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The ethical pathologist


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The ethical pathologist

  1. 1. The Ethical Pathologist<br />
  2. 2. Odontologicalethics<br /> Duty in good faith is ethical (independent<br />of outcome)<br /> Consequence-based ethics<br /> Acting to increase health benefit is ethical<br /> Classical clinical ethics (4-principles)<br /> Autonomy & beneficence<br />justice<br />Ethics in medicine (briefly)<br />
  3. 3. Clinical ethics applied to pathology<br /> 4-principles apply but are clumsy<br /> Designed for face-to-face patient care<br /> Ethics in pathology<br /> Autopsy and tissue retention<br /> Surgical pathology: not much written!<br />Ethics in pathology<br />
  4. 4. 'Now this quack wants me to see a specialist- what the hell is a PATHOLOGIST!?<br />
  5. 5. Leave clinical ethics aside<br />Concentrate on ethics for pathologists<br />See how this can help us be ethical pathologists<br />Our approach in this Lecture<br />
  6. 6. Pathologists are Guardians of the Wax<br />
  7. 7. Legal issues and the pathologist<br />Civil liability<br />Licensure & disciplinary actions<br /> Torts and discipline<br />Misdiagnosis of biopsies and cytology<br />Breast, prostate, lung, pap smears<br /> Misdiagnosis of forensic autopsies<br />Murder, child abuse<br />Ethical issues are often legal<br />
  8. 8. How can we be ethical pathologists?<br />
  9. 9. To whom we owe a duty Trust relationships:<br />Patients<br /> Other physicians<br />Pathologists, surgeons, oncologists<br /> Technologists<br />Histology and cytology<br />Medical community<br /> Public<br /> Courts and Coroner<br />
  10. 10. Surgical pathology and cytopathology<br />Medical autopsy<br /> Forensic autopsy<br /> Second opinion reviews***<br />Oncology: Cancer treatment<br />Forensic: Expert witness<br /> Today we will concentrate on surgical<br /> pathology<br />The scope of our work: ethicseverywhere<br />
  11. 11. Ethical issues most frequent with<br />misdiagnosis<br /> Misinterpretation (under & over-call)<br /> Disclosure of errors<br /> Shared decision-making for patients<br />Pathologist = tissue diagnosis<br />Clinicians = clinical diagnosis<br /> Who is responsible for an inappropriate<br /> treatment decision?<br />The ethical surgical pathologist<br />
  12. 12. Over-call misinterpretation<br />Un-necessary operation (organ removal)<br />Chemo and radiation therapy<br />Premature death by therapeutic<br /> complications<br /> Under-call misinterpretation<br />Delayed diagnosis (increased stage)<br />Delayed therapy<br />Premature death by disease<br />Pathologic misdiagnosis<br />
  13. 13. Clinical & radiologic<br /> Mobile nodule (3 cm)<br /> Not cystic or microcalcified<br /> Needle core biopsy<br />High-grade invasive ductal carcinoma<br />No excisionalbiopsy<br /> Radical mastectomy<br />No quick section or sentinel node biopsy<br />50 year old woman with abreast lump<br />
  14. 14. Primary breast lymphoma<br /> Un-necessary radical operation<br /> Treatment would have been different<br /> Post-operative complications<br />Wound infection<br />Lymphedema of arm<br />Increased risk of other complications<br />Radical mastectomy<br />
  15. 15. Pathologist-patient relationship<br />Punch's view of one patient's reaction to the new methods of diagnosis<br />
  16. 16. PATIENT<br /> Right diagnosis<br /> Blind trust<br /> Definitive<br /> Since therapy is based on it<br /> Anonymous<br /> Faceless pathologist<br /> “The Lab”<br />
  17. 17. PATHOLOGIST<br /> Tissue diagnosis<br />Gold standard<br /> Objective<br />Scientific and<br /> minimally subjective<br /> Anonymous<br />Faceless patient<br />Patient is a number<br />
  18. 18. A slide is part of a patient Not only an <br /> exercise in pattern recognition<br />We often dissociate reading slides with a<br /> pivotal medical act<br />Pressures of work often make us<br /> concentrate on signing out rather <br /> than our role as medical consultants<br />The ethics of diagnosis: 1<br />
  19. 19. How we act in an ethical dilemma<br /> speaks about us as physicians and people<br /> Pride (arguing about being right when you<br /> are wrong)<br /> Shame of making a mistake<br /> Questioning your worth as a person and a<br /> physician<br /> People may judge you on how you react<br />The ethics of diagnosis: 2<br />
  20. 20. Never cover-up a mistake<br />No one wants to make mistakes but we<br /> all do<br /> Rarely (2% in surgical pathology)<br /> Most errors do not cause patient harm<br /> Some errors lead to serious harm, loss of<br /> liberty, or death<br /> Make a commitment to life-long learning<br />The ethics of diagnosis: 3<br />
  21. 21. Good ethics comes as much from the search to be ethical as it does from understanding ‘ethics<br />How to be an ethical pathologist<br />