The number of radiological examinations has increased substantially over time.1^–3 Annual utilisation is increasing typically by 5–11% in developed countries, and the appetite for images is characterised as bottomlessi.4 5 There are many reasons for this increase. New technology, physician self-referral, altered reimbursement systems, increasing patient demands, commercial liability office-based imaging by untrained personnel, professional insecurity and increased fear of lawsuits, to mention only a few.

Many of these aspects have been discussed extensively in the literature. One aspect that has received undeservedly little attention is how moral principles, such as patient autonomy, influence the use of radiological examinations. Does increased respect for patients’ autonomy change the use of radiological services? There is little empirical knowledge about this, and in order to answer this question we need to know why and how patient autonomy can have an influence. Therefore we have investigated how patient autonomy is relevant to the increased use of radiological services. We do this by reviewing the literature in radiology—that is, literature concerning the extension of radiological services where patient autonomy is frequently referred to as a relevant factor.

It is, of course, not surprising if moral principles that regulate how healthcare services are offered (for example, through legislation) influence the extension of a healthcare service. However, what is not obvious is whether the extension of radiological services results from the good intentions behind the moral principle of autonomy or from other, less overt, intentions.

THE CONTEXT OF PATIENT AUTONOMY

At the outset of the inquiry, it is important to acknowledge that the role and effects of the principle of patient autonomy depend on the context. They may depend on the mode of referral—for example, whether the examination is requested by the patient, is by referral from a general practitioner, or is by self-referral of a physician.

Moreover, the idea of patient autonomy can be relevant both as an explanation of why there is extended use of radiological services and as a justification of why this is right. Correspondingly, an analysis of the role of patient autonomy will depend on the concept of autonomy—for example, whether it is viewed as a (consumer) right, a moral principle, or a cognitive capacity. Whether the patients actually are autonomous (as commonly understood) in situations where their autonomy is used as an explanation or justification is also relevant to the role of autonomy—for example, is autonomy used as a moral device to legitimise otherwise unwarranted actions?

Hence, patient autonomy can be relevant to the extended use of radiological services in a number of ways. As our aim is to investigate how it can influence the extension of radiological examinations, we do not restrict the investigation to one specific context. Patient autonomy can influence the extension of radiological examinations both by intent and as a desirable side effect. Both aspects are acknowledged in the literature, and both deserve scrutiny.

AUTONOMY IN HEALTHCARE

Standard roles of patient autonomy in healthcare in general are said to be

• to respect a basic human right of self-determination or promoting a fundamental human value

• to legitimise otherwise unwarranted interventions (such as exposure to radiation)

• to protect the individual against encroachment (by requiring voluntary informed consent)

• to support the public’s trust in the healthcare system (for example, through informed consent)

• to promote rational decisions (by increasing patients’ understanding)

• to increase transparency in the physician–patient relationship and to reduce paternalism.14

It is quite clear that patient autonomy plays such roles within radiological services and that this influences the use of health services. However, as the review of the radiological literature shows, the role of autonomy may also depart from these ideal intentions.

SELF-DETERMINATION AS A LEGITIMISING HUMAN RIGHT

One obvious explanation for the extension of radiological services is that it is a result of increased self-determination. Patients have become more educated and demanding with respect to healthcare services. Groups with higher socioeconomic and educational status take the lead; they “… use services more readily and demand more elective services …”.15 From the patients’ perspective, access to healthcare services is conceived of as a “human right”: “More and more often patients perceive CT and MRI scans as something they are entitled to.”16 They may feel neglected if the professionals refuse to give them an examination.17 The public requests greater availability of radiological services.18

Correspondingly, it can be argued that measures to reduce uncertainty are more prevalent in (“risk-free”) diagnostics than in treatment. Hence, the idea that it is better to be safe than sorry may be stronger in diagnostics. This coincides with a general increase in people’s need for security, safety and control. Besides, it has been argued that professionals meet patients’ demands because there are “no strong professional or legal sanctions against unnecessary X-ray.”19 Moreover, competition over patients (and turf wars) may make professionals more sensitive to patients’ requests.

Hence, there are many reasons why professionals are inclined to respect patients’ autonomy when they ask for radiological examinations. This can help to explain the increase in use of radiological services. Respect for patients’ autonomy is used both to explain the phenomenon and to justify it. As one person put it, “We have to respect patients’ autonomy and give them what they want”.20 It is claimed that a “liberal” attitude to utilisation of radiology is a modern response to changes in society. To respond in compliance with patients’ requests and demands for radiology is a result of a democratisation process, also reflected in legislation (patients’ rights acts).21

Hence, a general shift in justification for radiological examinations, from paternalism to respect for patient autonomy, can lead to and explain the increased use of examinations. However, although partly correct, this is an idealisation and oversimplification of the role of the moral principle of autonomy.

