Willful Ignorance: When Is It Acceptable?
Willful ignorance is the conscious intent of a person to avoid obtaining information about a matter. The issue is: What do you see is the significance of willful ignorance in medical practice? There are some interesting aspects of this question based on whether the willful ignorance is on the part of the patient or on the part of the physician. For example, do you ever think it is reasonable for a patient not to want to be told the results of a test or given a diagnosis or a prognosis about an illness or details about treatment? If so, under what circumstances?
Do you ever think it is reasonable for a person to refuse to be tested for a genetic abnormality.. if the person is healthy? ..if the person already has a disease that can have an associated genetic abnormality such as breast and ovarian cancer but the results of the test might be of significance to the health of family members? Or what about a family member who does not wish to know the results of a genetic test on another member? If the results of any test could have medical significance to the health of some other individuals, should the test be performed even if the person to be tested refuses to be told the results or even be tested?
Do you see any reason why a physician’s willful desire for ignorance regarding some aspect of his/her patient’s history or physical exam or test would have ethical merit or be professionally acceptable? For example, if a physician knew that the results of a test that the patient requested would most likely provide a result that would be ambiguous and if abnormal would only lead to additional procedures which, in the long run, would not be beneficial for the patient, that physician would desire ignorance (remember, it is the physican’s duty to interpret the test) and refuse to perform the test. (An example might be performing a PSA test to screen for prostate cancer in an 85 year old man.) Would that be ethical?
Well, what do you think? ..Maurice.
posted by Maurice Bernstein, M.D. @ 6:23:00 PM
6 comments
6 Comments:
Free will. Where the patient is concerned, he has (or should have) free will, and his right to ignorance - although possibly blameworthy and ill advised - should be inviolate.
One would hope that he could be persuaded to be tested, especially if others stand a chance of being impacted by his decision.
Regarding physicians willful desire for ignorance regarding certain tests ...
... the physician is the "expert" being consulted ... why would he agree to order (or perform) tests which would have ambiguous results, and ultimately not be in the patient's best interest? That would be bad medicine ...
As far as testing for prostrate cancer on an 85 year old man, though ... not all 85 year olds are the same. Some octagenarians are young physically and emotionally, and actively give back to society on a ongoing basis. Why not treat them according to their lifestyle and current health situation rather than the blanket surmises which accompany their age?
I think that I would answer: respect free will, carefully examine each situation's unique circumstances ... and add a liberal amount of common sense.
Great question, Dr. Bernstein! Have a happy New Year!
Moof, the basis for willful ignorance for a person most likely is because the person fears harm or physical or mental discomfort or perhaps some unwanted obligation to come personally and in some way if the person becomes aware of the information. A physician who willfully ignores history, physical or laboratory tests as part of the professional obligations may have a less obvious basis for the decision. As far as a doctor trying to avoid performing a test which the physician anticipates may yield ambiguous results, the reason may well be that the doctor doesn't want to face the dilemma of which way to respond to the test result. That is, proceed with further tests likely to go nowhere but cost the patient money, discomfort and unnecessary risk or the other possiblity of missing, by chance, a beneficial result for the patient by continuing on with the testing. The missed diagnosis being a black mark on the physician's record and perhaps lead to legal problems, so the physician might wonder why take a chance? The physician might feel better to simply avoid getting a result of the test in question. It boils down to a dilemma related to the physician's responsibility for beneficence and non-malificence to the patient and it would be a "cop out".
Another basis for willful ignorance on the part of the physician in history-taking is a common behavior of avoiding to ask the patient questions related to sexual preferences, sexual activities and sexual history. (How often have you, as a patient, been asked by your doctor about your sexual preferences,activities and history?) The issue there is the physician may never have felt comfortable asking these questions of patients or may be concerned about how the patient may respond to being asked. So the physician rationalizes that the details are really not necessary so why ask. You don't know how often we have to stress to medical students the importance of asking these very personal questions in appropriate situations such as with symptoms that could be associated with sexually transmitted diseases or even during a routine complete history and physical so we get the whole picture of the patient. But there is resistance at first by medical students to obtain this history but hopefully that resistence will not continue into later practice. An example of willful ignorance during the physical exam again may be due to the physician attempting to prevent their own emotional discomfort in performing rectal or genitalia exams or as has been noted on my Naked and Patient Modesty threads avoidance of physicians from inspecting the skin in the genitalia area. In both the history and physical exam examples, it may be discomfort with the process as well as the results which lead to the physician avoidance.
