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Legal aspects of obstetric sonography


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L%:                                                                                                                                                                                                  1
 Legal                 Aspects                       of Obstetric                                 Sonography
 Alexander           J. Macones,13                Anna    S. Lev-Toaff,1             George A. Macones,4 James W. Jaffe,1 and Valerie B. Williams2

     Whereas diagnosis was the radiologist’s        sole concern in                                         Next, damages            to the plaintiff must have been incurred.
 the past, the current political and social milieu demands an                                               Finally, the breach must be the proximate cause (legal cause)
 understanding    of ethical, moral, and legal issues that are now                                          and the cause-in-fact         (actual cause) of the damages.
 intimately related to daily practice. This requirement has been                                               Historically,      no action could be brought by or on behalf of
 further magnified by the boom in newer imaging techniques                                                  a fetus for damages that occurred            prenatally. Courts did not
 and      the     increase     in public          awareness         about      imaging          and         recognize        the fetus as a separate living or legal entity; it was
 medicolegal issues. Sonogmaphy, in particular, is an area in                                               considered         merely a part of the mother. Concern oven fraud-
 which technologic   innovation has become the standard of                                                  ulent       claims,    fear     of suits    brought      by a child     against    the
 came in a relatively           short     time.     Clinicians      now      rely heavily         on        mother, and difficulty in showing proximate causation justified
 sonogmaphy  to assess fetal growth                       and development.            The link              the courts’ rulings on a public-policy     basis [5]. Slowly, courts
 of new technology    (sonogmaphy)                        and a high-risk            specialty              began to create a right to sue on behalf of the dead fetus
 (obstetrics)        has increased          the potential          for significant         liability        under states’ survival statutes or wrongful-death            statutes.
 [1, 2].                                                                                                    Currently,  every    American jurisdiction     recognizes     possible
    The Roe v. Wade decision            has added further import to                                         liability    for prenatal       injuries.
 obstetric sonogmaphy. This landmark case held that a woman                                                    Courts have based such claims solely on the strict definition
 has the right to terminate her pregnancy until the end of the                                              of negligence. Plaintiffs claim that the physician’s act on failure
 second trimester on the basis of hen right to privacy [3]. The                                             to act has caused them injury. These misdeeds or nondeeds
 decision to abort sometimes         is made primarily on the basis of                                      include failed sterilization    procedures,     failure to perform    di-
 a sonogmaphic diagnosis of fetal anomalies.               Lapses in this                                   agnostic tests, laboratory errors, missed diagnosis of preg-
 assessment        result in multiple legal actions and a variety of                                        nancy, and failed abortion. Many courts, however, have been
 damages. These are grouped under the general theory of                                                     bothered    by the tenuous    link between      the negligence    of the
 tort. It is essential that all those who perform sonogmaphic                                               physician   and the ensuing     damages     [6, 7]. One cannot argue
 examinations       be familiar with these concepts, because more                                           that the radiologist   caused the fetal anomaly that was over-
 than 80% of sonogmaphy-related           litigation arises from obstet-                                    looked. These are legally difficult concepts grouped under the
 ric cases [4].                                                                                             category of preconception        torts. However, when the madiolo-
     Tort litigation attempts to compensate one whose interests                                             gist negligently performs sonography,         conception has already
 have been harmed. A plaintiff must prove several elements                                                  occurred. Unlike cases involving failed sterilization or defective
 by a preponderance           of the evidence. First, the defendant                                         genetic counseling,     damages have been incurred by a living
 must owe the plaintiff a legal duty that has been breached.                                                being       with   legal rights-the         fetus.

    Received     May 30, 1989; accepted after revision July 18, 1989.
    I Department    of Diagnostic Imaging, Temple University Hospital,                Broad      and Ontario Sts., Philadelphia,        PA 19140.
    2 Temple University   School of Law, Philadelphia, PA 19140.
    3   Present   address:   Department     of Diagnostic        imaging (M5206), Hahnemann            University Hospital, Broad         and Vine Sts., Philadelphia,   PA 19102. Address reprint
 requests to A. J. Macones.
    4 Department  of Obstetrics         and Gynecology,       Pennsylvania     Hospital,     8th and Spruce Sts., Philadelphia,         PA 19106.
