pathology situational ethics

8/8/2019 Pathology Situational Ethics

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Situational ethics inpathology

Michael Pollanen

Pathologist


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Ethics in pathology seminars (4)

1. The ethical pathologist2. The ethics of human tissue use

3. Situational ethics in pathology4. The ethical forensic pathologist


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Ethics in pathology: review1. The ethical pathologist

How to be ethical when doing pathology?Mis-diagnosis: patient harm , and damageto trust relationships

2. Ethical use of human tissueTissue retention and bankingEthics of tissue chipping

Pathologists are gatekeepers


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Clinical and pathological ethics

ClinicalAutonomyBeneficenceNon-maleficenceJustice

PathologicalValuesTrustHarmVirtues


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Our approach in this seminar

Explore ethics for certain challengingsituations that pathologists faceSee how we respond to the situationsDetermine what our ethical

obligations are and to whom


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53 year old man withabdominal pain

ClinicalModerately intense pain, lower quadrantsAppendicitis

LaparoscopyPeritonitisPerforated rectosigmoid diverticulitis

LaparotomySegmental resection with partial omentalresection


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Surgical pathologyGross

Colonic segment unremarkableSerosal and omental exudate

MicroscopicInflammatory and myofibroblastic reactionin mesocolon and omentum (septal)Colonic mucosal and wall unremarkable

Sclerosing mesenteritis?Consultation obtained from a trustedcolleague


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Second opinion

Second pathologistPeritonitis and reactive changesInfection/inflammation in peritoneal cavity

First pathologists addendum reportDescriptive diagnosis: unusualinflammatory and myofibroblastic reactionAdvise to clinician: re-review clinical andradiological results to reveal diagnosis


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Follow-up: 2 years later

ClinicalNodule in laparotomy scarMalignant mesothelioma

Review of pathologyInitiated by first pathologist (not requestedby another party or patient)Diffuse epithelial-type malignantmesothelioma with septal infiltration andmyofibroblastic/inflammatory reaction


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Ethical questions

Should the first pathologist write anaddendum report and amend thediagnosis ?What ethical duty does the firstpathologist have to the secondpathologist and vice versa?What role does the pathologist have indisclosure to the patient ?


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Ethical questions: resolutions

The pathologist amended the diagnosisand informed the second pathologist

The second pathologist agreed with theamended diagnosis on re-reviewThe pathologist did not initiate disclosure

to the patient directly


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Bigger ethical questions

Did the pathologists harm the patient?Misdiagnosis = delay in diagnosis

Did the pathologists do their duty ?Well sampled, diligently analysed, involveda consultant

How do the pathologists come to termswith their mistake?

Act ethically & recognize the pitfalls withmesothelioma


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30-year old woman with pelvicpain

Clinical and radiologicalG0P0Related to menstrual cycle

Pelvic examination unremarkableUltrasound shows ovarian cysts(interpreted by gynecologist)

EndometriosisHysterectomy BSO


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Pathology

Gross and microscopicNormal uterus, tubes and ovariesFollicular cysts

No endometriosisReport

Reported as no pathologic diagnosis

Not the first time this has happened


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Ethical questions

Should the pathologist discuss the casewith the surgeon apropos excisingnormal tissue?Should the pathologist inform themedical advisory committee (MAC) oranother party?What steps should the pathologist taketo make sure this is not repeated ?


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Ethical questions: resolutions

The pathologist shouldInform the tissue audit committee in thehospital that reports to the MACDiscuss the case with the surgeon

The pathologist should notAlter the surgical pathology report

Come to a premature conclusion about thesurgeons competence


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37-year-old woman with arenal transplant

ClinicalFailed renal transplant (renal arterialocclusion)Kidney explanted

PathologyPseudomonas infection of renal artery

Renal arteritis and thrombosis withinfarction of kidney


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What is the pathologists duty?

As a surgical pathologistMake the correct diagnosisMake a timely diagnosis

As consultant and medical specialistRecognize the urgency of the case(pseudomonas infection)

Inform the nephrologist immediatelyWrite a note in the patients chart


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Follow-up: the next day

ClinicalPatient treated for septicemiaSurvived

Organ donor programmeMultiple recipients infectedSome died

No autopsy was performed on donor


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Ethics of second opinions

Common in cancer treatmentTwo types of second opinions

Initiated by a pathologist who would likehelp from another pathologistInitiated by referral to a different treatmentcentre, to ensure diagnosis is correct

before treatment


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Second opinions for helpWhen?

When the patient might benefit from itWhy?

If you are uncertain about diagnosis.

Who?A sub-specialist that you trust.

What?Biopsies before major planned therapyRecognize pitfall diagnostic areas


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Second opinions for treatment

Enhances patient care by reducingerrors (mostly related to stage)Second opinions are not necessarilybetter than first opinions

Either or both pathologists can be wrongMostly pathologists agree


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Ethical second opinions

Will always enhance patient careMaking the right diagnosisMaintain trust relationships particularlyamong pathologists

It is almost never appropriate toJudge the first pathologists competencyunless you believe he/she is unsafe

Undermine the first pathologists ability todo his/her job effectively


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Healthcare delivery failure andpathology

Pathologic misdiagnosis +dysfunctional healthcare system =catastrophic failure in health caredeliverySystemic and large-scale failure ofhealthcare can sometimes be traced tobad pathology


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Gisborne cervical screeninginquiry (New Zealand)

Dr Bottrill missed a case of cervicalcancer when reading a pap smearSuspected large-scale under-reporting ofpap smears in Gisborne health district inthe north island of NZPublic inquiry

Cytology reviewTestimonySystemic reforms


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Review of pap smears

12,108 women22,978 pap smears reviewed

616 women: ASCUS-H, HSIL, cancer

5% of total patient population

519 of 616 women: Misdiagnosed84% of high grades lesions missed

Only 9 of 616 women: Lost to follow up


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Gisborne: How did it happen?

PathologistInsufficient skillLack of CME in cytology

No biopsy correlationScreening system

No quality assurance

No proficiency or auditNo consist referral practices


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How to be an ethical pathologist

Good ethics comes as much fromthe search to be ethical as it doesfrom understanding ethics

pathology situational ethics

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