Bioethics Discussion Blog: Physician Paternalism: Not Telling the Truth

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Saturday, July 10, 2004

Physician Paternalism: Not Telling the Truth

To give you some insight into what represents physician paternalistic behavior, I can present the following scenario, which is only an example representing that which has been practiced in the past and may still be practiced.

A) The physician has found, on routine x-ray of the chest of his patient, a shadow which to the physician is suspicious for cancer of the lung. When describing the chest film to the patient, the doctor, however, does not mention the abnormality rationalizing that since he had yet to review the film with a radiologist, which might take a day or two, he would keep his suspicions to himself until the finding was confirmed. The physician felt that until the radiologist confirmed his suspicions it would be beneficent for the patient if unnecessary emotional upset could be avoided.

Would you find this rationale acceptable? If not and you were the physician, what would you say to the patient? If you were the patient, how would you feel about the physician if you discovered that the physician did not tell the truth?

B. Scenario A continues. On consultation with the radiologist several days later, the radiologist could not explain the shadow and advised that the patient obtain a CAT scan of the chest for clarification of the finding. The physician, considering that if a repeat chest film does not show the shadow and realizing that the CAT scan study might cost the patient $1000, decides on his own to order a repeat chest film which costs perhaps 20 times less. He feels that he is doing good for the patient by saving the patient the expense. Also he decided that if no shadow appears, a CAT scan would have been unnecessary. If the shadow was still present then a CAT scan could be ordered later. The physician calls the patient and simply tells him that another chest film is necessary, since on reviewing the film again, he felt the film was of poor quality but does not describe the consultation or advice by the radiologist.

Is the physician doing good for the patient by saving the patient money for a procedure which the physician, himself, feels may not be necessary? Should the physician have now informed the patient about the shadow on the first film and his review with the radiologist? How should the physician explain his previous lack of disclosure? Should the physician have revealed to the patient the advice of the radiologist before ordering another chest film? Who should be making the decisions regarding cost vs. effectiveness of diagnostic tools?

7 Comments:

At Sunday, July 11, 2004 6:46:00 AM, Blogger BrianinTN said...

When ever I think of a physician (or anyone for that matter) withholding troublesome information from someone for the sake of their emotions, I'm reminded of a Juice Newton song "Break It to Me Gently." And, having been a cancer patient since 1999, I appreciate it when a physician tells me he "sees something" but isn't sure what it is at this time and needs to order another test or get a specialist to take a look so (X, Y and Z) can be ruled out. When in doubt, say so. Ordering a CT to confirm the shadow in question is the prudent thing to do because, chances are, the first x-ray was done by a competent technician and more than one exposure was made to begin with. If another set of x-rays shows nothing different, you’ve wasted x-ray film, exposed the patient to more x-rays, and gone nowhere. That only adds to the patient's frustration on more than one level (i.e., with you and the medical profession in general). What the doctor can say is what I've heard from my doctors; "There's a chance it's something, but there's a chance it's nothing. Most of the time, it's nothing, but just to be sure, let's do a more advanced test." As far as paying for the test - that depends on whether or not the patient has insurance. If the patient is not insured, it's time to contact a social worker who can put the patient in contact with public assistance programs.

 
At Sunday, July 11, 2004 8:02:00 AM, Blogger Maurice Bernstein, M.D. said...

And break it to me gently
Give me time
Oh, give me a little time
To ease the pain

BrianinTN, the physician in the scenario I described might defend his action with these lyrics of Juice Newton. He might argue that the overriding reason for his action is not malificence but beneficence towards the patient... to use "time to ease the pain". Obviously in the opinion of the physician, no harm will come to the patient by a brief delay and he may be right. On the other hand one can argue that it may be that even during a brief delay, use of the inappropriate technique for more definite diagnosis could lead to more delay and more confusion. The significant part of this discussion about the decisions by this physician is whether he should be making them alone and without the *informed* agreement by the patient.
..Maurice.

 
At Thursday, January 03, 2008 5:47:00 PM, Anonymous Anonymous said...

Do no harm. Sometimes the words are contradictory. I do not disagree with the doctor withholding but at the same time withholding and delaying are not the same. In the situation that he is not sure finding more information before scaring the patient is plausible, and does LESS to NO harm. As opposed to mental/emotional harm.I know I would rather the doctor be sure if he was gonna tell me I had a tumor in my chest as opposed to suspicious of it. Worrying not sure or being sure. One way or another KNOWING offers clarity and freedom that suspecting never can. However should the doctor be SURE that I have a tumor but takes it on himself to decide that I should not have that information yet I disagree entirely. It is not his right to decide knowledge concerning me like that.

 
At Sunday, March 02, 2008 7:38:00 AM, Anonymous Jay Chawla said...

Informed consent is an absolute right. Physicians should give patients a vague idea of what the probabilities are and let the patient decide, within the discretion permitted by insurance companies and patient funds.

"Break it to me gently" is part of informed consent -- it's a process. The doctor should sit with the patient, and break it to him or her gently -- but break it -- i.e., tell the patient everything, over time. And give the patient full access to the medical record.

 
At Sunday, March 02, 2008 9:30:00 AM, Blogger Maurice Bernstein, M.D. said...

The physician breaking the news "gently" to the patient should be guided by the communication with the patient as to how much the patient wants to know at any one time and not some arbitrary "gentleness" as established by the physician's own views or desires. ..Maurice.

 
At Sunday, April 05, 2009 8:37:00 AM, Anonymous Yvette Rivas said...

How does a physician determine "how much the patient wants to know at any one time". As a patient, I prefer to know what the doctor is thinking and what the doctor is doing to prove or disprove their findings or assumptions. According to the Patient's Bill of Rights, institutions, physicians and all medical care-givers must be sure that patient's understand the need for treatments, medications, and procedures completely and thoroughly before consent is given. Asking the patient to forego another chest X-ray with the excuse that the first one was not clear, is a lie and a form of coersion. The patient in this case, would not have been given all information necessary to consent to another procedure.

 
At Sunday, April 05, 2009 9:30:00 AM, Blogger Maurice Bernstein, M.D. said...

"How much a patient wants to know" should be guided by communication with the patient which will lead the physician to an appropriate answer. This is particularly important when the doctor has to relay "bad news". When dealing with issues where "informed consent" is necessary, the physician must relay all information regarding risks and benefits for which an average person would want to know to make a decision. Sometimes, because of cultural norms, informed consent must be made through surrogates when issues dealing with diseases such as cancer are involved.

If any patient finds that the information being presented for consent is unclear or seemingly inadequate, the patient must make the doctor aware that more information is needed. ..Maurice.

 

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