The Use of Sonography in Pediatrics: The Bioethical Concerns in Clinical and Research Practice

Ethical Guidelines

Clinical and nonclinical uses of sonography demonstrate the use of dynamic imaging to evaluate varying structures in the body. It is a common tool of choice for both physicians and researchers to eliminate radiation exposure to children. Although ultrasound is characterized as nonionizing radiation, as sonographers, researchers, educators, and clinicians, special consideration must be taken to take into account technologic features, medical knowledge, maturity, and examination to ensure imaging efficiency and safety. Bioethics of sonography in the pediatric population has not been greatly explored, and the varying ethical guidelines intensifies these bioethical concerns.

Ethical guidelines for clinical pediatric care and research must balance the protection of the child with the importance of needed examinations and research to improve pediatric medicine and overall well-being. ¹ Federal regulations entrust Internal Ethics Committees to oversee the bioethical concerns of clinical and research practice. These committees are used in hospital-based settings to provide bioethics education, drafting and review of hospital policy, and clinical case consultation. ² Whereas, an institutional review board (IRB) determines enrollment of children into research studies by determining if risks are minimal or minor and the research offers a direct benefit over the risk. ¹ Although these committees and boards are meant to monitor and regulate pediatric bioethics, as imaging professionals, there is an inherent responsibility to each patient. It is essential to demonstrate confidentiality, privacy, quality of examination, and patient advocating. This discussion will dive into The Principles Approach developed by Beauchamp and Childress ³ : autonomy, beneficence, nonmaleficence, and justice and how these principles guide action and thinking in the pediatric population.

Autonomy

The use of sonography in the pediatric population promotes children’s well-being and improved medical care. However, bioethical considerations must be taken before performing any type of examination involving children. Part of the problem stems from the limited capacity of children to provide informed consent and fully understand any risks or concerns associated with examinations. ⁴ Autonomy is a main principle when it comes to making decisions about one’s health and refers to the moral core of informed consent in medicine. ⁵ To respect a patient’s autonomy, we must allow individuals to exercise their right to make medical decisions and provide informed consent. However, there are difficulties pertaining to autonomy in the pediatric population. In order for autonomy to be exercised, the patient must have the capacity to make required decisions. In circumstances where the child lacks the capacity, parents are assigned the right to make medical decisions on their child’s behalf. ⁶ Overall, a child’s decision-making capacity should be based on their ability to evaluate their own health and the consequences of the medical decisions made. ⁷ This would mean that ethical guidelines would need to reflect the maturity and knowledge of the child receiving the examination. The decision-making capacity will look much different between a 17-year-old and a 5-year-old. In some cases, especially in research, informed consent is not possible and therefore, assent is obtained. In order for meaningful assent to be provided, the child must voluntarily choose to undergo procedures, examinations, or research participation. ⁸ This process offers respect for the child’s developing autonomy. However, this process can leave children vulnerable to authoritative influence and coercion to participate in a research study. ⁸ Regardless of decision-making being made by the child or the parent, adequate information must be provided regarding the examination or research study at hand. The value of children being a part of their own medical decision-making has become more recognized in practice and the child should be recognized as the moral with appropriate human rights and dignity. ⁹ The assent process should have the following elements: assessment of the child and parents’ understanding of the examination, providing adequate information and what to expect from the examination, and assessment of inappropriate pressure to accept testing or research enrollment. ⁹ At the very least, by keeping these factors in mind during our practice, both parent and child can assess the procedures at hand with clarity and providers can work to respect the autonomy of the child.

Beneficence and Nonmaleficence

Imaging in pediatrics requires accurate imaging techniques and knowledge of working with children and the use of effective methods to reduce anxiety for the child and the family. ¹⁰ The principle of beneficence and nonmaleficence guides clinical decision-making when promoting patient well-being. Beneficence refers to doing what is best for the patient. ³ Nonmaleficence encompasses the idea of doing no harm to a patient. ³ The increasing portability and usability of ultrasound equipment has promoted the use of sonography in nontraditional manners. This use may include those who are not registered for clinical or research purposes. To best protect the pediatric population, it is vital that when utilizing sonography as a tool, the operator has received the proper education and training including the validation of the methods being used and the education and training of the researcher or clinician. The principle of beneficence and nonmaleficence requires that we do not intentionally create harm or injury to our patients. Providing proper standards of treatment and ensuring adequate training avoid and minimize risk. ¹¹

The well-being of the patient should also be protected when choosing to use sonography as the imaging tool. It is necessary that research does not exploit children and that the research question is scientifically sound. ¹² If the research patient is not receiving direct benefit from the examination being done, then patients must understand that the research will benefit the pediatric population as whole and add to pediatric medicine. In clinical practice, the examination benefits must outweigh the risks and be in the best interest of the patient. For example, performing a transvaginal ultrasound on a nonsexually active female patient. There is a moral obligation to ask the following: Is this test necessary to diagnose the patient’s problem? Are there other means to acquire the information needed? Even if the parent consents, does the patient? What are the risks if the examination was to be performed? What are the risks if the examination was not to be performed? The argument of cases like this come from, what is considered “best for the patient”? These views may differ from those of the patient, parent, or person providing the examination. The patient’s view and health professional’s understanding of what constitutes harm and benefit must be considered when deciding what is morally acceptable, right, and “best” for the patient.

Justice

To build trust within the patient population, we must provide justice. Justice refers to the distribution of health care resources fairly. This principle is applied similarly, regardless of the patient population being worked with. Each person must be held equally and all families and children should be treated fairly and just. There are two major categories of justice. Procedural justice, which refers to whether fair procedures were in place and followed properly. ¹³ Distribution justice is the distribution and allocation of resources. ¹³ These two categories work together to ensure that patients are receiving the same type of care and opportunity to receive care. Both concepts are important for maintaining ethical standards in sonography. All examinations should be completed with the same amount of effort and knowledge and when enrolling children into a study, it must be fair, based off specific inclusion and exclusion criteria that do not single our specific populations of children.

Although it is challenging to fully apply some of these principles when working with children, especially those cognitively unaware of the risks and benefits of their own care, by working within a defined ethical framework, we can resolve or avoid some difficulties that may be encountered when working with children. To ensure that pediatric patients are provided with the best care clinically or nonclinically, ethical considerations must go beyond the code of ethics outlined by individual hospitals and institutions. It is vital to have a proactive ethical approach to best practices of using sonography in the pediatric population.