Apply standards of care equitably

Ethics Forum. May 1, 2006.

Scenario: When is a CT scan to diagnose appendicitis appropriate?

Two patients in a hospital's emergency department exhibit similar symptoms, including white blood count results, that suggest appendicitis. The patient with health insurance is sent for a computed tomography scan, but a surgeon is called for consultation on the patient without insurance. Is the latter patient being treated fairly?

Reply:

This scenario touches on many ethical and decision-making issues, including the utility of imaging for appendicitis diagnosis, how standards of care are developed, assessment of risk in medical decision-making, equitable distribution of care, and physicians' attitudes regarding patient input and socioeconomic status.

The use of CT scans in the diagnosis of suspected appendicitis has become fairly common in the past 10 years. The test has very high sensitivity and specificity when properly performed; yet in practice, its value is less clear.

Research studies have yielded conflicting results for the impact of CT scanning on undesirable outcomes. Some studies have linked "liberal" use of scanning to dramatic reductions in both unnecessary operations and appendiceal rupture rates due to improved speed and accuracy of diagnosis. Other studies have shown no significant reductions in undesirable outcomes to justify the added expense and risk of additional radiation exposure. Nevertheless, many physicians and hospitals have embraced the promise of the test and recommend its use, either judiciously or liberally, as a matter of standard care. A significant drop in rates of negative appendectomy (unnecessary surgery) has been noted during the period of adoption of scanning, although a cause-and-effect link between the two trends is uncertain.