 AJR 153:1251-1254,          December      1989 0361-803X/89/1536-1251                C American       Roentgen     Ray Society
1252                                                                                    MACONES         ET AL.                                                          AJR:153, December 1989

Wrongful          Pregnancy                                                                             pregnancy.    This “openness  to abortion” is exceedingly difficult
                                                                                                        to prove. In some of the wrongful pregnancy cases, the act
   Claims   of wrongful pregnancy arise most commonly after
a failed sterilization procedure on unsuccessful    abortion that                                       of attempting to obtain sterilization on an abortion is, in itself,
                                                                                                        definitive proof of such openness. This, however, does not
has resulted in the birth of a normal child. These claims are
                                                                                                        exist in most wrongful-birth    cases or in wrongful-pregnancy
brought by the parent(s), who allege that the negligence of
the physician has resulted in the birth of an unplanned, albeit                                         claims in which a pregnancy has been overlooked.         Therefore,
healthy, child [8]. The application to obstetric sonogmaphy is                                          a significant burden of proof exists on the plaintiff’s part.
clean. If a pregnancy (on a twin pregnancy) is overlooked,    the                                           Nonetheless,    a vast majority of jurisdictions      recognize
radiologist   may be liable under this theory, provided       the                                       these claims, awarding the cost of pregnancy, extraordinary
                                                                                                        medical    costs, and, occasionally,    costs of child-rearing.     At
couple would have terminated the pregnancy with the correct
                                                                                                        this time, however, courts are split as to whether parents
information     before the third trimester. Wrongful pregnancy
has gained widespread acceptance in American jurisdictions                                              also may recover for associated mental distress [1 0]. A few
                                                                                                        courts have denied medical costs if mental distress awards
    The damages awarded for these claims have been incon-                                               are granted [6]. Finally, a small minority of states have denied
sistent [1 0]. In the earliest cases (and some recent ones as                                           these actions entirely via statutes, possibly representing           a
                                                                                                        new trend in jurisprudence    [22, 23].
well) monetary compensation       was denied under the “bless-
ing’s mule,” whereby the birth of a child is viewed as “God’s
                                                                                                        Wrongful       Life
gift” [1 1 12] to the parents. Recently,
              ,                             a few courts have
                                                                                                            Wrongful-life claims are closely related to those of wrongful
followed  the “burden     rule,” asserting  that an unwanted child
                                                                                                        birth,   but   are broughtby the defective    child and not by the
is an unnecessary    stress and, as such, the parents should be
                                                                                                        parents. These claims have met with fan less judicial and
awarded    costs of pregnancy,      emotional distress, and costs
                                                                                                        legislative acceptance, primarily because of public-policy con-
of child-nearing [1 3, 14]. One court even awarded general
damages to the parents, not specifying the exact breakdown,                                             cems and difficulty in accurately determining       damages. The
but awarding an amount fan in excess of medical costs,                                                  cases that created this concept did not involve medical neg-
possibly to compensate     for intangible emotional injuries [15].                                      ligence. Instead, a child sued his father for having been born
                                                                                                        into an imperfect life, that is, illegitimate. Although the court
Virtually all courts, however, deny costs of child-rearing,     but
                                                                                                        recognized   that a child has a right to be born “unencumbered”
award pregnancy and childbirth costs in an attempt to inte-
grate the cost-benefit ratio [1 6-1 9]. In most jurisdictions, this                                     and, as such, recognized the validity of the cause of action,
is the current            limit   of liability      to a radiologist           for missing          a
                                                                                                        damages were not awarded. They believed the public-policy
pregnancy.   As a missed twin involves no additional pregnancy                                          concerns were too far-reaching,       and, as such, should be left
                                                                                                        to the legislature     [24]. Similar             claims    are now      referred      to as
and delivery costs, damages are not likely to be awarded.
                                                                                                        “dissatisfied   life” [1 0, 25].
