H e a l t h C a r e Po l i c y a n d Q u a l i t y • O p i n i o n

Camargo et al.
Ethics Education and Radiology

Health Care Policy and Quality

Opinion
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Radiology and Ethics Education

Aline Camargo1 OBJECTIVE. The purpose of this study is to assess medical ethics knowledge among
Li Liu trainees and practicing radiologists through an online survey that included questions about
David M. Yousem the American College of Radiology Code of Ethics and the American Medical Association
Code of Medical Ethics.
Camargo A, Liu L, Yousem DM CONCLUSION. Most survey respondents reported that they had never read the Ameri-
can Medical Association Code of Medical Ethics or the American College of Radiology Code
of Ethics (77.2% and 67.4% of respondents, respectively). With regard to ethics education dur-
ing medical school and residency, 57.3% and 70.0% of respondents, respectively, found such
education to be insufficient. Medical ethics training should be highlighted during residency,
at specialty society meetings, and in journals and online resources for radiologists.

n the past 3 decades, the teaching cal Society of North America. The link re-

I of medical ethics has garnered

Keywords: ethics, radiology, residency, training
DOI:10.2214/AJR.16.17779
Received December 4, 2016; accepted after revision
February 1, 2017.
D. M. Yousem receives royalty income from Elsevier,
personal fees from medicolegal consulting, educational
honoraria from the American College of Radiology,
and royalty fees from CMEInfo.com, none of which have
any bearing on this work.
1
All authors: Division of Neuroradiology, The Russell H.
Morgan Department of Radiology and Radiological
Science, Johns Hopkins Medical Institutions,
600 N Wolfe St, Baltimore, MD 21287. Address
correspondence to D. M. Yousem (dyousem1@jhu.edu).
AJR 2017; 209:640–642
0361–803X/17/2093–640
© American Roentgen Ray Society
attention among educators at
medical schools [1, 2]. Ethics ed-
ucation plays an essential role in building the
professional character and self-understand-
ing of physicians, both of which are funda-
mental qualities for establishing a safe and
high-quality practice. Teaching medical eth-
ics is also justified by the high incidence of
ethical misbehavior that leads to disciplinary
action, malpractice, insurance fraud, and the
loss of physician licenses [3, 4].
On the basis of a review of the literature,
we developed a self-administered question-
naire that was made available online through
a research platform (Research Core, Qual-
trics). On three separate occasions over a
6-week period, a link to the online question-
naire was e-mailed to 1569 radiologists and
radiology trainees identified through a search
of a database maintained by The Russell H.
Morgan Department of Radiology and Ra-
diological Science at Johns Hopkins Medical
Institutions for continuing medical education
purposes. The link to the questionnaire was
also posted on social media sites, such as the
Facebook, Twitter, and Instagram accounts
of the authors and their institution, and the
forums section of the Aunt Minnie website.
In addition, the questionnaire was publicized
on the Internet blogs of the American Col-
lege of Radiology (ACR) and the Radiologi-
mained active between September 17, 2016,
and October 31, 2016.
A total of 424 radiologists and radiology
trainees responded to the survey. The char-
acteristics of the respondents are presented
in Table 1. Because the survey allowed re-
spondents to skip questions if they preferred,
different numbers of respondents answered
each question.
Ten questions in the survey tested the re-
spondents’ knowledge regarding the ACR’s
Code of Ethics and the Code of Medical
Ethics of the American Medical Associa-
tion (AMA). Table 2 presents the responses
for each survey question. Of the 346 respon-
dents, only 10 (2.9%) answered all 10 ques-
tions correctly.
Table 3 summarizes the survey responses
regarding medical ethics education. Most re-
spondents reported that they had never read
the AMA Code of Medical Ethics (77.2%)
or the ACR Code of Ethics (67.4%). Even
though 72.1% of respondents received med-
ical ethics training in medical school, they
thought that their ethics education was not
sufficient during medical school (196 re-
spondents [57.3%]) and residency (238 re-
spondents [70.0%]). The collected data re-
vealed that 171 respondents (49.4%) do not
actively seek to fill such a gap in their edu-
cation by, for example, following discussions
on medical ethics.

