In the Patient’s Best Interest: But Within What Limits?
It is said that the physician has a fiduciary responsibility to the patient. This means that the doctor must keep the trust of the patient. In that regard, the patient retains a trust that the doctor will always be making decisions and caring for the patient in the “patient’s best interest”. This would meet the ethical requirement that the physician’s acts be consistent with beneficence to the patient. But what does “patient’s best interest” really include and should, indeed, there be limits to the extent of those professional actions?
One question might be: under what conditions, if any, should a physician consider a responsibility to the patient’s family, to other parties including society in general? Should the physician’s concern at the bedside be only for that ill person lying in the bed? How does the “patient’s best interest” actions conflict with professional standards of medical treatment, established laws, responsibilities of shepherding common resources especially if they are scarce in order to enable the ethical principle of justice in the distribution of those resources?
Is “patient’s best interest” to placate the patient to prevent unpleasant or even unhealthy emotional turmoil? Or is it an expression to emphasize the exclusion of actions of self-interest by the physician for his or her actions? Many questions—but, in practice, these issues abound. Take these common examples and decide for yourself how the physician should respond or act. The patient wants an antibiotic for a viral respiratory illness that has been shown not to be improved by antibiotic treatment. The patient wants a medical excuse from jury duty or wants the physician to authorize a disabled parking permit when none is medically indicated. The patient, surrogate or family request a test, treatment or life-support, perhaps to produce a miracle response, when any of these requests would be a medically futile action for the patient’s condition based on known scientific knowledge and standards of practice Would it be right to deny all these requests? Would “best interest” be satisfied by educating the patient about scientific facts, the law, about ethical behavior, about social demands and requirements?
How do physicians know what is in the patient’s “best interest” if they never did or were unable to ask the patient what were the patient’s own view about needs and goals? Or is “best interest” only something the physicians know? And if the physician knows and acts, should there be limits to that action? ..Maurice.
posted by Maurice Bernstein, M.D. @ 5:39:00 PM
3 comments
3 Comments:
Dr. Bernstein, I think that a physician, when looking out for a "patient's best interest," should perhaps do so from the perspective of what is medically indicated in the particular circumstance and moment.
From your examples: antibiotic therapy for something which isn't treatable by antibiotics ... wouldn't the physician be doing more harm than good in giving the patient the requested medications? The same antibitic may not work as well at a later time if the patient really does come to need it; also, this sort of behavior will teach the patient to demand that sort of thing the next time they're in the same or a similar position, and through their example, perhaps encourage members of their family, or close friends, to make the same demands. "Give a mouse a cookie ... "
As far as things like jury duty, disabled permits ... etc. ... that comes under the heading of "medical honesty." Doctors who give in to such requests may be complimented and thanked by their patients, but they are not respected by their patients. With the fallen respect ... there's also some modicum of lost trust. That's the same as in any relationship.
Regarding the tests/treatments/life-support in medically futile situations ... that's a bit tougher, and I think the physician needs to have extremely good discernment and empathy to know what to do in each instance. In some cases, allowing a bit of slack may be helpful emotionally and psychologically for those making the requests ... and in other cases ... it might not be. When presented with a distraught family, a good physician realizes that he has more than one patient on his hands ... and perhaps empathy mixed with gentle firmness would be called for.
How do physicians know what is in the patient’s “best interest” if they never did or were unable to ask the patient what were the patient’s own view about needs and goals?
Another really good question. I could be wrong on this, since I know I'm only seeing an incomplete picture, but I think that the same could be said of most patients: 1) they want to get better, and 2) if they're not going to get better, they don't want to suffer any more than necessary. Would a particular patient want extraordinary measures expended to save their lives if they're going to end up quadriplegic and blind, or if it's only going to bring them back for a short span of time during which they will remain in considerable discomfort or pain? Tough call.
On a personal level, I would always prefer any physician I would be seeing to put 1) his medical knowledge ahead of my own requests/desires ... since his medical knowledge is why I'm seeing him, and why I trust him, and 2) if there is a gray area which truly does leave him with a variety of choices, then I would like to be involved in the decision making once I've been properly informed regarding the choices' ramifications ... and 3) there's never a time in which I would expect anything less than honesty - no matter how terrifying the honesty is in the moment of receiving it.
Moof, I fully agree with your comments. "Tough calls" are in the attending physician's court to make. However, often consultation with a hospital ethics committee may ease the call through education and mediation. ..Maurice.
The patient's best interest is being compromised by the use of hospitalists who keep hospital records ready for inspection by accreditors. Patients' doctors are not allowed to treat their patients in the hospital. The entire process is one of processing not caring and not responsibility to the patient. I have proof of falsification of discharge paperwork done by the hospitalist who forced patients out of the hospital too soon. Then, he made the records look like the entire discharge was a joint patient/doctor decision. Not only is the patient prevented from choice as to treating physician, the patient is forced against his or her will and better judgment to leave the hospital before ready creating risk and winding up with a poor discharge result.
Karin Huffer, M.S., M.F.T.
author Overcoming the Devastation of Legal Abuse Syndrome.
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