Estimating Medical Risks: Physician vs Parents:Who Can Do the Better Job?
Society takes a responsibility for the care and life of children. This is in addition to the responsibility that parents naturally hold for their children. If society finds that particular parents fail to accept that responsibility, then in the United States, as an example, individual states will take on the management and decision-making for these children.
Parental surrogates for their children actually have considerable latitude in the care, education and development of their children. They also can and do make many medical decisions toward their health. The question arises in various specific cases brought to light by the news media whether parental medical decisions are really in the best interest of their children or whether the state is overreaching its authority and denying parental rights. An Idaho case in the news, follows:
“The parents of an infant who was given a spinal tap against their wishes hope to change the way medicine is practiced in Idaho.
U.S. District Judge B. Lynn Winmill recently ruled that the state violated Corissa and Eric Mueller's civil rights when a Boise police officer took custody of their 5-week-old daughter so a doctor could give her a spinal tap to check for signs of meningitis. But Winmill left several issues for a jury to decide, including whether the system to determine imminent danger in medical cases is flawed.”
Read the entire AP description of the case and then return with your comments.
One issue is whether there are some subtleties in medical diagnosis and treatment that are obtained by physicians only through education and experience and which only trained physicians can evaluate one risk against another. Of course, the physicians should then describe their estimation of the risks to the parents. Then the parents can evaluate and decide what is best for their child. Should the parents such as in the Idaho case, who do not have the medical education and experience estimate the medical risks on their own and then make a decision based on what they consider the risk probability? ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:06:00 PM
9 comments
9 Comments:
First- they kept the kid even after they were totally certain she did not have meningitis? Maybe to teach the parents a lesson? I think the right thing to do in such a situation would depend on whether doctors can be depended upon to give accurate information about the risks and benefits, and not "filter" information based on their personal beliefs about what info the family needs and/or can handle. In my family's experience, at least, that is not the case. Partly because of that, I would lean heavily in favor of the parents. Once the state apparatus for child protection gets going, it can be very, very, difficult to stop, even when terrible mistakes are made.
It's also very easy to say, "I'm smart, I'm educated, I went to med school/grad school/whatever, so of course I know what other people should do" (this is by NO means confined to doctors!) The impulse to force other people to do what you think is "right" is pretty strong, and must be very carefully controlled.
You know, there is a risk which I don't recall was mentioned in the AP news article. The physician's estimate of the probablility of a serious and potentially lethal infection such as meningitis was about 3 to 5% as I recall. What wasn't mentioned was the even greater risk of a serious malpractice action against the physician if a lumbar puncture was not done and the child's illness was within that 5% probability.
I am sure that parents would have their way without argument in many cases if the risk and probablility of physician malpractice suits were not hanging over the doctor's head.
When the risk of complications of a lumbar puncture in an infant, as in the current case, is virtually nil unlike the risk of malpractice suit, one can understand why the physician would be compelled to do a lumbar puncture. ..Maurice.
Maurice, That's nonsense. The fact that the parent attempted to refuse treatment (and that refusal were documented) would largely defuse any lawsuit had the child actually had meningitis.
As for "risk," I find doctors largely inept statisticians. Further, they seem oblivious to the various (well documented) phenomenon that cloud their judgment (confirmation bias, financial interest, etc.).
Let parents make the call--until and when there's any good evidence that their fully informed choices led to worse outcomes.
Anonymous from today 4/2/2007: You write "The fact that the parent attempted to refuse treatment (and that refusal were documented) would largely defuse any lawsuit had the child actually had meningitis." I am not sure that declaration would be entirely comforting to a physician who has a moral and ethical duty to do the best for the patient and incidentally not necessarily the what is in the best interest of the parents. Thus if the patient died or was crippled from an untreated meningitis, do you really think the physician could live with the fact that he or she was "defused" from a law suit because of the parents decision and the terrible consequences of the child's outcome was not the doctor's doing but only that of the parents who rejected the LP?
I know that if I were the physician, I wouldn't sleep well knowing, that without any attempt to find another way to provide the child the established standard of care, I had permitted the terrible outcome. ..Maurice.
