Now It’s Time to Take Ethics Quiz 2
Back in June 2005, I posted “Now It’s Time to Take Ethics Quiz 1.”
I thought it was about time now for my visitors to take ethics quiz number 2.
Here is a made-up scenario but someone in the pharmaceutical research profession tells me that this is not an unrealistic scenario.
Dr. R. has a patient with epilepsy who is not adequately controlled on any of the current anti-seizure drugs. Dr. R. is aware of a formal clinical study being performed in the clinic of Dr. S. with a new experimental anti-seizure drug that is being tested in hopes of benefit for intractable epilepsy patients. Dr. R. does not inform his patient about this study as an alternative option because of fear of losing the patient to the other clinic.
Here is the question: Is there anything unethical or unprofessional about Dr. R.’s decision not to inform the patient? Now,here is one way of looking at the issue. Dr. R. knows that a new drug is studied in a research experiment because any beneficial effect on human patients is unknown or that the beneficial effect as compared to the best present treatment is unknown. He is aware that in a randomized study his patient might be getting the new drug with unknown benefit or the other drug to which his patient has not responded, then wouldn’t Dr.R.’s decision be ethically reasonable? Why? Because there is no proof at present that whatever drug was given to the patient in the experiment would be of any medical benefit.
When considering this rationale, wouldn’t the possible loss of a patient to another clinic trump any act of informing the patient about the research project? I am eager to read what my visitors think about the behavior of Dr. R. ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:32:00 PM
6 comments
6 Comments:
Maurice - How does the _physician's_ interest in maintaining a stable of patients translate into a relevant consideration about what constitutes the _patient's_ best interest? I'm not suggesting that physician's should strive to be "interest free" -- that's impossible. But in the clinic, the physician's personal interests aren't supposed to influence decisions about how best to serve the patient's interests.
Bob, I am not saying that I support Dr. R.'s decision. I know that a physician in practice is a human being, notwithstanding any conclusions by the public otherwise, and with some decisions and actions there really is a possible conflict between two consequences: professional vs personal. The public must face the facts that their physicians are NOT inhuman machines. Now, Dr. R is facing that conflict in the scenario. He has to consider whether referring the patient to the competing clinic will provide the patient what he and the patient desires, a therapeutic benefit or in the end will the possiblity of loss of a patient be the only result. And there is another consequence which ties the professional to the personal. That is, if his stable becomes depleted through his mistaken decisions, his ability to provide financial support to his office so that he can run an effective and efficient professional office for his remaining patients will be affected. In my comments above, I am only trying to explain why any physician must and does consider personal implications vs the professional responsibility in some decisions. Again, I am not saying by this explanation that I agree with Dr. R's decision. That is because I know of another way out which is the best ethics under the situation and it is neither of the choices already implied. That's the purpose of the quiz, to see if my visitors can spot it. ..Maurice.
Maurice - Your concluding question was about the physician's interest _trumping_ the patient's interest in knowing what "reasonable" options are avialable. Now maybe the experimental drug will prove to be ineffective, or no more effective than present treatments. Maybe... And maybe the patient will be randomized to receive the experimental drug, and maybe to receive the (known, for this patient) ineffective treatment. Again, maybe...
It seems to me that this patient, having exhausted presently available treatment is a prime candidate for inclusion on the experimental protocol. That decision belongs to the patient, not the MD. If the MD is worried about "losing" a patient, that should be taken up with his/her colleage running the clinical trial.
Bob, that sounds reasonable to me. By the way, for those who came directly to this thread and are unaware of a thread that follows which is also a scenario on a conflict between the physician's professional responsibilities and his personal self-interest click here. ..Maurice.
I don't think the value of a long-term patient/doctor relationship should be undervalued. History with a particular physician is very useful in monitoring a patient's condition over time. Should this drug prove effective and become available, Dr. R would prescribe it for his patient, and if the patient received it during the course of the study and found it effective, he may leave Dr. R, which would be to his detriment in the long-run. Provided that Dr. R doesn't know if there is benefit to the new treatment, I don't think he's acting unethically. If the scenario were such that Dr. R refused to inform his patient of a newly available and effective treatment that isn't offered in his particular clinic, the situation would be vastly different.
Of course Dr. R was unethical in the scenario that you posed. Fear of losing a patient is not a valid reason for withholding information.
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