“We need to define and articulate the ethics of IR”

Eric J Keller

Interventional radiology (IR) is a growing, dynamic field, still working to define its professional identity— who we are and where we are going as a specialty. I believe an important part of that maturation rests on our ability to articulate our collective values as a professional group, particularly in regard to challenging questions that arise in our work. Through my ethics graduate education and medical training, I have come to view ‘ethics’ as just that— the collective values of a group of people. So, to help IR establish itself as a clinical specialty, we need to define and articulate the ethics of IR.

Unfortunately, many common approaches to ethics tend not to feel particularly practical or helpful in day-to-day clinical practice. Ethics often feels abstract and verbose and tends to treat clinicians as a monocultural group, assuming that the ethical issues and solutions for IR are the same as internal medicine or gynaecology. Although there are certainly common issues across healthcare, medical specialties have remarkably distinct cultures, workflows, and ways of thinking. As such, my hypothesis has been that the salient ethical issues and means of navigating
them probably vary in important ways across specialties. To make ethics feel more practical and useful, I decided to test out an applied, specialty-specific approach to ethics in IR. Instead of starting with ethical theory and a top-down approach, I work bottom-up, starting with an understanding of how people in IR are approaching an ethical issue and why, and then using that understanding alongside ethical theory to design practical approaches and tools to better navigate those issues. The ultimate goal is to foster an ethics consciousness in IR, a common understanding of our shared values and how best to navigate the sticky situations we face as a specialty.

To do this, I founded a multi-institutional working group of faculty and trainees focused on research, education, and public relations using this new approach. Creating something new always comes with challenges and setbacks, but we now have approximately 30 people affiliated with the group, and since being founded in 2019, we have published over 20 manuscripts, given multiple invited lectures at major IR conferences, and have a column in Seminars in Interventional Radiology called the ‘Ethics Corner.’ We have found that IRs face a wide array of ethical issues in their work; the vast majority consider these to be important issues but state that they often feel limited by a lack of tools and specific guidance for navigating them. Common issues include differentiating palliative from futile care, managing complications, consent and surrogate decision-making, conflicts of interest and research ethics, tribalism and medical business ethics, and social media ethics.

For example, consent is a ubiquitous part of our daily workflows and right at the core of our relationships with patients and families. Nevertheless, studies suggest that consent practices tend to be limited in quality and completeness across healthcare. This is important not only ethically, but because poor periprocedural communication and understanding is a common source of medical mistakes and lawsuits. We first completed an exploratory study of consent in IR, finding that the dynamic nature of IR practices and limited baseline public awareness can make truly informed consent particularly challenging in our specialty. To improve consent practices, we have not only been working to develop more engaging educational resources on ideal consent practices for IR, but also better patient decision aids (PDA).

PDAs are handouts, videos, or other tools that present balanced information on the risks, benefits, and alternatives of a healthcare decision, ideally at the average reading level (seventh grade in the USA), using patient-friendly, plain language. Unfortunately, current PDAs for image-guided procedures tend to be limited in quality and consistency, so we partnered with a not-for-profit called The Interventional Initiative to create better PDAs via an extensive vetting process. We then trialled them at two institutions where people were randomised to receive a PDA or not, while waiting to talk to their clinician. This way, clinicians did not have to do anything differently; rather, we took advantage of dead time in the patient flow, which is ideal for sustained adoption. We found that the people who received a PDA were not only more likely to have better understanding and satisfaction, but were also more likely to feel that their clinician had spent enough time with them and answered all their questions.

This is one example of our applied approach. Rather than writing a 50-page analysis about how interventional radiologists should ‘do better’ at consent, we instead assume that people are doing their best, try to understand current barriers, and construct environments and workflows that support better consent practices in IR without requiring more time or energy.

We are always looking for collaborators and partnerships to help establish our collective values as interventional radiologists.

Eric J Keller is a resident physician at Stanford University, Stanford, USA and founder of the Applied Ethics in IR working group.

Disclosure: Keller is a board member of The Interventional Initiative.


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