How Do You Solve a Problem Like Incidentalomas?

Leonard Berlin, MD, FACR


Appl Radiol. 2013;42(2):10-12. 

In This Article

The Patient's Right to Know

Ninety-eight years ago, the Honorable Judge Benjamin Cardozo issued a dictum that became the foundation for informed consent between patient and doctor: "Any human being of adult years and sound mind has a right to determine what shall be done with his own body."[14] This judicial pronouncement was incorporated into the American Medical Association's Code of Ethics: "The physician's obligation is to present the medical facts accurately to the patient…. Physicians should disclose all relevant medical information to patients."[15]

The quandary as to whether to disclose a radiologic finding that has an extremely low likelihood of having an adverse effect on a patient's health was the subject of an editorial written by radiologist Roy Filly. Referring to the very high percentage of false-positive markers indicative of Down syndrome found all too frequently on prenatal ultrasound examinations, Filly wrote:

"The identification of these 'abnormalities' in low-risk women has crossed the line of 'more harm than good'…For the tiny number of Down syndrome fetuses that potentially may come to light by chasing down every last marker, we put at least 10% of all pregnant women with perfectly normal fetuses through a great deal of worry…. Should I simply ignore these features? I wish I had the courage, but I don't. Even with my considerable clout in the world of obstetrical sonography, I cannot unilaterally ignore them. This is not how American medicine works."[16]

In her novel Handle with Care, author Jody Picoult created a fictional scenario in which an obstetrician who, while performing a prenatal ultrasound, observed a questionable marker for osteogenesis imperfecta, but because of the high false-positive rate of the marker, decided not to inform the patient. Later, the mother delivered a baby with the disease and subsequently filed a medical malpractice lawsuit against the obstetrician, claiming that she would have aborted the fetus had the obstetrician informed her of the abnormal finding. In his closing argument at the conclusion of the fictional malpractice trial, the plaintiff's attorney told the jury, "This case is about facts that the obstetrician knew, but didn't give the patient. The obstetrician did not cause the illness, but is to blame for not giving the family all of the information. When a physician withholds information from a patient, that's malpractice."[17]

Emphasizing that patients should be informed of every bit of information that could adversely affect their health, even information that is highly unlikely to be injurious, a New York internist asserted, "My patients want to know if they have cancer as early in the process as possible so that they can be treated. They don't want to have to rely on mathematical projections or statistics about 'hypothetical' death rates."[18]