This paper applies the Dowd model of ethical decision making to two distinct scenarios in medical imaging. The first scenario — an employee suspected of intoxication who refuses a drug test — is analyzed as an ethical dilemma in which the employee's right to privacy conflicts with the patient's right to safe, competent care. The second scenario examines a case of ethical distress in which an employee faces termination after a false positive drug test result. Using each step of the Dowd model — assessment, issue isolation, data analysis, plan development, plan implementation, and outcome analysis — the paper demonstrates how structured ethical reasoning can guide medical imaging professionals through complex workplace situations.
An ethical dilemma arises in a situation where two "right" courses of action are mutually exclusive — that is, when doing one "right" thing necessarily leads to leaving the other "right" thing undone, or even to doing the opposite (Towsley-Cook & Young, 2007). A scenario in which an employee's rights must be weighed against those of the patient is typical of this kind of dilemma. The American Society of Radiologic Technologists and related professional bodies have long recognized that medical imaging professionals face distinctive ethical challenges arising from the intersection of patient care, workplace policy, and individual rights. Structured ethical frameworks such as the Dowd model provide a systematic means of working through these challenges.
The first scenario involves a medical imaging professional who is suspected of having an alcohol problem. He arrives for his shift with the smell of liquor on his breath and shows some difficulty walking straight and enunciating clearly. After a confrontation by his supervisor, the employee refuses to submit to a blood test for drugs and alcohol. The dilemma lies in determining whether this refusal constitutes insubordination or whether requiring the test would violate the employee's privacy rights.
According to the Dowd model of ethical analysis, assessment is the first step (Towsley-Cook & Young, 2007; Wilson, 2010). The basic problem here is the possibility that the employee's ability to perform his duties is impaired by alcohol use. It is standard to expect employees in all industries to arrive for their work shifts sober and to remain so throughout the workday. For medical professionals, the responsibility for sobriety is even greater, as the lives of patients may depend on the lack of impairment in the individuals caring for them.
This leads directly to the second step of the Dowd model: isolation of the issue (Wilson, 2010). The danger to patients that the employee presents must be weighed against the danger to privacy protections and a fair work environment that an on-demand drug test would entail. The ethical question is not whether it is appropriate for the employee to arrive intoxicated — clearly it is not — but whether the ethical risk of administering a drug test outweighs the risk of either acting on unconfirmed suspicions or allowing the employee to continue working despite those suspicions.
Analyzing the data is the next step in the Dowd model, and it is here that things become somewhat more complex (Wilson, 2010). Research has shown that among radiologic technicians specifically, and among nursing staff more broadly, substance abuse problems affect approximately three to four percent of all professionals, with alcohol abuse more prevalent than any other substance (Van Valkenberg et al., 1998). Such abuse presents a serious risk to patients. It is difficult, however, to directly compare this empirical data with the more subjective considerations that arise from an examination of drug testing policies and privacy law. One could attempt such an analysis from a utilitarian perspective, weighing the costs in efficiency, turnover, and staffing ratios caused by drug testing against its benefits, but this approach risks ignoring the imperative of nonmaleficence that is central to the medical profession (Towsley-Cook & Young, 2007). Allowing impaired individuals to perform medical procedures cannot be meaningfully compared to the privacy interests of those individuals.
Developing a plan is the next step in ethical action according to the Dowd model, and in this case it is relatively straightforward given the evidence and analysis described above (Wilson, 2010). Because there is no direct comparison between the two ethical rights in conflict, one must be prioritized over the other by determining which is more closely aligned with the values of the community and individuals involved. Ethical decisions only make sense within the context of specific communities and their applied values, and the medical community defines these values in a clear and unequivocal manner (Towsley-Cook & Young, 2007). Analyzing the values of the medical imaging community and applying them to the two competing rights is the proposed plan of action.
Plan implementation requires first identifying the core values of the medical community. Nonmaleficence toward the patient is the primary goal of all medical practitioners and is even stated as such in the Hippocratic oath (Towsley-Cook & Young, 2007). The risk of causing harm exists in most medical procedures, so the imperative of nonmaleficence must be weighed against the priority of beneficence (Towsley-Cook & Young, 2007). In this case, there is a clear risk of harm if the possibly intoxicated employee is permitted to perform his duties, and the potential beneficence of allowing him to continue working while refusing a drug test is minimal — particularly in an organization where others can perform his tasks. As the patient must be the most respected and valued individual in any medical transaction, the ethical decision here appears clear.
Analyzing the outcome of the plan — the final step in the Dowd model — leads to the conclusion that the employee must not be permitted to perform his duties without first demonstrating sobriety by submitting to a drug and alcohol blood test. While the employee has a right to privacy, the right of patients at the medical facility to receive the highest quality of care with the least possible risk of harm is of paramount importance in the medical profession. The employee's right to privacy is outweighed by the patients' right to safety. The employee remains free to exercise his right to privacy by refusing to submit to the test, but he cannot be allowed to perform his duties while intoxicated. The circumstantial evidence of inebriation is strong enough to justify requesting direct evidence through a blood test. His right to privacy ends where his private decisions begin to affect others; this is no longer a question of personal autonomy, but of the commitment to nonmaleficence that must be at the heart of all ethical decision making in the medical professions.
When there is a clear course of ethical action but practical barriers prevent its successful completion, there is said to exist a state of "ethical distress" (Towsley-Cook & Young, 2007). Such instances can be somewhat more complex than ethical dilemmas, though they can be analyzed in largely the same manner. For example, consider a medical imaging professional who has submitted to a random workplace drug test and has been informed that discharge proceedings are underway due to a positive result — despite never having used drugs or alcohol in their life. The clear ethical objective is maintaining employment and having the positive result removed from the professional record, but this is far easier said than done. Applying the Dowd model allows for a clear course of action to be identified.
The Dowd model begins with an analysis of the issue (Wilson, 2010). In this case, that analysis is straightforward: the individual is about to lose their job, their ability to find employment in the same profession, a great deal of social standing, and likely a great deal of faith in the fairness of institutional systems — all based on a false positive drug test result. By agreeing to take a random drug test that was not necessarily mandatory (depending on the laws of the state in which the institution is located), this individual is now being penalized for actions they never took (Moeller et al., 2008). This situation is both ethically unjust and poses a significant practical risk to the accused individual.
"Applies Dowd model to false positive distress scenario"
An analysis of the outcome of this plan is, of course, impossible to truly achieve in a hypothetical scenario. There are several possible outcomes, and each is fairly likely depending on the personalities involved in the actual case. An especially stubborn supervisor, or a situation in which pre-existing interpersonal tensions compound the false positive result, would make continuation of discharge proceedings a more likely outcome. It would be in the interests of both veracity and justice to pursue the matter through legal channels if necessary, though from a utilitarian perspective this course of action may not serve the individual's best practical interests, as it generates expense and could make securing a position at another facility considerably more difficult. The Dowd model, in both scenarios examined here, demonstrates that structured ethical reasoning does not always yield easy answers — but it consistently provides a principled and defensible path through even the most complex professional situations in medical imaging.
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