Željka Znidarčić, M.D., Ph.D., M.I.A.C., University of Zagreb, Medical School, Zagreb, Croatia.

Summary

The great advance in medical science has resulted in a number of ethical problems and there is a need to discuss such problems in cytology.

After an analysis and discussion about ethical problems in cytology some proposals can be made.

In organization of a cytological department, an adequate education of cytologists and cytotechnicians is very important, as well as their sufficient number.

The contact with clinicians has to be very close and clinicians have to be well informed in cytology.

Cytological reports should be completed in the shortest possible time and written in an adequate way. Professional secret has to be carefully respected.

Cytologists have to be included into medical teams and to be involved with the patients from diagnosis, treatment control and follow-up, not as a service, but as representatives of clinical diagnostic branch.

Quality control has to be provided in cytological departments not only in internal but also in external form, on the state level.

New technologies should be used according to the best scientific results but always after the cytological analysis.

Scientific work in cytology has to respect general principles of scientific ethics. The patient's interest has to be the main reason for such work.

Introduction

The recent technical advances have brought about a number of ethical problems in science, especially in its biological part. Bioethics as the result of such problems is now of great interest not only for scientists but also in everyday life.

Although ethical problems were known already in the time of Hippocrates, medical ethics is now increasingly discussed in all medical branches and it is often one of topics at various congresses.

I may be wrong, but it seems to me this is the first time that medical ethics is a topic at a cytological congress. Therefore I shall try to speak about it from my thirty-year experience in clinical cytology.

Methods of analysis

Ethical problems specific for cytology can be divided into three main groups:

a)      problems in the relationship between cytologist and patient,

b)      problems in the relationship between cytologist and clinician, and

c)      problems in the relation to new technologies in cytodiagnostics.

The correlation of these problems with the kind of cytological unit (in- or out of hospital) was then studied together with their correlation to the education of cytologists and the cytological education of clinicians.

Discussion

Clinical cytology has specific ethical problems because of its position between patient and clinician. Being a physician, a cytologist has responsibility for his work, both moral and legal.

In practice, gynecological cytology, because of a great number of cervical smears, is still the greatest part of cytology, but non-gynecological cytology is increasingly applied. Therefore ethical problems in clinical cytology should be analyzed generally regardless of the kind of particular cytological units.

When there is no direct contact between a cytologist and patients, the cytologist should not forget that the cells he/she is examining belong to a patient. Each patient is a case for himself and all information available should be included in cytodiagnostic observation together with microscopic examination of cells. The cytologist's responsibility includes technical procedure of the admitted material as well as the way of expressing the cytological finding. The time between taking material and issuing the cytological finding should be as short as possible.

It is much better when a cytologist has direct contact with patients, when he/she sees the patient and can get information necessary for cytodiagnosis. It is usually the case when cytology exists as a department in the hospital. Then the cytologist is included in a team which takes care about the patient from diagnosis to treatment. Often the cytologist also takes part in the treatment control and in the follow-up of the patient. It is important to say that clinical cytology should not be considered as a service in medical care, even from the cytologist's side. The cytologist has the responsibility for his part of work, but he/she should take part in decisions about the way of taking material for cytologic examinations, about the indication for cytodiagnostics, about other diagnostic procedures, as well as in the interpretation of obtained results.

Besides microscopic examination of cells, a number of new technologies is now applied in cytodiagnostic laboratories or in relation to cytodiagnosis .Some of them are in routine practice, as immunocytochemistry/cytochemistry, others are applied also routinely in greater cytological departments and some are explored for specific cases only. Microscopic analysis of smears remains the basic cytological procedure and the cytologist indicates other necessary procedures after the cytological examination.

After such an analysis of the cytologist's responsibility we can see ethical problems in cytological practice more clearly.

A cytologist cannot make a reliable cytological diagnosis without adequate information about the patient. If there is no possibility to get such information, the cytologist should make it clear in his report. The same case is when the material for cytoanalysis is not adequate.

Cytological smears should be made by qualified persons and cytologist must not analyze technically inadequate smears.

Cytological laboratory should be technically well equipped, with instruments and with sufficient number of adequately qualified cytotechnicians. When this is not the case, cytologists will have too much work and too many chances to make inadequate or even false diagnoses. Insufficient number of cytotechnicians shall result in too long period of waiting for cytological diagnoses, which is also an ethical problem.

Cytological reports can be expressed in various ways, and interpretation of these reports by clinicians is very important. Cervical smears are reported in a uniform way, which is not the case with other cytological materials.