640 AJR:209, September 2017

 Ethics Education and Radiology

TABLE 1: Characteristics of TABLE 2: Overall Performance of Respondents

­Survey  Respondents
No. (%) of Total No. of
Characteristic Value Ethics Topic (Correct Answer) Correct Answers Respondents
Age (y), median (IQR) (n = 336) 46 (33–60) Charging a separate and distinct fee for the incidental ­administrative 279 (66.3) 421
nonmedical service that the physician performs in securing the
Sex (n = 348) admission of a patient to a hospital is unethical. (True)
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Male 256 (73.6) History, diagnosis, prognosis, and the like acquired during the 268 (63.2) 424
Female 92 (26.4) physician-patient relationship may be disclosed to an insurance
company representative. (False)
Years after completing residency, 14 (0–28)
median (IQR) (n = 308) The AMA Code of Medical Ethics directly addresses disclosure of 254 (61.5) 413
records to data collection companies. (True)
Status (n = 308)
Payment by or to a physician solely for the referral of a patient is fee 362 (85.8) 422
Practicing radiologist 220 (71.4) splitting. The Code of Medical Ethics of the AMA and the Code of
Trainee 88 (28.6) Ethics of the ACR allow this practice, as long as the skills of the
physician to whom the patient has been referred are guaranteed.
Work setting (n = 342) (False)
Academic 231 (67.5) Concerning the retention of medical records, the records of any 349 (83.3) 419
Private practice 57 (16.7) patient covered by Medicare or Medicaid must be kept at least 5
years. (True)
Hybrida 38 (11.1)
The Code of Medical Ethics prohibits the physician from 134 (31.9) 420
Government 8 (2.3) ­accepting any in-kind gift from pharmaceutical, biotechnology, and
Other 8 (2.3) medical device companies. (False)

Country of practice (n = 350) Physicians should not recommend that a patient obtain a second 415 (98.1) 423
opinion because this may harm the patient-physician r­ elationship.
United States 334 (95.4) (False)
Other 16 (4.6) A physician is not allowed to charge a patient for a missed appoint- 293 (69.4) 422
Country where medical school was ment. (False)
attended (n = 276) Unethical conduct that violates state licensing provisions should be 408 (97.6) 418
United States 226 (81.9) reported to the state licensing board. (True)

European countries and Canada 32 (11.6)
Other 18 (6.5)
Country where residency was
completed (n = 276)
United States 253 (91.7)
European countries and Canada 12 (4.4)
Other 11 (4.0)
Note—Except where otherwise indicated, data are
number (%) of survey respondents. IQR =
interquartile range.
a Academic and private practice.
Previously published research studies
showed that knowledge of ethics among resi-
dents and the confidence to deal with ethical
situations increased when ethics education
was included as part of the residency curric-
ulum [5, 6]. Such findings highlight the state-
ment by Perkins that “medical ethics (educa-
tion) provides the conceptual tools necessary
for residents to develop their own ethical de-
cision-making frameworks” [7].
A previous Brazilian study that evaluated
medical students revealed that less than one-
half of them considered ethics education in the
core curriculum of medical school as instru-
mental in the formulation of their philosophy
regarding ethics, and 41.4% reported that they
The AMA Code of Medical Ethics does not address sex d­ iscrimination
in the medical profession. (False)
Note—AMA = American Medical Association, ACR = American College of Radiology.
had never read the nation-based code of medi-
cal ethics [8]. Similarly, we found that only 79
of the respondents (22.8%) had ever read the
AMA Code of Medical Ethics, and only 113
(32.6%) had ever read the ACR Code of Eth-
ics. On the basis of data from the ACR, the to-
tal number of Internet downloads of the Code
of Ethics (including the Bylaws section) was
only 723 in the 1-year period between June
1, 2015, and May 31, 2016, after the most re-
cent update of the Code of Ethics occurred
(Farmerie S, personal communication, January
26, 2017). Given that the ACR has more than
38,000 members, this finding suggests that if
each download was intended for review by a
single person, only 1.9% of those 38,000 mem-
bers have viewed the most recent version of the
ACR Code of Ethics. This finding highlights
that many physicians do not consider ethics a
critical educational subject but, rather, a per-
sonal concept based on their own perceptions.
The perception that ethics might just be an
intrinsic group of values that cannot be learned
may justify the lack of interest in the pursuit of
ethics knowledge from external sources, as re-
302 (72.6) 416
ported in the present study. Another possible ex-
planation may be that respondents did not have
an interest in the subject because they think that
such educational material will not change their
already established conduct and opinions.
Our survey touched upon only a few issues
associated with medical ethics knowledge.
We chose the AMA Code of Medical Ethics
as a focus for assessing the ethics knowledge
base among our survey respondents because it
is widely applied and available. However, ev-
ery code of ethics has limitations in shaping
appropriate responses to ethical dilemmas.
Beauchamp and Childress stated, “Theory and
principles are only starting points and gener-
al guides for the development of norms of ap-
propriate conduct” [9]. Their theory assumed
that deontologic absolute principles (i.e., rules-
based ethics) can govern ethical behavior. In
contrast, a more pragmatic approach, known
as casuistry, involves looking at each case indi-
vidually and determining whether precedence
has been established by similar examples else-
where in society to determine what should be
done. This approach is similar to the use of

