Ethical dilemmas in the field of histopathology rarely provoke the passion that accompanies subjects such as euthanasia or genetic cloning.

A search of the literature and of Internet materials provides little on this topic. This is because histopathologists spend most of their professional lives beyond the public’s view, in laboratories and libraries. However, disillusionment with the medical profession is combined with a growing trend towards litigiousness in India. As the words ‘ethics’ and ‘quality control’ are touted by the media, people seek vengeance when they feel short-changed. So far, clinicians have been the targets of aggrieved patients and relatives. But there is a growing awareness of the silent but pivotal role played by the histopathologist.

Recently, two excellent and upright pathologists were hauled to the courts to answer for misdiagnosis, though they were not negligent, stupid or even avaricious. Many more heads will be placed on the chopping block in the future. Committed pathologists observing this trend could end up as practising ‘defensive pathology’,unwilling to commit themselves freely in their histopathology reports. Histopathologists should start tackling the ethical problems that arise from their own work — rather than wait for the storm to hit them.

I do not suggest that we defend those who break the Hippocratic Code. However, we must find ways to protect the professional character and dignity of our discipline. For this, we must put our house in order before the roof caves in. Some of the issues that must be discussed are those involved in

• rendering a ‘safe’, scientifically accurate and complete histopathological diagnosis in a reasonable time frame.
• propriety of tissue samples and blocks
• medical audits specifically aimed at the pathologist
• the pathologist -pathologist relationship

A ‘safe’ diagnosis

How does rendering a ‘safe’ diagnosis come under the purview of a discussion on ethics? This is because even the most experienced pathologist is human, and cannot claim 100 per cent accuracy for every diagnosis in his or her career. In the interests of the patient, there will be situations where the pathologist must seek help, from experts, colleagues, books, telepathology, the Internet or any other medium. However, some pathologists may be reluctant to seek timely help in the interpretation of problematic histopathology slides, believing themselves to be perfectly competent, till it is too late.

It is important to appreciate the strengths as well as the inherent weaknesses in the science — and art — of histopathology. Histopathology is basically learning the language of cells, interpreting shapes, sizes and architectural patterns of tissues within a given specific clinical context. Outside the world of pathologists, there is only a dim understanding of the truly subjective nuances innate to this discipline. Some clinicians tend to equate a histopathology diagnosis with a mathematical formula providing predictable and consistent answers. They do not accept any leeway for inter-observer variation in pathology. Such clinicians must understand that a difficult case is similar to interpreting a semi-abstract work of art. Different people looking at the same picture come up with a different and often divergent interpretations.

This is not to say that every histology case poses problems. More than 85 per cent to 90 per cent of the work is routine and straightforward, and the experienced histopathologist can be confident 95 per cent of the time, or more. However even the most experienced can falter. This is most apparent in the interpretation of borderline cases, rare diseases, badly processed samples, or in the absence of complete clinical data. Of course the inexperienced or unmonitored pathologist falters more often.

How can we ensure the submission of a ‘safe or consensus diagnosis’ in situations where the lesion is truly borderline or rare?

Both institutional and private practices must have built in checks to sift out such problems. For example:

• Difficult cases must be routinely reviewed with seniors or with other experts in departmental meetings. It must be acknowledged that not all pathologists are exposed to — or experienced in — all areas of histology. Departments fortunate to have experts in particular areas must draw on their expertise. Help should be sought when warranted.
• Reports involving the opinions of more than person should be carefully worded. In genuinely controversial cases, the opinions and differential diagnoses of other staff should also be documented. The ultimate responsibility for the final decision must rest with the pathologist who signs the report.
• Frozen sections and fine needle aspiration cytology reports must be compared with, and audited against, the final histopathology reports. In large departments, the pathologist who sees the initial sample should not, ideally, sign the audit or final report. This automatic auditing serves as a built-in check to reduce inaccuracies and can also enable a continuous teaching process.
• Reports signed by junior staff should, ideally, be co-signed by senior staff till the former reach a level of maturity or experience. The institution should build up the department of histopathology by drawing upon the experience of experts in different areas for all difficult or controversial cases.
• Reports must be signed completely and clearly. This not just a matter of professional pride; it is also both prudent and fair, to rule out ambiguity in treatment decisions.

