Not Telling Bad News: An Ethical Dilemma
In my now inactive "Bioethics Discussion Pages", I presented a scenario which provides a true dilemma with regard to the telling of bad news to a patient. The conflict is between the ethics of a patient's culture and the law and ethics and standards of practice in the "American culture". The most recent responses by visitors to the "Pages" are at the top of the posting. What would be your response? ..Maurice.
Not Telling Bad News
The patient, Mrs. F., is a 66 year old female mother of 4 sons and 5 daughters, who was born in Italy and lived there until 2 years ago when she moved to a northern city in the USA to be closer to 7 of her children who are now residents in America and live not far from each other. The patient is now living with her eldest daughter. The patient’s husband died some 10 years ago. The patient speaks and understands some English but is not at all fluent.
In the past several months, the patient has developed abdominal pain, nausea and a 15-pound weight loss from her usual 150 pounds. She was taken to a physician, Dr. G., the private physician of her daughter. Dr. G. examined Mrs. F, ordered tests and finally requested a gastro-intestinal specialist consultation. With the understanding by Mrs. F. that some tests needed to be done to find out the cause of her pain, she accepted the tests. By these tests including a biopsy, Mrs. F was found to have an ulcer in the stomach that was a cancer. According to the gastroenterologist the cancer could be surgically removed but the patient needed a surgical consult to determine how much of the stomach needed to be removed.
Before Dr. G spoke to the patient, the elder daughter talked to him and requested the diagnosis. He told her about the suspected stomach cancer. She then insisted that he not tell her mother that she had a cancer. She said that in her Italian culture these serious matters belonged to the knowledge and decision of the family and that the patients were not told since they might be harmed by the information through emotional fright and worries and as a consequence might not try to get better. She said she and the rest of the family would be the ones to be informed about the prognosis and treatment and the family would decide and give informed consent for the treatments. She was very emphatic about this directive she gave the physician. Two other family members present at the time confirmed what their sister said. The physician told them that Mrs. F was no longer in Italy and that in this country it was ethically and even legally wrong not to tell the patient what she had and not to get her own informed consent for the surgery and subsequent treatments. After much discussion with the family, Dr. G. suggested he go and ask the patient how much she wanted to know about her illness and what needs to be done. The daughter and family refused for the doctor to speak to the patient about this matter since they feared their mother might infer a bad diagnosis.
What should Dr. G. or any other doctor responsible for this patient do?
---- THE DISCUSSIONS ----
Date: Fri, Jul 16, 2004 1:40 PM From: email@example.com To: DoktorMo@aol.com
It is true that the context of practice is North America, not Italy. Consequently, the law and ethics that guide clinical practice here must be seriously considered. As such, we cannot forget the principles of patient autonomy, beneficence, disclosure, and consent: the patient has a right to information to make informed choices. The patient also has the right to forego information and I think that the doctor's responsibility is to delicately find out how much the patient wishes to know. Autonomy also means respecting and working with a patient's beliefs and culture as much as possible. Relating to beneficence, would telling the patient cause her more harm? Most commentators don't think so, but if they don't have the same point of reference as the patient, how do they know? It strikes me that the challenge is not what the doctor should do, but HOW she or he finds out what the patient wants. Hopefully this doctor was taught some communication skills. The children may be right and so be it, or they may be wrong and then patient can be informed.
Date: Sun, Aug 4, 2002 12:27 AM From: firstname.lastname@example.org To: DoktorMo@aol.com
At first glance there may seem to be a dilemna here for Dr. G. After a moments thought, however, any such dilemna proves illusory. Mrs. F is the patient, not her family. Dr. G is the physician, not Mrs. F's family. Mrs. F has rights to the information regarding her health. The physician has the right to inform his patient as well. I'm not sure that any mentally stable person would want to be ignorant about their illness. Though one may not want bad news, it's certainly better than no news.
Let us not forget the gravity of the term, "rights" in this context. How often do we confuse rights with sole privilages? Remember that our duties and responsibilities in addition to our privilages give us our rights. Our right to act is not always just something we have the choice of doing, but also duties we must perform and responsibilities we must be held accountable for.
Having to disregard family/cultural tradition may not be easy, but Dr. G's responsibility as a physician is clear.
Date: Tue, Jul 23, 2002 9:59 AM From: email@example.com To: DoktorMo@aol.com
The doctor has an ethical dilemma. Is his responsibility to the patient or to the family of the patient? I would answer that in this case it is to the patient, (sometimes families have bad intentions or are ignorant or both). His obligation is to inform the patient. His skill as doctor to do so in a kindly supportive and understanding way is now put to the test. This meeting may be had with the family present, if the patient wants that.
Ultimately we are all prisoner's of our culture. If it was an ethical requirement to treat people form a different culture in the same manner that they would be treated were they still in that culture well... you can imagine the doctor putting on the voodo feathers and killing a chicken because that the way it was done in the patients old country.
This particular patient is not described as mentally incapacitated in any way only having a language fluency problem. This can be over come with a translator or by bringing in a doctor fluent in Italian. Bad news is bad news and no amount of cover up will make it go away. I believe some studies have show that the not-knowing the sense that things are going badly but nobody is telling me what is going on is more stressful, ultimately, than knowing the bad news and moving on to dealing with it or making peace with the outcome.
Date: Tue, Jul 2, 2002 8:48 PM From: firstname.lastname@example.org To: DoktorMo@aol.com
Of course the doctor should tell the patient of the situation that she is in...he should have told her before he told her daughter...then there would be no dilemma to begin with!!!!
Date: Tue, Jul 2, 2002 1:44 PM From: JeriNrich@aol.com To: DoktorMo@aol.com
Under the umbrella of veracity and autonomy (self-determination)the patient must be told. There are precious few times that I could think of where the patient should be lied to. Throw in the concepts of least harm/ most good as well as cultural relativism serve to strengthen my resolve. Richard Cherrin