The blog of the 2009 – 2017 Presidential Commission for the Study of Bioethical Issues

Incidental Findings in the Clinical Context

In its recent report, Anticipate and Communicate: Ethical Management of Incidental and Secondary Findings in the Clinical, Research, and Direct-to-Consumer Contexts, the Presidential Commission for the Study of Bioethical Issues (Bioethics Commission) made recommendations for practitioners in each of these three contexts, as well as several overarching recommendations. This blog post will outline the distinctive ethical considerations in the clinical context.

Clinicians have always had to contend with incidental or secondary findings; however aspects of the structure of contemporary clinical care, such as how and by whom images are read, as well as increased use of modalities such as magnetic resonance imaging (MRI), make identifying what is the best course of action for the disposition of incidental findings more complex. In developing its recommendations, the Bioethics Commission considered several issues that shape providers’ and patients’ approaches to incidental findings.

The Bioethics Commission highlighted consequential aspects of the physician-patient relationship including asymmetry in expertise. The Bioethics Commission recognized that clinicians have a fiduciary duty that requires them to act in the patient’s best interest, even though that interest might not always be clear, in part because of uncertain or conflicting scientific evidence or clinical guidance. The Bioethics Commission also acknowledged the difficulties providers and patients might have in employing “diagnostic elegance” or “therapeutic parsimony” (ordering and conducting only the tests and interventions necessary for addressing health concerns). For example in her April 2013 presentation to the Commission Dr. Danielle Ofri said, “We have a bias toward doing something as opposed to doing nothing. It feels right even if it’s wrong, which in many cases it surely is. And our patients almost uniformly want us to do something. Both doctor and patient are enthralled in this overwhelming medical imperative to act. Remaining still, old-fashioned watchful waiting requires a fortitude that few doctors are able to muster.”

In addition, the Bioethics Commission made several recommendations that are sensitive to the fact that information does not always equate with meaningful knowledge for decision-making, which takes into account how patients and providers interpret information about risk. The Bioethics Commission stressed the central importance of communication and prudent clinical judgment for the optimal clinical management of incidental and secondary findings, based on ethical principles including respect for persons, beneficence, and justice and fairness.

The Bioethics Commission’s recommendations for the clinical context include that:

  • Clinicians should make patients aware of possible or likely incidental or secondary findings of testing being conducted, and what can be done about them, as part of a process of shared decision making. If a patient opts out of knowing such findings, the clinician should respect patient preferences to the extent possible and consistent with his or her fiduciary duties and relevant reportable disease statutes.
  • Clinicians should facilitate patient understanding of pertinent information for decision-making. This includes presenting numerical and visual data in ways that maximize comprehension, such as by offering absolute risk instead of or in addition to relative risk.
  • Researchers should collect additional data and conduct cost effectiveness analyses to elucidate the relative financial costs and medical consequences of ordering discrete diagnostic tests as compared to the common practice of ordering batteries or bundles of tests, which might result in incidental or secondary findings with minor or ambiguous clinical significance.
  • As a critical component of cultivating clinical judgment, medical education should equip providers with the skills and knowledge to selectively and appropriately undertake diagnostic testing and treatment.
  • Relevant organizations should develop evidence-based guidance for screening programs that take into account the possibility of incidental findings.

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This is a space for the members and staff of the 2009 -2017 Presidential Commission for the Study of Bioethical Issues to communicate with the public about the work of the commission and to discuss important issues in bioethics.

As of January 15th, 2017 this blog will no longer be updated but continues to be available as an archive of the work of the 2009-2017 Presidential Commission for the Study of Bioethical Issues

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