AUTONOMY: FROM “WASTE OF TIME” TO A LEGAL REQUIREMENT

Historically, radiologists have argued that concern for autonomy is unnecessary or “a waste of time”, and that informing patients about examinations in order to promote their autonomous decisions would result in “wholesale refusal of patients to undergo the procedures”.22 Hence, a paternalistic attitude appears to have been prominent in radiology, as in other specialties.

However, as it was documented that patients did not refuse procedures after being informed,22 and that patients were more inquiring and informed than expected,23 it was argued that informing patients about complications would make them anxious and apprehensive and thus worsen the outcome.23 However, once the requirement for informed consent meant that patient autonomy was “imposed by law”,24 the argument based on beneficence lost its prominence.

AUTONOMY, INDIVIDUALISM AND CONSUMERISM

Just as in healthcare in general, radiologists are subject to stronger notions of individualism and liberalism than before. This trend appears to have influenced the concept and position of patients’ autonomy in general.25^–27 Furthermore, it is argued that the individualistic interpretation of patient autonomy reduces the patient–doctor relationship “to that of client and technician”.28 Radiologists, because their interaction with patients often is brief and episodic, may be particularly receptive to the role of service provider. Hence, the consumer model appears to play an important role in radiology, as in other parts of healthcare.9

Strong consumer rights and radiological services conceived of as easy, painless and risk free may have contributed to entrenchment of the individual consumer model. However, the practice in radiology differs from that in a traditional consumer model, as most patients do not themselves pay for imaging services. Nevertheless, it appears that patients behave more like consumers than before, providers describe their activity as “production”, and reimbursement systems encourage competition—making the relationship between radiologist and the patient more like that between a customer and a service provider in a market.

Corresponding to the general trend of individual consumerism, which could explain part of the increase in use of radiological services, consumerism is also used as a way to justify and promote a liberal practice with respect to examination decisions. Professionals supporting self-referrals by patients “advocate patient autonomy and unrestrained imaging”.29 It is argued that there is no difference in principle between letting patients order examinations themselves and doing examinations requested by clinicians (whose referrals radiologists hardly ever question), and since we allow people to decide more serious medical matters, such as abortion, it is hard to argue that they should not decide on matters of radiological services.30

In mixed healthcare systems (such as the Norwegian system), representatives of market-based medical services tend to promote the individual-consumer aspect of patient autonomy more vigorously than their colleagues in public healthcare.21 This, of course, corresponds with the fact that consumer ideology (still) is more forceful in private than in public healthcare. It also corresponds with studies showing that private radiological institutions contribute to the increase in examinations31 (including those for which medical justification is controversial).

Hence, a liberal, consumer-based conception of patient autonomy is used both to explain and to justify the extended use of radiological services: “We give them what they rightly demand!” However, the justification strongly depends on true premises: that patients are autonomous. If the premises are not clear or true, so-called autonomy may have some adverse side effects.

AMBIGUOUS PREMISES FOR AUTONOMY

The general concerns about whether the premises for autonomy are true appear to be relevant in radiological services—that is, whether patients have sufficient understanding of the healthcare service they require. Patients’ sources of knowledge are not always neutral, balanced or evidence based:32 33 radiological services often do not provide sufficient information10 34 and involved risks are “understated with the intention to reassure patients”.10 There is also a question of patients’ comprehension of information when it is provided.35 Their understanding may not be exhaustive with respect to diagnostic accuracy, complications and outcome.

The prerequisite deliberative capacity for autonomy is questioned in radiology as in healthcare in general.29 36 37 Even healthy (asymptomatic) people might be in a state of anxiety, due to fear of potential disease. Besides, in radiology “the harm patients fear most is the harm caused by unwise choice. And exactly because patients are afraid of choosing foolishly they delegate decisions”,36 or, more generally, patients may decide to have an examination in order to avoid “anticipated decision regret”.38

Additionally, patients may be under substantial pressure—from family members, professionals or marketing forces—reducing the voluntariness of their decision. Another influence reducing real autonomy is the belief in technology and progress. The notion that “you should take advantage of everything that modern medicine can offer”36 appears to be particularly prominent with respect to radiology. It may be counter-intuitive to people that information such as that provided by a radiological examination might not be useful to them.36 The fascination with the capability of radiology, especially the high-tech procedures, provides an imperative towards examinations. Correspondingly, it is argued that personal autonomy is threatened because radiology indirectly undermines people’s ability to assess their own health, and that they must undergo imaging tests in order to know whether they are healthy or not.39

Moreover, people’s perception of risk related to radiological services is low, if acknowledged at all. Accordingly, one could argue that it is unlikely that patients would refuse an examination when one is offered or available. General notions, such as “to know is better than not to know”, “hi-tech is better than lo-tech (or no-tech)”, “more choice is better than less”,40 and a general belief in progress can undermine (consumer) autonomy, in healthcare in particular and in commerce in general.