                                                                                                            The so-called           diminished       life suits,       the second        category
Wrongful          Birth
                                                                                                        of wrongful         life,   involve   impaired       infants    [19].   These      claims,
   Wrongful-birth            claims      are also brought             by the parents         and        often brought    simultaneously   with wrongful-birth     claims, are
are similar to those of wrongful                    pregnancy        with one exception:                brought    by the child [26]. It is alleged that, if not for the
the infant        is born defective.          The parents           do not claim that the               negligence   of the physician,  the defective     child would never
defect  was caused by the physician’s         negligence.  Rather,                                      have been born [2]. Once again, the physician is not alleged
because   the parents were not given the option to terminate                                            to have caused the anomaly; it is the life itselfthat   is construed
the pregnancy, it is the birth itself that is wrongful [10].                                            as a burden [27]. These decisions                     have received       a great deal
   These actions usually arise from negligent genetic coun-                                             of press because of the large amount of damages     sought.
seling.     The parents           assert     that     they    were      not informed         that          A great majority of American courts (and British, as well)
the risk   of having an afflicted child existed, and if they had                                        are bothered by a complex ethical and philosophical question:
been so     informed, they would have opted for an abortion.                                            Is an impaired existence better than no existence at all? Most
One recent case was brought by the parents of a child with                                              courts have responded       yes, relying on various measonings
autosomal      recessive polycystic kidney disease. When their                                          [26]. Some base this determination      solely on the “sanctity of
first child died from the disease, they were advised wrongly                                            human life” at any level [21]. As such, birth can never be an
that      theme was        virtually     no risk of having             a second         affected        injury in the eyes of the law. This concept has been somewhat
child. A wrongful-birth                claim was successfully                 brought    [20]. A        undermined          by the legalization          of abortion,     the acceptance             of
case with even wider                  ramifications      involved        the lack of coun-              “do not resuscitate”   orders in terminally ill patients, and the
seling about the efficacy                          tests and the
                                           of prenatal       diagnostic                                 rights of patients to discontinue     medical treatment     under
increased         risk    of Down        syndrome  of a 37-year-
                                                         in the       fetus                             certain circumstances.    In some cases, it has been decided
old woman. When the baby was born defective, the parents                                                that theme may be times               when       the cost-benefit        ratio     of a life
sued and were awarded damages [21].                                                                     is so imbalanced that nonlife becomes preferable [28]. Other
   One basic purpose of the fetal survey is to exclude fetal                                            courts choose not to deal with the philosophical    issue. In-
malformations.    When such anomalies are diagnosable         but                                       stead, they rely on the inability to determine the amount of
overlooked    on examination, claims of wrongful birth may arise                                        damages accurately to deny recovery. What compensation      is
against      the radiologist.          The parents           must    show       that had they           appropriate   for one who claims he would rather not have
known        of the deformity,               they     would         have terminated           the       been born? Clearly, the formula should weigh the value of
AJR:153,     December1989                                  LEGAL        ASPECTS              OF OBSTETRIC               SONOGRAPHY                                                                          1253

deformed         existence        against       the value        of nonexistence              [201.     As these innovative radical therapies                             become        more routine,               a
As one court stated,               this “is a mystery             more properly              to be      boom in litigation may ensue.
left to the philosophers              and the theologians”               [21].
    The courts also examine public-policy    concerns, to assess                                        Wrongful Death
whether it would be of benefit on detrimental to society as a
                                                                                                            When        negligence             has resulted        in death,      claims         of wrongful
whole to mule one way or the other. Some courts fear that an
award of damages for wrongful life would lead to an onslaught                                           death may ensue. Early statutory law did not create a cause
of litigation. Also, if these claims could be brought against                                           of action on behalf of a fetus [2, 5]. However, since Roe v.
                                                                                                        Wade,         the fetus        fatally    injured      in utemo may make                 a wrongful-
physicians, they might also be brought against mothers who
chose not to abort defective fetuses. Ultimately, some fear                                             death        claim provided               it was viable at the time of insult                           [4].
                                                                                                        Courts         are      largely        undecided          about       damages.            Some          will
compulsory abortions for mothers of afflicted fetuses and the
practice of defensive      medicine to avoid wrongful-life  suits                                       award medical and funeral costs and, occasionally,   even pain
[29]. Nonetheless,     a few courts have accepted these wrong-                                          and suffering. Most deny claims for loss of earnings as these
ful-life claims. One early case, Curlender   v. Bioscience Labo-                                        are too difficult to assess [38]. A few jurisdictions     have
ratories [30], involved laboratory error in Tay Sachs screening.                                        enacted         statutes          to prevent          these     actions       entirely      [2].     If an
After the parents were told that they were not carriers,        an                                      anomaly            is erroneously            diagnosed          when      in fact the fetus                 is
afflicted child was born. The court summarily         ignored the                                       normal, and the parents choose an elective abortion, a wrong-
social and philosophical   arguments    in ruling in favor of the                                       ful-death claim may arise. If sonographically guided therapy
                                                                                                        is unsuccessful               on leads to the death of the fetus, the nadiol-
child. Even more curious,     this same court felt that parents
should be liable for a defective child if they refused abortion                                         ogist       may be liable.