Finally, Moof, specifically with regard to PSA testing in an asymptomatic 85 year old, because of the slow growing nature of prostatic cancer and that a great number of men over 60 have prostate cancer that doesn't become the cause of their death, testing a asymptomatic 85 year old is still controversial and may lead to the dilemma of what to do with the PSA value obtained and perhaps the test shouldn't have been done in the first place. ..Maurice.
I have seen instances of willfull ignorance, though never knew the term for it. Thank you. Great post.
For you PSA posters, you are talking about informed consent, not willfull ignorance in the 85 yo man for PSA screening.
To me, willfull ignorance can be malicious, self-serving, and hypocritical.
I think it is totally unexceptable for any medical person at any level to just assume that it is OK to omit or gloss over test results, details of a treatment, or all aspects of a treatment or drug including adverse affects. We should always be given a choise as to how much information we recieve before the treatment. The idea of not informing the patient because it will help ease their anxiety or make it easier on them in my opinion is nothing more then a way for so called medical professionals to maintain control over us and to make their job go faster and easier. It is just terrible when $ signs and greed control these people actions at the expense of a patients health. It is ironic how medical professionals don't like patients questioning their actions, but it is by their not telling us the truth and not disclosing all the facts that we have come to distrust them. After a very adverse reaction to a evil drug called VERSED and before hand not being told any more then that I was going in for a 20 minute "nap" I learned not to ever trust these people or let them out of my sight.
Although all of the discussion so far has been about willful ignorance in the context of major medical decisions, the original question is simply, "What do you see is the significance of willful ignorance in medical practice?" Therefore I offer a different kind of scenario, and my opinion on it:
Patient comes in with a relatively minor skin infection for which I believe an oral antibiotic (say a 1st generation cephalosporin) will be useful. She says to me, "Please don't tell me all the side effects. I'm so suggestable that any time I know something could happen, it's sure to happen to me." I agree that the patient is, indeed, quite suggestable, so here's what I say:
"Ok. I can certainly understand that. How about this: call me if you get a rash, or if anything else untoward happens."
I have covered the major side effect of an allergic skin reaction, but haven't mentioned GI upset, diarrhea or yeast infection. These things can certainly still occur, but I have covered my bases by telling the patient to call with any other symptoms. Yes, I'm leaving myself open to calls about unrelated phenomena, and to theoretical liability for not disclosing all the information, even though it's at the patient's request. The other working assumption in this scenario is that of an ongoing relationship with the patient. I agree that knowing the information could have an adverse effect on her, so her request for ignorance is not inappropriate in this instance. In addition, the patient trusts my judgement that her ingnorance is unlikely to do her significant harm. Finally, I have provided enough information to keep her safe.
Therefore in some circumstances, a patient's request for willful ignorance can be appropriate, and should be honored.
My 23 year old niece died 2 years ago of a brain tumor, she was married with 2 children. She was accompanied by a large entourage of extended family and friends every single time she had any sort of doctor visit or test. The family had taken it upon themselves to keep her from knowing the seriousness of her illness because she had said on diagnosis that, ‘she didn’t want to die.’
The doctors were manipulated by the family’s wishes then. She then had zero chance of mobilizing her own forces using her mental ability to fight this, she could have made better nutritional choices (oh we are letting her eat Chinese take out everyday she loves it)) she did not have a chance to say goodbye to her children in such ways as video diaries, journals, gifts etc.
I have another young friend in the same scenario. She has not only survived and thrived with stage four cancer for over five years; it has been an experience of growth and tremendous learning for her, her children, her family and friends.
I believe she was given the better chance, had a better outcome and the damage to her family should she die will not be so unforgiving.
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