Ethical Dilemmas in Sonography: How to Handle the Hard Situations at the Console

Why Ethics Is Not a "Soft" Topic in Sonography

Sonography ethics isn't about abstract principles — it's about specific situations that happen in real scanning rooms and put sonographers in genuinely difficult positions. You will eventually be asked to do something that makes you uncomfortable. Knowing the professional and legal framework before it happens is the difference between responding well and making a career-affecting mistake.

The SDMS Code of Ethics and ARDMS Standards of Ethical Conduct are the foundational documents. They are worth actually reading — not because of the formal language, but because they provide the backing when you need to decline an inappropriate request.

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Dilemma 1: The Incidental Finding You Can't Ignore

Scenario: You're scanning a 42-year-old for right upper quadrant pain. The gallbladder looks fine. But you notice a 2.8 cm hypervascular liver lesion that wasn't the reason for the exam.

The ethical obligation: You cannot ignore an incidental finding and hand the images to the radiologist without a notation. Your obligation is to image the finding completely, document it in your technologist notes, and ensure the radiologist is aware.

What "complete imaging" means:

• Multiple projections
• Measurement in three planes
• Doppler interrogation if appropriate
• Any comparison to prior studies if available in PACS

What you should not do:

• Mention the finding to the patient ("I noticed something on your liver...")
• Speculate on its significance
• Fail to image it because it's outside the exam indication

The documentation: Most PACS systems have a technologist note field. Use it: "Incidental hypervascular liver lesion noted in right lobe, approximately 2.8 cm. Multiple views obtained."

If the radiologist misses it or doesn't address it in the report, that's a QA issue between the radiologist and the department — but you've fulfilled your professional obligation.

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Dilemma 2: The Physician Asking You to Change the Report

Scenario: A physician calls after receiving a report showing a 4.5 cm AAA. They say the patient is a poor surgical candidate and ask you to "re-measure" because they think you measured it wrong.

This is a serious ethical and legal situation. Medical records are legal documents. Altering an image measurement after the fact — particularly when motivated by a clinical outcome rather than a genuine measurement error — can constitute fraud.

How to respond:

1. Remain professional and non-accusatory.
2. Explain that you can review the study and re-image the patient if there's a clinical reason to believe the measurement is inaccurate.
3. If the physician believes there was a technical error, the appropriate path is a repeat study with documentation, not altering the existing record.
4. Escalate to your lead sonographer, ultrasound medical director, or radiology department if pressure continues.

Your protection: Do not alter measurements in a completed study. Document that the request was made and how you handled it. If this is a pattern with a particular physician, report it through your compliance or risk management department.

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Dilemma 3: Confidentiality and Third-Party Requests

Scenario: A patient's spouse is in the waiting room and asks you, as you pass by, "Did you find anything on the ultrasound? She's been really worried."

HIPAA applies directly here. You cannot share any information about a patient's study with a third party — including a spouse — without the patient's explicit written authorization (or verbal consent documented in the chart). This is true even if the spouse is well-intentioned and clearly concerned.

How to respond:

"I understand you're concerned. The results will go to [patient's] doctor, who will share them with her. If she wants to share information with you, that's absolutely her choice."

Never say: "Everything looked fine" or "The doctor will explain what we found." The first discloses results. The second implies there are results to disclose.

Emergency exception: If a family member is the designated healthcare proxy for an incapacitated patient, the rules change — but the documentation should already exist in the chart. Don't improvise proxy determinations at the waiting room.

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Dilemma 4: Scope of Practice Pressure

Scenario: You work in a busy OB practice. The physician is running 45 minutes behind. The front desk asks you to do a quick "bedside scan" to check fetal position and tell the patient whether she's dilated, so the physician can plan her afternoon.

Cervical dilation is a physical examination finding — not an ultrasound finding. Assessing dilation is outside the scope of a sonographer's practice. Even if you are personally experienced with TVUS and have scanned thousands of OB patients, describing dilation to a patient is practicing medicine.

How to respond:

• "I can do a limited exam to document fetal presentation for the chart. Cervical assessment would need to be done by the provider."
• If there's institutional pressure to expand scope: request a written policy from medical leadership before complying.

Scope of practice pressures are among the most common ethical situations sonographers face in understaffed outpatient environments. The SDMS Practice Standards document defines the sonographer's scope. Know it and cite it when needed.

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Dilemma 5: The Patient Who Asks You to Perform an Unauthorized Study

Scenario: A patient is scheduled for a renal ultrasound. She asks you to "also just take a look at the baby" since she's 16 weeks pregnant and "just wants to see it."

This happens constantly in clinical practice. The answer is no — but delivered carefully.

Why:

• The exam is not ordered. Insurance won't cover it. There is no physician order.
• If you image the fetus and miss a finding, you've created undocumented medical risk.
• "Just looking" at a fetus is a medical examination with clinical implications.

How to respond:

"I wish I could — I understand how exciting that is. But I can only scan what's been ordered by your doctor. I'd hate to miss something without the proper documentation. Ask your OB to schedule a separate appointment and you'll get a full look."

This is warm, non-judgmental, and leaves the patient with an action path.

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Dilemma 6: Suspected Child Abuse Imaging

Scenario: You're scanning a 3-year-old for abdominal pain. In the process you notice multiple bruises in various healing stages. The parent's explanation doesn't match the injury pattern.

You are a mandated reporter in most states. Ultrasound technologists are typically covered under allied health mandatory reporting statutes for suspected child abuse or neglect. Your obligation is to report your observations to the ordering provider immediately and, in most states, directly to child protective services if you have reasonable suspicion.

Critical steps:

1. Complete the scan professionally. Do not alter your behavior toward the parent.
2. Document your clinical observations objectively in the technologist note (bruising, exact location, approximate healing stage).
3. Immediately notify the radiologist and the ordering physician.
4. Know your facility's child abuse protocol before you need it.

You are not required to prove abuse. Mandatory reporting applies to reasonable suspicion, not certainty. Failure to report when suspicion exists is a legal violation in most states, regardless of whether abuse is ultimately confirmed.

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Dilemma 7: Scanning a Family Member or Friend

Scenario: Your brother-in-law asks if you can "just check his gallbladder" since you have access to equipment at work.

Do not perform unauthorized scans on family or friends. This applies even if you're off-shift and think no one will notice.

Why it's a problem:

• Liability: if you miss something, you have no physician order, no formal documentation, no diagnostic protection
• Employer policy: most hospital employment agreements prohibit personal use of equipment
• Clinical context: you lack the clinical information to interpret what you scan appropriately
• HIPAA creates documentation obligations even for informal scans

The appropriate response is simple: "I can't scan you at work, but here's who you should see for that."

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The Ethics Documentation Habit

For any situation where you're uncertain, document in real time:

• What was asked of you
• What your response was
• Who else was notified

A brief contemporaneous note — even in your own personal file, not just the chart — is your protection if questions arise later. Ethics situations rarely escalate to formal complaints, but when they do, documentation is what distinguishes "I handled this correctly" from "we only have your word for that."

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Resources for Ethical Guidance

• SDMS Code of Ethics: sdms.org — the profession's primary ethical framework
• ARDMS Standards of Ethical Conduct: ardms.org
• Your state's allied health practice act: Defines scope of practice legally in your state
• HIPAA Privacy Rule summary: HHS.gov/hipaa
• Your facility's compliance/ethics hotline: Use it. It exists for situations exactly like these.

When in doubt, slow down and consult before acting. Ethical violations in healthcare rarely come from malicious intent — they come from acting too quickly under pressure.