimate roles in
medical decision-making with respect to radiological services.
Just as there can be both use and misuse of radiological services,
there can be use and misuse of patient autonomy. Our intention
is to point out the relationship between them.
CONCLUSIONS
Although the literature on radiological services shows an
acknowledgement of many challenges with patient autonomy
discussed in the general literature, there is little evidence that
this reflects a general awareness among radiologists. To what
extent radiologists actually use patient autonomy to legitimate
a liberal practice is an empirical question, which we will address
in an empirical study. Our point here has been to investigate
how autonomy can be misused. Moral principles can play an
important role in regulating the use of healthcare services, both
with respect to how health services are offered and accepted and
with respect to their extension.
Acknowledgements: We are grateful to the reviewers for relevant, inspiring and
encouraging comments.
Competing interests: None declared.
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