A dilemma for sonographers, and considering the greater good

I was on another panel last week. An annual gathering of sonographers (ultrasound specialists), nurses, radiologists and other imaging professionals. This conference covered a lot of ground, with sessions called ‘Face’, ‘Spine’, ‘Placental Function’ and other prosaic-sounding topics that didn’t leave much to the imagination. I didn’t attend these sessions, but somehow I can picture how they went.

The session in which I participated was titled ‘Sex and Ultrasound’ – sex, in this case, meaning gender. (I was amused to note we were slotted somewhere between ‘Diagnosis and Management of Limb Anomalies Which are not Part of a General Skeletal Dysplasia’ and ‘Thorax’.)

It was a small panel: me, a lawyer/bioethicist and a diagnostic radiologist; and a large crowd of several hundred people. The panel was assembled in chairs in front of the whole group to discuss Sex and Ultrasound as it pertained to a rather inflammatory news item (published in the Toronto Star) that had been making the rounds since last year.

The gist of the news report was this: some Toronto area hospitals were implementing communications policies which disallowed ultrasonographers from revealing the sex of their fetus. Instead, the patient would need to wait until she saw a physician, who had seen the written report signed by the radiologist. The journalist then noticed that, “whether by coincidence or by design”, these hospitals were situated amongst large concentrations of Southeast Asians, a cultural group thought to perform ‘female feticide’–aborting a fetus because it is female. The suggestion then, is that Toronto hospitals were making moves to combat this barbaric problem which immigrants have brought over with them.

(A follow-up editorial calling out this racism is here.)

Starting the session with this news item was intended to provoke and irritate. Fair enough. It was a conversation-starter, providing the backdrop for a number of questions posed to the audience.  Loosely paraphrased:

Do the audience members’ hospitals have a communications policy in place? Do the audience members feel comfortable talking to their patients? Do the audience members tell their patients what they see on the screen if it’s good news? If it’s bad news? Do the audience members tell their patients the baby’s gender but not other details? And more of the like.

This seemed an odd discourse to me.  Many pregnant women have had ultrasounds where the person scanning has pointed out fingers, toes, a healthy beating heart, and if it’s there and we want to know, also a penis.  I wouldn’t have guessed it was a matter of debate.

During the panel discussion I learned about some of the complicating factors:

Sonographers can ‘observe’ but not ‘diagnose’

The distinction between what you see and what you conclude because of what you see is an important one. Sonographers are allowed to make observations but not diagnoses. So one of the debated points was whether the sex of the fetus was an observation or a diagnosis.  Generally speaking most agreed it’s an observation–although things get murky if patients are getting abortions because of these off-the-record remarks.

The patient can generally tell what’s going on anyway

In the olden days before real-time scanning, the patient wasn’t immediately privy to the scan images or findings. The technician was essentially a specialist photographer, who would capture the images and send them to the radiologist.  The radiologist would then write a report and send it to the patient’s doctor – whose receptionist would phone the patient and tell them the news right then, or would schedule the patient for an appointment to discuss the results.

As technological advances made scanning more transparent to the patient, the sonographer, as yet unfettered by hospital bureaucracy, might freely chat with the patient and relay what he or she was seeing. Usually it’s a happy exchange, but what if the scan results aren’t as planned? In my case, the horrific discovery by the technician of Owen’s fetal hydrops rendered her speechless and insensitive, caught in her own discomfort. She wouldn’t look at me, turned the screen away from me and told me she couldn’t talk to me—all the while making a digital audio recording of the scan, narrating the abnormalities into a microphone which I could easily hear.

Real-time scanning has changed the nature of the testing. The patient can see what is happening, on the screen and on the technician’s face. She can ask questions, demand answers, look the unfortunate scanner in the eye while he tries to hide his panic when he can’t find the heartbeat the patient so eagerly wants to see.

If information is wrong, the hospital or clinician can be liable

If a patient makes a decision based on the unconfirmed ‘observation’ of a sonographer, and the observation proves to be wrong, the hospital may find itself at the wrong end of a lawsuit it perhaps felt could have prevented.  So rather than properly train the sonographers to have uncomfortable conversations (which, by the way, many can do quite capably), some hospitals and clinics wonder if they should ‘policy’ their way out of risk by not allowing them to talk.

So back to the matter at hand:

The discussion was focused on gender, and whether or not sonographers should tell patients the sex of their baby if, based on their observations and experience with the mother, they suspect female feticide.

Many in attendance (including the presenters) easily identified the racist undertones. But, the discussion brought out points that are worth exploring. So let’s unpack some of the details, and explore why the answer to the above question is an unequivocal yes.

Rights of the fetus

• In Canada, women do not need to explain their reasons for wanting an abortion, and do not need to justify having had one.
• In Canada, a fetus has no legal status as a person. A live baby of course does, but a mother or physician cannot be charged with murder (for example) if they participate in an abortion.

For these reasons alone, it should be obvious that a woman cannot be prevented from having an abortion or be granted fewer rights because someone finds a suspected or (even known) reason for wanting an abortion distasteful.

Rights of the patient

• Unfortunately, we don’t have a charter of patient rights in Canada. However in Ontario we do have the Ontario Health Care Consent Act, which protects our rights to refuse or consent to treatment.  There is also legal precedence to support that healthcare providers have a variety of obligations to the patient, including right to information. And most professional colleges and governing bodies in healthcare acknowledge the patients’ right to access their own medical information.  I realize as I write this that my knowledge of patient rights legislation is quite low…  If anyone wants to chime in about patient rights in Canada as it pertains to access to information (whether documented or not), please do!

Reproductive and human rights

• It’s not lost on me that we’re talking about a 100% female patient population. One could say it is a population which the ‘powers that be’ wish to influence and subjugate for what is perceived to be a greater good. I probably don’t have to throw a rock too far to hit examples of how this misguided ideal can go horribly wrong.
• Historically, the arrogance of medicine and healthcare has had ill effects for men and women alike. Lobotomies, forced sterilizations, over-medication, institutionalization, over-surveillance… This particular issue–fear of female feticide and poor resulting public policy–is not out of place in this unfortunate narrative.

 Just when I thought everyone was on the same page

My last comment in the panel discussion was to say that fear of litigation (which had been another related topic) and the desire to socially engineer all of humanity were two different things and should be discussed as distinct issues. They could probably do something about the first problem, but the second?  I thought not.  The scan in the ultrasound clinic is not the time or the place to express one’s distaste (or act upon it by withholding information) for a patient’s motives, especially if she is behaving within the bounds of the law.

This prompted a question from the audience:  “But what if,” she said, “what if I know for sure that the patient is going to have an abortion if she finds out she is going to have a girl?  If I tell her, wouldn’t that be like handing her a loaded gun? Maybe I shouldn’t tell her?”

I answered in a way you may have guessed (“Yes you should, and it’s none of your business”) and the other panelists had similar remarks. But I felt for her and her internal conflict.  With technological progress comes some of most difficult moral dilemmas of our time.