[30]. (Later the state of this jurisdiction, California, passed a
statute outlawing wrongful-life claims brought against parents                                          Agency Law
[31].) In Turpin v. Sortini [28], the court awarded only special                                            It is essential            that      all practitioners            of sonography                under-
damages for the child, denying general damages for emotional                                            stand the relationship between                           the radiologist (physician) and
distress  and impaired childhood.     They asserted    that impaired                                    the sonographer    (technologist).                        In the private office, the tech-
life was not always preferable    to nonlife, and that public policy                                    nologist  is an agent, working      for and under the control and
dictated  the importance   of the individual  deciding the value of
                                                                                                        direct supervision   of the physician.    Any reasonable act com-
his own life [28]. Thus, in jurisdictions   permitting wrongful-life                                    miffed by the technologist     within the scope of employment
claims, damages usually are limited to the more tangible costs                                          yields concomitant                  liability   for the physician,              under the “bom-
of pregnancy and extraordinary        medical costs during infancy                                      mowed servant”                rule. For example,               if the technologist              takes       a
and childhood: the less tangible general damages for emo-                                               patient       hostage,         the physician  is not likely to be liable (unless
tional distress or impaired childhood are denied as being too                                           the physician               had prior knowledge     of the technologist’s    pre-
difficult to assess [28, 32]. Presently, only high courts in                                            disposition)            because          the action       is outside       the scope            of em-
California   [28], Washington     [32], and New Jersey [33] and                                         ployment. On the other hand, if a technologist  overlooks an
intermediate     courts in Colorado    [34] recognize these claims                                      anomaly, the physician would be found liable as this omission
[6]. In fact, many states are now passing legislation to pne-                                           occurred           within     the scope          of employment.               Many        physicians
dude       these actions          entirely:       Pennsylvania        was the most me-                  do not mescan patients      or mescan only selectively   after the
cent in April       1 988 [23].                                                                         technologist’s examination.     Physicians  are as liable for mis-
   The implications for the radiologist are in many ways similar                                        diagnosis or nondiagnosis     in these cases as they would be if
to those of wrongful birth. If an anomaly is diagnosable        on                                      they had scanned the patient themselves          [35, 36]. In the
sonognaphy     but is overlooked,   and the parents would have                                          hospital-based               practice,       the radiologist          would      probably           shame
aborted the fetus with this knowledge,     claims for wrongful life                                     liability     with    the     hospital       depending          on the    degree         of technol-
(in addition to wrongful birth) may arise, provided these are                                           ogist       supervision.
not precluded by legislation.
  Wrongful-life    claims may                  also      arise   in another          situation.
Recent technologic      advances                  have   given    physicians         the ability
to perform          interventional            procedures         and invasive           testing             Seven          suggestions             aimed at improving     protection from
(including        amniocentesis             and     chorionic       villus       sampling)         in   potential  claims             related      to obstetric sonography follow. These
utero.            of shunts under sonographic
             Insertion                             guidance into                                        recommendations                    are    by    no means          exhaustive;            they      repro-
the    hydrocephalic or hydmonephrotic     fetus may improve or                                         sent a baseline of prudent practice.
prolong life, but may also result in significant additional med-                                           1 . Follow the American College of Radiology                                 (ACR) guide-
ical expenses throughout    life. If the procedure is successful,                                       lines       for fetal       surveys.       (These        guidelines       are printed on pp.
the fetus        may     claim,    “But       for the procedure,             I would         never      1 256-1 257.) When a malpractice                              claim of any type arises,                     it
have been born,” and yield a wrongful-life        claim. Wrongful-                                      must        be shown          that the physician              deviated     from      the standard
birth claims are less likely in this situation because informed                                         of came. The courts                      originally      looked       to the community                      in
consent is obtained from the parents before the procedure                                               which        the     physician           practiced        to determine            this     standard.
