The Ethical Pathologist

Odontological ethics Duty in good faith is ethical (independent of outcome) Consequence-based ethics Acting to increase health benefit is ethical Classical clinical ethics (4-principles) Autonomy & beneficence justice

Ethics in medicine (briefly)

Clinical ethics applied to pathology 4-principles apply but are clumsy Designed for face-to-face patient care

Ethics in pathology Autopsy and tissue retention Surgical pathology: not much written!

Ethics in pathology

'Now this quack wants me to see a specialist- what the hell is a PATHOLOGIST!?

Leave clinical ethics aside Concentrate on ethics for pathologists See how this can help us be ethical

pathologists

Our approach in this Lecture

Pathologists are Guardians of the Wax

Legal issues and the pathologist Civil liability Licensure & disciplinary actions Torts and discipline Misdiagnosis of biopsies and cytology Breast, prostate, lung, pap smears Misdiagnosis of forensic autopsies Murder, child abuse

Ethical issues are often legal

How can we be ethical pathologists?

Patients Other physicians Pathologists, surgeons, oncologists Technologists Histology and cytology Medical community Public Courts and Coroner

To whom we owe a duty Trust relationships:

Surgical pathology and cytopathology Medical autopsy Forensic autopsy Second opinion reviews*** Oncology: Cancer treatment Forensic: Expert witness Today we will concentrate on surgical pathology

The scope of our work: ethicseverywhere

Ethical issues most frequent with misdiagnosis Misinterpretation (under & over-call) Disclosure of errors Shared decision-making for patients Pathologist = tissue diagnosis Clinicians = clinical diagnosis Who is responsible for an inappropriate treatment decision?

The ethical surgical pathologist

Over-call misinterpretation Un-necessary operation (organ

removal) Chemo and radiation therapy Premature death by therapeutic complications Under-call misinterpretation Delayed diagnosis (increased stage) Delayed therapy Premature death by disease

Pathologic misdiagnosis

Clinical & radiologic Mobile nodule (3 cm) Not cystic or microcalcified Needle core biopsy High-grade invasive ductal

carcinoma No excisional biopsy Radical mastectomy No quick section or sentinel node biopsy

50 year old woman with abreast lump

Primary breast lymphoma Un-necessary radical operation Treatment would have been different Post-operative complications Wound infection Lymphedema of arm Increased risk of other complications

Radical mastectomy

Pathologist-patient relationship

Punch's view of one patient's reaction to the new methods of diagnosis

PATIENT Right diagnosis Blind trust Definitive Since therapy is based on it Anonymous Faceless pathologist “The Lab”

PATHOLOGIST Tissue diagnosis Gold standard Objective Scientific and minimally subjective Anonymous Faceless patient Patient is a number

A slide is part of a patient Not only an exercise in pattern recognition We often dissociate reading slides with a pivotal medical act Pressures of work often make us concentrate on signing out rather than our role as medical consultants

The ethics of diagnosis: 1

How we act in an ethical dilemma speaks about us as physicians and

people Pride (arguing about being right when you are wrong) Shame of making a mistake Questioning your worth as a person and a physician People may judge you on how you react

The ethics of diagnosis: 2

Never cover-up a mistake No one wants to make mistakes but we all do Rarely (2% in surgical pathology) Most errors do not cause patient harm Some errors lead to serious harm, loss of liberty, or death Make a commitment to life-long learning

The ethics of diagnosis: 3

Good ethics comes as much from the search

to be ethical as it does from understanding ‘ethics

How to be an ethical pathologist