The Ethics Of Retail Radiology

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"The Ethics of Retail Radiology

Imagine a future where diseases are caught in their infancy and disorders are slowed, stopped and even reversed before patients ever suffer from the symptoms. With AccuScan, that future is available right now, right here in Salt Lake City (1).

Nestled between a megaplex and a boutique in the Gateway outdoor mall, AccuScan Health Imaging is a body imaging center that offers the promise of early disease detection in asymptomatic individuals. No physician referral is required; any customer willing to pay out-of-pocket can choose from a selection of computed tomography (CT) screening exams, including whole body scan, heart scan (coronary artery calcium screen), lung scan, head scan, and virtual colonoscopy. The scans are read by a board-certified radiologist and the patient receives the images, a detailed written report, and referral to a specialist if there are any concerning findings (1).

A decade ago, self-referred body imaging centers were on the rise, fueled by publicity on talk shows, stories in health magazines, direct-to-consumer (DTC) advertising, and dissatisfaction with managed care. Within a few years, however, the retail radiology bubble burst, and many initially successful centers went out of business (2). The collapse has been attributed to economic forces (e.g., competition driving down prices) and the influence of medical professional societies, which have been uniformly skeptical of the value of whole-body screening. Critics have raised many concerns, such as unethical advertising, unnecessary radiation exposure, high false-positive rates, and low cost-effectiveness (3-6). The FDA warns that "whole-body CT screening has not been demonstrated to meet generally accepted criteria for an effective screening procedure" (7).

In spite of these misgivings, the demand for imaging centers like AccuScan has not evaporated completely. They remain unregulated by the FDA (7). A recent survey found that 2% of radiologists still support whole-body CT screening, and many more support CT screening exams of the heart or lungs in particular patients (3). Supporters emphasize the patient’s right to know and argue that the benefits of early disease detection outweigh the risks (8,9).

Are self-referred imaging centers ethical? In this paper I would like to examine the controversy in the light of widely accepted bioethical principles: autonomy, beneficence, nonmaleficence, and justice. How does each principle support or discredit the practices of retail radiology? At the end, rather than simply applying the label of "ethical" or "unethical," I would like to address a more practical question: what can businesses like AccuScan do to function as ethically as possible?

Autonomy

Take control of your own health and stay as healthy as you feel with AccuScan (1).

One of the most compelling arguments in favor of self-referred imaging centers is patient autonomy. Proponents view their services as a form of "medical self-empowerment" (9). Frustrated with a "paternalistic payor-physician culture that controls the practice of medicine and patient referral,"(10) some customers are willing to pay more for a different kind of experience. In addition to data the patient cannot obtain from their regular providers, AccuScan promises a visit with "no green scrubs, sterile surroundings, long waits, or impersonal treatment" (1). Patients enjoy the highest possible sense of autonomy because they are paying out-of-pocket for a service of their choice.

However, critics contend that patients are choosing whole-body CT scans with incomplete or even inaccurate information (6). According to the AMA Code of Ethics, the "patient’s right of self-decision can be effectively exercised only if the patient possesses enough information to enable an informed choice" (11). One analysis of print advertisements and brochures concluded that DTC marketing of self-referred imaging services "fails to provide prospective
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