[35, 36]. Since the Canterbury       v. Spence [37] decision in                                         Presently, the determination     is made on the basis of a nation-
1 972, patients must be informed of the risks, benefits, and                                            wide level of minimal acceptable       performance,    often deter-
alternatives to the intervention in order to yield a valid consent.                                     mined by professional     society guidelines.   In 1 985, the ACR
approved        such      recommendations                for fetal      surveys,      detailing       in the innovative       legal theories
                                                                                                                                       of wrongful pregnancy, wrong-
the structures that should be visualized during each trimester                                        ful birth,     and wrongful          claims may arise during the
                                                                                                                                        life. These
[39]. Although the guidelines are not conclusive, noncompli-                                          routine fetal survey on in the course of sonographically  guided
ance represents            strong        evidence of deviation from the stan-                         interventions       on invasive      tests.
damd of came and bodes                    poorly for the radiologist in a mal-
practice action.                                                                                      REFERENCES
   2. If an abnormality     is identified    or suspected,   obtain a
                                                                                                       1 . Bundy AL. Obstetrical         ultrasound.    In: Bundy AL, ed. Radiology     and the
second   opinion  and/or   a follow-up     study. Rescanning     by an                                     law. Rockville, MD: Aspen, 1985:159-178
unbiased    second radiologist     is helpful to confirm   a possible                                  2. Bundy AL, Jones TB. Guidelines for obstetrical               scanning   and reporting:
fetal anomaly. Although this may seem excessive, it is helpful                                             the legal necessity.     J Ultrasound     Med 1985;4:483-484
                                                                                                       3. Roev. Wade,410U.S.             113 (1973)
to minimize the risk of an “imagined” anomaly resulting in an
                                                                                                       4. Sanders     AC. Update on the legal survey.            Presented    at meeting of the
elective abortion    and a wrongful-death                            suit. Any question                    American    Institute of (Jtrasound       in Medicine, Las Vegas, NV, 1986
about fetal structures   on measurements,                            amniotic  fluid, and              5. Dietrich   v. Inhabitants    of Northampton,       138 Mass. 14, 52 Amer. Reports
placental or fetal position should be confirmed on a follow-up                                              242(1884)
study or by a second opinion preferably before submission of                                           6. Fleisher LD. Wrongful births-when is there liability for prenatal injury? Am
                                                                                                          JDis Child 1987;141:1260-1265
a final report.
                                                                                                       7. Shaw MW. To be or not to be? That is the question.        Am J Hum Genet
   3. Detail which fetal structures                      were     normal       in a written               1984;36: 1-9
record.   Merely stating “the fetus                   appears normal” is made-                         8. Rivera v. State, 94 Misc. 2d157, 404 N.Y.S. 2d950 (1978)
quate.      Each fetal structure               and its measurements   should be                        9. Schmidt SM. Wrongful life. JAMA 1983;250:2209-2210
                                                                                                      10. Pelias MZ. Torts of wrongful   birth and wrongful life-a review. Am J Med
noted       in the written           record.     This    is strong       evidence          of the
                                                                                                          Genet 1980;25:71-80
content and quality of the examination              and also aids the                                 1 1 . Christensen  v. Thornby, 192 Minn. 123, 255 NW. 620(1934)
radiologist’s     memory if called to testify. Also note which                                        12. Terrell v. Garcia, 496 SW. 2d 124 (rex. Civ. App. 1973), cert. denied, 415
structures were identified suboptimally.                                                                  U.S. 927(1974)
    4. Be familiar with yourjurisdiction’s       case law and legisla-                                13. Bowman v. Davis, 48 Ohio State Reports 2d 41 , 2 Ohio Opinions 3d 133,
                                                                                                          356 N.E. 2d 496 (1976)
tion. This basic knowledge is acquired easily from newspapers
                                                                                                      14. Greenfield VA. Wrongful births: what is the damage? JAMA 1982;248:
and local bar associations.      It gives the radiologist an edge in                                      926-927
dealing with counsel and prospective        litigants should the need                                 15. Jones v. Mallnowski, 299 Md. 257, 473 A. 2d 429(1984)
arise.                                                                                                16. Flowers v. District of Columbia, 478 A. 2d 1073 (D.C. 1984)