Hence, with reference to the radiological literature it appears that the basic premises for autonomy are not always met. Therefore, even if an individual-consumer conception of patient autonomy may seem to be a sound explanation for the increased use of radiological services, it may not be valid as a justification if the premises for consumer autonomy are not met. Furthermore, if general criteria for autonomy are not met, appealing to persons’ autonomy when deciding in favour of radiological examinations may have adverse effects.

ADVERSE EFFECTS OF PATIENT AUTONOMY

The continued insistence on patient autonomy even though the premises on which it is based may not be met has been explained as a way to promote professionals’ rather than to promote patients’ autonomy.14 41 In particular, patient autonomy (regarding consent to a radiological procedure) can reduce the risk of a lawsuit.42 Hence, autonomy may fulfil a protective role, but to the professionals instead of to patients. Rather than preventing paternalism, autonomy may become a tool for its covert promotion.

Furthermore, patient autonomy is used as an argument to allow controversial procedures, as in CT screening for lung cancer.20 29 30 It is far from obvious that patients know that these procedures are controversial.

Correspondingly, patient autonomy may result in a shift in responsibility in general—that is, in the legal sense in order to avoid lawsuits, and also in a moral sense. An autonomous person demanding a particular examination, possibly against professional advice, gains responsibility. This is an expected result of reduced paternalism: the paternalist is responsible, the (radiologist as a) service provider is not.37

Although most professionals set limits on patients’ self-determination—for example, with respect to liposuction for people with anorexia—they appear to have a different view on unnecessary (low-risk) radiological examination for reassurance and to relieve anxiety.43 44 This is not the place to enter into the interesting debate on therapeutic use of diagnostic radiology. The point is that there are challenges associated with transferring the responsibility for professional issues to patients, both morally and legally. Moreover, if it is not clear to the patient that this is what is happening, it undermines the premises for their autonomous choice (because of a lack of understanding).

The side effect that patients can be made consumers on demand, forcing them to make decisions beyond their capacity,32 is also noted in radiology.30 Claiming that “it is for you to decide” may go beyond mere respect for autonomy. However, although this potential side effect has been noticed, there is no evidence that it is acknowledged by radiologists in general.

Moreover, because the increased use of radiological services comes at a substantial cost,5 18 41 45 it may result in a reduction of available resources for other kinds of healthcare. If this results from increased autonomy, we have a paradox: the increased autonomy (of patients with regard to radiological services) reduces the autonomy of other patients—which is contrary to standard conceptions of autonomy. (The relevance of this is demonstrated by the great geographical variations in the use of radiological services.5 18 31)

PATIENT AUTONOMY AND PROFESSIONAL POWER

So far we have investigated the roles of patient autonomy in explaining and justifying the extension of radiological services. Although many of the roles are based on good intentions, some may have side effects that counter these intentions. We have so far not argued that anyone promotes autonomy because of these side effects.

Nevertheless, it is worth asking who could gain from such side effects of patient autonomy in radiology. Healthcare professionals could gain by reducing their professional, legal and moral responsibility (as explained above), by increasing their professional power (under cover of respecting patients’ autonomy), by having an excuse for pursuing professionally interesting issues, by increasing the popularity of the profession (because we give the people what they want), and by increasing the professional activity or status. Moreover, professionals may have an economic interest in “respecting patients’ autonomy”— for example, professionals can come to “rationalize medical unsound or financially self-interested decisions as autonomy-respecting decisions”.19 Industry could benefit from the extended use of radiological technology. Healthcare institutions could gain economically.46 Hence, although we have no evidence that patient autonomy is used to covertly suppress or abuse people or patients, review of the radiological literature indicates that this is a possibility that should be taken into account.

AUTONOMY AS AN END AND A MORAL MEANS

Personal autonomy is a well-established moral principle, with many praiseworthy roles that are widely acknowledged in radiological literature. However, patient autonomy also has less overt and appealing functions. It can be used as a protective device to reduce professional responsibility in general and to avoid lawsuits in particular. It can be used to promote professional pecuniary interests and to provide opportunities to perform certain procedures. These adverse functions are not peculiar to radiology, but they become particularly clear in explanations and justifications of the substantial increase in radiological services and in debates about their overuse. Hence, a moral end (patient autonomy) can be applied as a moral means for quite opposite purposes (such as paternalism).

Our analysis is not a valid argument against patient autonomy: we have only pointed out some of the possible adverse (opposite) effects, as well as which premises that must be true if patient autonomy should play legitimate roles in medical decision-making with respect to radiological services. Just as there can be both use and misuse of radiological services, there can be use and misuse of patient autonomy. Our intention is to point out the relationship between them.

CONCLUSIONS

Although the literature on radiological services shows an acknowledgement of many challenges with patient autonomy discussed in the general literature, there is little evidence that this reflects a general awareness among radiologists. To what extent radiologists actually use patient autonomy to legitimate a liberal practice is an empirical question, which we will address in an empirical study. Our point here has been to investigate how autonomy can be misused. Moral principles can play an important role in regulating the use of healthcare services, both with respect to how health services are offered and accepted and with respect to their extension.