Normal cervical smear reports could be signed by cytotechnicians, but the cytologist is also responsible for them.

Cytological reports should include a description of all elements important for diagnosis. Now it is possible to add one or more pictures with characteristic details. The conclusion should be understandable to every physician. Two ethical problems are present here: professional secret and informing the patient about the malignant diagnosis.

The professional secret obligates the whole personal in the cytologic department. It is sometimes a problem in hospitals when diagnosis should be reported by phone. The best way of reporting is direct communication between cytologist and clinician, in written form and, if necessary, with oral explanation.

Although the patient (in majority of cases) should know his diagnosis also when it is malignant, the cytologist should not be the first person to inform him/her. When the patient takes his cytological finding personally and wants to speak with the cytologist about it, it is better to say only a part of the truth and to give him time to prepare himself for a talk with his doctor.

In a well organized cytological department with a sufficient number of adequately educated staff, all ethical problems mentioned here shall be solved or even prevented in an easier way. It is important that the head of the cytological department is an adequately educated cytologist with experience in all cytological branches. It would also be of importance to introduce quality control in cytology on the state level.

The education of cytologists and cytotechnicians is a problem «per se».

Clinical cytology is now a medical diagnostic branch, interdisciplinary like other diagnostic branches, so a cytologist has to be completely cytologically educated. It is not possible to be «partly-cytologist», to know, for instance, only thyroid or breast cytology, or to practice cytology as a second profession. Only exceptionally were such cases known among cytologists in earlier times, but the great development of all medical branches makes this now impossible. We know of course that  there are still such «cytologists», but this is also an ethical problem.

Education of cytotechnologists also should be uniform, and they should know both gynaecological and non-gynaecological cytology. The need of introducing new technologies into cytological laboratories puts new requirements on their education.

A great problem for an adequate exploitation of cytology is poor education of medical students in clinical cytology. All medical doctors should know the advantages of cytodiagnostics, the indications for it, the possibilities of taking material, the main principles of cytoanalysis and the interpretation of cytological findings. Working in teams with cytologists makes clinicians better informed about cytology and that also improves cytodiagnostics. Members of a team are legally responsible, each one for his part of work, but their ethical responsibility is even greater – they, in a way, should control each other and at the same time learn from others and teach others.

A cytologist also has responsibility in relation to new technologies used for improving cytological diagnoses. Like other morphologic diagnostics, cytology is subjective and various technological methods are introduced to make it more objective. Morphometry, AgNOR technique, cytochemistry/immunocytochemistry, flow-cytometry, in-situ hybridisation, PCR are the most important among them and a cytologist has to learn about them to be able to use them if necessary, after microscopic cytoanalysis. Some of these technologies are routinely used, especially in hematology for classification of hemoblastoses. Others are used in special situations and the interest of the patient should be the only reason for them. None of them can replace somebody's ignorance because there is no (till now) such method which can replace microscopic cell analysis. The critical economic situation in medical care should not be worsened by uncontrolled use of new technologies.

Scientific activity of cytologists cannot be neglected in an ethical analysis of their work either. General ethical principles for scientific work should also be respected in cytology. One of the most important things in cytology, when reporting the results, is evaluation of the accuracy of cytological diagnoses. The problem is the method for such an evaluation. A scientifically reliable evaluation demands an accurate diagnostic method for comparison. We all know that pathohistological diagnosis is not objective, but if this method is chosen as control method for cytodiagnosis, there are rules which should be respected. The material for both methods should be taken from the same place. The time between taking material for both methods should be as short as possible and each method should be done by a different person. If a great group of patients is examined, the same way of taking the material (i.e. core biopsy, or surgical biopsy, or operation material or autopsy material) should be used for pathohistological examination, and not several ways for the same group. In the practice it is not always respected. The best way for evaluating cytological diagnoses is follow-up of the patients, which is not easy to achieve.

One must always have in mind that scientific work has to serve the patient and not the doctor and his/her career or some other benefit.

 Conclusions

1.Cytology is a medical branch (not a method!) and it should be optimally exploited because of its advantages, to serve the patients.

2.Organization of cytological work and cytological education in all its parts should be performed by cytologists.

3.In all his/her activities a cytologist must always keep in mind, he/she is a physician. It is not enough to look at slides under the microscope and write a diagnosis. Rather than do our minimum – just answer the clinician’s questions, we must do our maximum – organization, education, scientific evaluation of our work – everything possible to help our patients.

This is our moral responsibility.