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Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology

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Abstract

It has been argued extensively that diagnostic services are a general good, but that it is offered in excess. So what is the problem? Is not “too much of a good thing wonderful”, to paraphrase Mae West? This article explores such a possibility in the field of radiological services where it is argued that more than 40% of the examinations are excessive. The question of whether radiological examinations are excessive cries for a definition of diagnostic futility. However, no such definition is found in the literature. As a response, this article addresses the issue of diagnostic futility in five steps. First, it investigates whether the concept of therapeutic futility can be adapted to diagnostics. A closer analysis of the concept of therapeutic futility reveals that this will not do the trick. Second, the article scrutinizes whether there are sources for clarifying diagnostic futility in the extensive debate on excessive radiological examination. Investigating the debate’s terms and definitions reveals a disparate terminology and no clear concepts. On the contrary, the study uncovers that quite different and incompatible issues are at stake. Third, the article examines a procedural approach, which is widely used for settling controversies over utility by focusing on the role of the professionals. On scrutiny however, a procedural approach will not solve the problem in diagnostics. Fourth, a value analysis reveals how we have to decide on the negative value of excessive examinations before we can measure excess. The final and constructive part presents a definition of diagnostic futility drawing upon the lessons from the previous analytical steps. Altogether, too much radiological examination is not a good thing. This is simply because radiological examinations are not unanimously good. Excessive radiological examinations can be defined, but not by one simple general and value-neutral definition. We have to settle with contextually framed value-related definitions. Such definitions will state how bad “too much of a good thing” is and make it possible to assess how much of the bad thing there is. Hence we have to know how bad it is before we can tell how much of it there is in the world.

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Notes

  1. There are studies of specific examinations with certain modalities, e.g., MRI of the knee joint, that show that over 75% of the examinations are unnecessary (Hanger 2005). See also (Robling et al. 2002).

  2. For specific references to the debate, see below.

  3. For other uses of “overuse” see (Villforth 1979; Shapiro et al. 1999; Abd El Bagi et al. 1999; Hage 1996; Guadagnoli et al. 2001; Fisher et al. 2003; Fuhrmans 2005).

  4. For other uses of “unnecessary examinations” see (Jonsson et al. 1978; Gibson 1987, Rosen 1985; Whittaker 1987; Burwood 1989; Bransby-Zachary and Sutherland 1989)

  5. For other uses of “inappropriate” see (Leape et al. 1990; Oakeshott et al. 1994; Armstrong 1999).

  6. More subtle reasons for excessive health care, such as increase in diagnostic sensitivity due to improved diagnostic technologies, resulting in increased prevalence of disease, and lowered treatment threshold (Black and Welch 1993; Fischer and Welch 1999) have not been included. That is, the highly relevant, but far too extensive, debate on medicalization has been left out of this study. The same goes for the debate on defensive medicine (defensive radiology) and self-referral (Fenton and Deyo 2003). The reason is that the debate on defensive radiology has a particular terminology addressing the intensions of the examinations directly. The issue is included, however, in the moral aspect discussed in this article. Furthermore, the interesting debate on inadequate requests is not addressed, as only a fraction of inadequate requests would lead to futile diagnostics.

  7. The term “excessive examinations” may serve as a generic term to denote all the (six) aspects of “too much” imaging, and “diagnostic futility” more specifically in line with the term “futile treatment” as discussed above to discuss the usefulness of a diagnostic service.

  8. Definitions that address utility much resemble those of therapeutic futility, although this debate is seldom referred to. Some definitions comprise the probability of achieving a goal, and the uselessness of doing so. E.g., unnecessary examinations are defined as those which are “clinical unhelpful in the sense that the probability of obtaining information useful to patients management is extremely low” (Roberts 1991; Royal College of Radiologists Working Party 1991). This makes them subject to the same challenges as are “quantitative futility” and “goal futility” (discussed earlier).

  9. Although many of the aspects fuelling the concern for excessive examinations are related to safety, it appears that few definitions (explicit or implicit) reflect this. This may be because there is a widespread agreement on the aspect of safety, while utility based conceptions of excessive examinations appear to be more controversial, and in need of explicit definitions. However, the heated debate on radiation protection indicates that this is not the case. Moreover, at the basis of utility based definitions we may find reference to risk, e.g. when weighing benefits against risks.

  10. One may of course argue that an analysis of definitions is in vain as the definitions, especially in reports or guidelines of (inter)national regulatory bodies, are so general and so vague that they are of no analytical interest. However, many of the definitions reviewed stem from the literature on down to earth practical diagnostic imaging. Besides, if the definitions are poor or vague, they are useless, and will fuel rather than settle debates.

  11. Furthermore, low acceptance rate of guidelines challenges the foundation of guidelines in (professional) virtue ethics: how can guidelines be based in the role of the medical (radiological) profession, when there is low adherence?

  12. We should differentiate between radiologists, referring GPs, self-referring specialists, other referring specialists. However, for the scope and purpose of this study the professionals will be treated as a group.

  13. This curtails a more elaborate axiological analysis. However, an all encompassing axiological study is beyond the scope of this article, and due to the lack of consensus on the various kinds of values, it suffices here to refer to categories of values that have been acknowledged since Platao’s Republic, where he (in 357) distinguishes between goods valued for their own sake and not for their consequences (intrinsic), goods that are valued for their consequences only (instrumental), and goods that are valued both for their own sake and for their consequences (intrinsic and instrumental). The analysis could of course have been performed with von Wrights varieties of goodness, or in terms of a more nuanced variety of extrinsic values, such as inherent, contributory, indicative, relational, and instrumental values.

  14. This is also more in accordance with what Mae West is supposed to have said. http://www.brainyquote.com/quotes/authors/m/mae_west.html

  15. It may be unnecessary to point out that this definition may be controversial.

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Acknowledgments

I am thankful to professor Thomas Pogge and colleagues at the Section for medical ethics at the University of Oslo who have commented on an earlier version of this paper. I am also thankful for inspiring comments from participants at the 21st EUROPEAN CONFERENCE ON PHILOSOPHY OF MEDICINE AND HEALTH CARE in Cardiff (15.08.2007–18.08.2007) for comments on a related paper and to two anonymous referees.

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  1. Faculty of Health Care and Nursing, University College of Gjøvik, PO Box 191, 2802, Gjøvik, Norway

    Bjørn Hofmann

  2. Faculty of Medicine, Section for Medical Ethics, University of Oslo, Blindern, PO Box 1130, 0318, Oslo, Norway

    Bjørn Hofmann

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Hofmann, B. Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology. Med Health Care and Philos 13, 139–148 (2010). https://doi.org/10.1007/s11019-010-9233-8

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