Amen Maurice. Risk of spinal tap vs. risk of having meningitis in a ill feverish newborn. Just read the risks... that's like saying a headache vs. death. Are you kidding me? This isn't about parental rights...The bottom line is this woman was willing to play the odds with her newborn babies life and this good doctor was not. I am sure that this physician would much rather be defending his actions in court with a child that is alive and well, rather than defending his actions in court with a dead or disabled one. Just read all the tragic stories from parents on Menengitis Foundation of American who would give anything to have their babies back in their arms. Oh how they wish they would have had THIS kind of doctor. If she wasn't willing to have the child tested for a serious bacterial infection, then she shouldn't have gone to the ER and involve the physician. What options did the physician have...he couldn't refuse treatment...that's against the law...if he let her go home, and the child had it and died or became disabled, she would've sued anyway...the only other option as I see it was the one he took...he contacted the appropriate authorities to ask for help... why...because he obviously cared about the life of his patient...the infant... And what thanks does he get for caring, for practicing standard of care medicine (notice this is not a medical malpractice lawsuit), and for attempting to ensure that this mother's sad story doesn't end up on Menegitis Foundation of America website? A LAWSUIT. Come on people...get educated. There is no way of knowing if your baby has this horrible disease if they present with symptoms of the disease unless you do the test, treat, and wait. Are you willing to play the odds with your children...because I certainly am not.
A question for the physicians posting: if you were in this situation with your child, and you disagreed with the ER physician's recommendation, what should happen to you? Who is wrong? Should your child be taken away, or is that something that should never happen to you because people who went to medical school can legitimately disagree about treatment options?
Lisa, excellent question. A physician who is a parent and therefore is a surrogate for a child who does not have the capacity to make medical decisions is no different than any other parent who is not a physician. And it is unprofessional for a physician parent to treat their own child for a potentially serious illness.
The parents must make decisions which are in the best interest of the child and nothing further. If it is clear to the attending physician that the parents are not taking into consideration the child's best interest and the health consequences of their decision are serious, the attending physician must report this to some appropriate governmental agency or in emergency to the court system (a judge) and, perhaps, through a request for police assistance. If the attending physician has any doubts regarding either the particular community standards of medical care of the condition or regarding the seriousness of the consequences if the parents request was followed, prompt consultation with specialists would be appropriate to help resolve these questions. This would also be the approach if the parent physician was debating with the attending physician regarding what was the established standard of medical care or what was the probablity of the outcome if the parent's request was followed.
This is my opinion on this interesting question. Perhaps another physician might contribute an answer. ..Maurice.
Okay, what is the "standard of care" in pediatrics, when there is a 5% risk of meningitis? What tests should be performed, according to the standard of care (I suppose I could go hunting for this on the AAP web site)? Does the standard of care/AAP address "playing the odds"? What does the insurance carrier say? That if there is a 5% risk, the spinal tap or other tests should be performed?
Were the parents told about the accepted standard of care at this hospital, in this state, relative to AAP guidelines? Were they given the risk/benefit ratio explanation?
Lisa, the first poster, talked about trusting the attending physician to do his patient-education job skilfully . . . Did that include a handout or diagrams? Were the parents given any time to digest the info and ask questions?
This same case was discussed on another medical blog recently, and I wrote in to say that some docs may come across like car salesmen, with pressure for an immediate decision . . . This may lead parents to mistrust these salesman tactics. And those parents might then hesitate to trust those doc-salesmen.
And this is the sniff-test: If the parents have a gut instinct which is mistrust of the doc-salesman, they are NOT going to put their child into that person's hands.
The parents brought their child to the ER in search of help--not to have someone (doc or salesman or whomever) take the care of their child completely out of their hands. Parents feel responsible for their kids, and they have to establish trust with another adult, in order to share that responsibility with that other adult.
Simple expertise, born of medical school education and experience, does not necessarily lead to trust. Experts do not trump parents' decisions made for their children out of their own value systems.
You cannot just be a brainiac, and well-educated and experienced. You have to pass the sniff-test . . . you have to be trustworthy.
(And all the reports of medical mistakes, including IOM reports over the years, do little to inspire trust in the medical profession. Parents do well to be skeptical, IMHO.)
Chris and Vic
Perhaps we should look straight through to the assumption in the common law that is becoming more prevalent as recording technology improves.
There is a presumption that, given accurate and sufficient observation and scrutiny, any reasonable person can be supplied with sufficient information NOW to address the legitimacy of the decision THEN.
It's Monday-morning quarterbacking. Any receiver shown on TV to be open, and ignored, on Monday morning, suffices to assure the viewer that the quarterback erred on Sunday if the play was not productive.
That presumption is strong and useful, but it is not the law. Sometimes (usually?) the experience of the physician at the center of the flow of information, and being in the present, is lonely. In general, we learn how to communicate by an algorithmic process. But sometimes, the risks cannot be well-communicated, as they lie on a rich bed of experience that cannot be translated.
I wrote in a consultation Friday - "Do not proceed with the surgery. The patient will die on the table if you do." Unsubtle enough even for a surgeon. But am I sure? I think the patient has a 1/20 chance of survival. Should I have said that instead of 0/20?
Welcome thoughts.
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