Propriety of tissues and blocks

The histopathologist has the right to process diseased tissue removed during surgery in any way s/ he feels fit to obtain diagnostic information for future therapeutic decisions. However, the tissue remains the patient’s property. The report based on the sample is a confidential document which should be relayed only to the clinician concerned and to the patient.

This can become a controversial issue in today’s society in which patients go ‘shopping’ for doctors’ opinions. They may wish to carry the tissue sample to several different histopathologists. It is to be expected that a controversial or difficult case may present variable, even divergent reports, confusing the patient. Nevertheless, the pathologist cannot deny the patient the right to tissues removed for diagnostic purposes, or for information based on their examination. To do so would be tantamount to malpractice.

On the other hand, departments in large institutions may argue that material obtained for diagnostic purposes should be stored and preserved for future research. This should be done only with the permission of the patient from whom the tissue was removed. It is my experience that nine out of 10 patients will agree to such storage, if their pathologist takes the time to explain the need for such research. However, if despite this explanation a patient refuses permission to have his or her tissue stored for research, the pathologist has no choice but to cooperate.

Ethics of the pathologist-pathologist relationship

There are a number of sensitive areas in histopathology, which need to be handled with care and honesty. One such area is when a clinician makes a referral to a pathologist, asking him or her to review a fellow pathologist’s earlier diagnosis. When a genuine change of diagnosis is made, the reviewer must talk directly to the first pathologist and explain why s/ he feels the need to change the diagnosis. Though this is sometimes misunderstood, it is not fair to keep the first pathologist in the dark.

Histopathologists have a right to their own opinions. However, divergent or contradictory diagnoses can create considerable apprehension for both the patient and the treating clinician. Sometimes the matter cannot be resolved without a third or even fourth opinion. It is my suspicion that in such cases, clinicians sometimes choose to believe that report which best matches their own clinical judgement.

Pathologists can and do hold differing opinions on the same diagnosis, and sometimes they may even criticise one another. However, such discussions should not go beyond the disagreeing parties, and should be carried out in complete confidence. It is unethical to criticise a fellow histopathologist before other colleagues or a clinician, and adversely affects both the critic and the criticised. As for the histopathologist who hears a patient complain about a colleague, s/he should refrain from listening to such complaints, or at the very least, refrain from making any comment that could be construed as acceptance of the criticism (2).

Professional loyalty demands understanding and mutual respect for one’s colleagues. A change in diagnosis can occur over a period of time. This can occur in the gap between the frozen section and the final diagnosis, and also as the disease progresses: more clinical or laboratory information becomes available, the picture becomes clearer and the diagnosis and prognosis become more apparent. This will necessitate a changed, more appropriate diagnostic label. While it may be embarrassing for the first pathologist, all of us encounter such situations in the course of our careers, and they should be seen as learning experiences. Similarly, diagnoses change with the use of more specialised or sophisticated tests such as electron microscopy, immunocyto-chemistry or molecular pathology.

At another level, our profession depends on sharing knowledge and disseminating scientific information. Pathologists should affiliate themselves with medical societies and scientific meetings, and contribute time, energy and means so that these societies may represent and uphold the ideals of the profession. Learning is a life-long process, and one can learn from different people: one should not be surprised to hear of students teaching their own professors in conferences, seminars and workshops. Pathologists who feel they know it all and have seen it all are dangerous. Sooner or later they are going to sign a report which could harm their patients because of their inability to keep up with the times.

Soliciting practice

This is often done subtly in institutional practice, but is more acutely felt by the private practitioner. It can also extend to cutting into the practice of a colleague. Pathologists who set up practice and announce their presence with a large signboard are probably not breaking the law, but they are certainly acting unethically (1). Signboards should not be glossy hoardings, nor should they proclaim more than the pathologist’s name, qualifications, and speciality. Blatant advertising not only lowers the dignity of the profession, it also lures patients into the flashier laboratories. Using unfair means to further one’s income or professional reputation must be frowned upon.

In conclusion, there is an ethical slant to almost all aspects of histopathology work. It requires a conscious effort to think and decide where to draw the line and how to live with dignity and professional pride.