                                                                                                      17. Morse   v. Soffer, 101 AD. 2d 856, 476 N.Y.S. 2d 170(1984)
  5. Rescan patients thoroughly    after the technologist’s ox-
                                                                                                      18. Custodio   v. Bauer, 251 Cal. App. 2d 303, 59 Cal. Rptr. 463, 27 A.L.R. 3d
amination. The physician is liable for any reasonable activity                                            884(1967)
of the technologist  performed in the scope of employment,                                            19. Troppi v. Scarf, 31 Cal. Sup. Ct. 3d 220, 182 Cal. Rptr. 337, 643 P2d 954
under the theory of agency law. The physician is thus respon-                                              (1982)
sible whether          or not the physician             personally       has scanned          the     20. Park v. Chessin, 60 N.Y. 2d 80, 400 N.Y.S. 2d 110(1977)
                                                                                                      21 . Becker v. Schwartz,    60 AD. 2d 587, 400 N.Y. 2d 1 19 (1977). Modified,
patient. Double-checking     the technologist’s  examination     is
                                                                                                           46 N.Y. 2d 401, 413 N.Y.S. 2d 895, 386 N.E. 2d 807(1978)
important to minimize potential liability.                                                            22. Hickman v. Group Health Plan, 396 NW. 2d 10 (Minn 1986). Constitution-
   6. Give prompt verbal and written reports, especially     if an                                         ality of Minn. Stat. 145.424 Subdivision 2(1984)
abnormality   is discovered.   Prompt and precise communica-                                          23. 42 Pa. C.S.A. 8305
tion between           radiologist       and clinician        is essential         for optimal        24. Zepeda V. Zepeda,     41 Ill. App. 2d 240, 190 N.E. 2d 849 (1963), cert.
                                                                                                          denied, 379 U.S. 945(1984)
care of patients. Reporting should always be prompt; this                                             25. Furrow ER. Impaired children and tort remedies:     the emergence  of a
becomes  even more important in the event of an abnormality,                                              consensus. Law, Medicine, and Health Care 1983;10:148-154
because       the patient       may opt to abort.             A significant        delay     may      26. Uu AN. Wrongful    life: some of the problems. J Med Ethics 1987;13:
result in claims for wrongful birth and wrongful life if the                                              69-73
                                                                                                      27. Botkin    JR. The legal concept         of wrongful life. JAMA 1988;259(10):
patient is denied the opportunity for elective abortion.
                                                                                                          1541 -1 545
    7. Document  the study. The best defense to any malprac-                                          28. Turpin v. Sortini, 31 Cal. 3d 220, 182 Cal. Aptr. 337, 643 P2d 94 (1982)
tice action is documentation.    If the study is normal, repre-                                       29. Gleitman v. Cosgrove,       49 N.J. 22, 227 A2d 689(1967)
sentative      images       of the normal          fetal structures,         fetal position,          30. Curlender    v. Bio-Science    Laboratories,   106 Cal. App. 3d 81 1 , 165 Cal.
placenta, and amniotic fluid volume                       should be taken. Video is                        Rptr. 447(1980)
                                                                                                      31 . Cal. Civ. Code 43.6 (West    1983)
an excellent permanent record of                         fetal heart activity. If the                 32. Harbeson    v. Parke-Davis Inc., 98 Wash. 2d 460, 656 P2d 483(1983)
results of the study are abnormal,                       obtain multiple images of                    33. Procanik v. Cub, 97 N.J. 339, 478 A2d 755(1984)
the abnormality.  Note when and to                        whom written and verbal                     34. Continental   Casualty Co. v. Empire Casualty Co., 713 P2d 384 (Cob. App.
reports were delivered.                                                                                   1985)
                                                                                                      35. James AE, FleiSCher AC, Thieme G, et al. Diagnostic        ultrasonography:
                                                                                                          certain legal considerations. J Ultrasound Med 1985;4:427-431
                                                                                                      36. James AE, Bundy AL, Fleischer AC, et al. Legal aspects of diagnostic
                                                                                                          sonography. Semin US, CT, MR 1985;6:207-215
   The      changing       social      climate     dictates      that     every     physician         37. Canterbury v. Spence, 464 F2d 772 (D.C. Civ.), cert. denied, 409 U.S.
be familiar with current legal and ethical issues. The radiologist                                    38. Jones v. Karraker, 109 III. App. 3d 247, 440 N.E. 2d 420(1982)
who performs            obstetric        sonography           is no exception.             Appli-     39. Leopold GR. Antepartum obstethcal     ultrasound  examination guidelines. J
cation of basic negligence                 law to the unborn child has resulted                           Ultrasound Med 1986;5:241-242

               The reader’s            attention    is directed         to the commentary           on this article, which appears             on the following        pages.

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