AJR:209, September 2017 641

 Camargo et al.

TABLE 3: Responses to Survey Questions Regarding Medical Ethics Education

Ethics Topic Yes Response No Response Total No. of Responses
Have you ever read the AMA Code of Medical Ethics? 79 (22.8) 268 (77.2) 347
Have you ever read the ACR Code of Ethics? 113 (32.6) 234 (67.4) 347
Did you have medical ethics training in medical school? 251 (72.1) 97 (27.9) 348
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Do you think your medical ethics training in medical school was sufficient? 146 (42.7) 196 (57.3) 342
Did you have medical ethics training in your residency? 122 (35.1) 226 (64.9) 348
Did you think the medical ethics training in your residency was sufficient? 102 (30.0) 238 (70.0) 340
Do you follow discussions on medical ethics as part of your ongoing education or interest? 175 (50.6) 171 (49.4) 346
Note—Except where otherwise indicated, data are number (%) of responses. AMA = American Medical Association, ACR = American College of Radiology.

case law in the courts or case-based learning
in medical education. In The Abuse of Casuist-
ry: a History of Moral Reasoning, Jonsen and
Toulmin stated that one should not be wedded
to absolute principles (e.g., because two good
principles, such as paternalism and individual
freedom, often may contradict each other) [10].
They recommended assigning a moral issue to
a taxonomy (i.e., a category of principles) and
then resolving the dilemma on the basis of ex-
amples in that taxonomy that have already been
adjudicated [10].
More studies are necessary to understand
the current state of ethics education in medi-
cal schools and radiology residencies, to im-
prove weaknesses and highlight the impor-
tance of the teaching of ethics.
On the basis of our survey, we concluded
that changes in medical ethics training and ed-
ucation in radiology residencies are required
to promote ethical behavior in radiology prac-
tice. We recommend the following changes.
First, just as the Accreditation Council for
Graduate Medical Education added a business
principles mandatory requirement to radiology
residency education, we believe that a similar
number of hours should be required for medi-
cal ethics education during residency.
Second, the ACR should solicit leaders in
thought in this arena to provide an updated
online program for radiology trainees and
practitioners as part of the offerings of their
Radiology Leadership Institute, and this pro-
gram should be made accessible to all radiol-
ogists. Leadership demands ethical behavior.
Third, ethics education for practicing radi-
ologists should also be encouraged through
the creation of specific materials by radiolo-
gy subspecialty societies, including seminars
at society meetings, with relevant case sce-
narios included for discussion.
Fourth, radiology journals should add
medical ethics–oriented articles for the edifi-
cation of their readership.
We believe that these changes in the ap-
proach toward medical ethics and its teach-
ing will improve how radiologists deal with
ethical situations and therefore will support
professional integrity.
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