The Ethics of Delay: A Good or a Bad?

The following article I wrote for Bioethics.net is reproduced here with permission.

06/02/2014

THE ETHICS OF DELAY: A GOOD OR A BAD?

by Maurice Bernstein, M.D.

Delay, something late or postponed, can be looked upon as either ethically good or ethically bad. The difference depends on the basis for the delay, whether it was intentional and, if so, what purpose and what was the outcome. Unintentional delays, may be either a good or a bad depending on its origin and the outcome. Intentional delays may be the result of following the Precautionary Principle. The Principle emphasizes the need to be aware of the consequences of an action or inaction.  If the action is necessary to prevent known harm then the action should be carried out.  On the other hand, if there is no definitive evidence that the action will prevent harm but is likely to produce it or increase its risk, then following the Precautionary Principle, one should avoid or delay the act.

Delay and its ethical consequences is a common experience in medical practice.  It may be the patient who delays a visit to a doctor for a symptom recognized by the patient as possibly representing some serious disorder but the visit is delayed by the patient’s fears of what the doctor may find and so the visit may be postponed to await a spontaneous resolution of the symptom. Following the Precautionary Principle, the patient, considering the symptom as serious should not delay but seek medical diagnosis.  On the other hand, when the patient’s symptom is evaluated by the physician and based on the physician’s experience and the literature, there is reason to consider the symptom trivial and that a CAT scan is unnecessary at this point, delaying the expense, radiation and the ever-present possibility of making an erroneous diagnosis, the physician may settle on delaying further workup and proceeding instead with further observation of the symptom and with attention to the patient’s comfort as necessary. By this approach the delay may be appropriate and ethical.

Interestingly, there have been proposals by professional organizations dealing with guidelines for medical practice that based on studies and following the Precautionary Principle, recommendations including delays or abandoning certain procedures like PSA testing for prostatic cancer, mammography, colonoscopy and screening chest x-rays for lung cancer.

Unintentional delays in diagnosis and treatment may be related to the physician’s inability to readily access appropriately needed diagnostic and consultative resources.  Nevertheless, when delay is not based simply on the Precautionary Principle, it is the professional responsibility of the physician to make an effort to resolve the delay and provide the patient the needed professional services.

In medical care, delay is unethical if it is based not on precautionary concerns or is unintentional but based on self-interest of physician or, indeed, the medical system itself. It is unethical because the goal of medical practice is to provide beneficence, primarily attempting to “do good” for the patient and whatever are the personal benefit for the physician or system is secondary.  If the delay shows no concerns by the medical profession  for the patient and the patient’s symptoms or illness then the delay is a “bad” and is unethical.

Although, all the facts are as yet unknown and yet to be further discovered, there is current public concern in the apparently profound delays in the scheduling, evaluating, diagnosing and treating of war veterans by the United States Veterans Administration hospitals and clinics.  If not accidental but designed specifically to meet the self-interests of the Veterans Administration’s staff and officers, such delays, in terms of the principles of beneficence, non-maleficence and justice would make such behavior considered unethical.

As noted above, delay, itself, in the performance of a professional duty, may be ethically either “a good” or “a bad” and the ethics evaluation must take into consideration all the facts including the rationale presented explaining the delay. However, particularly in medical practice, dealing with humans who may need prompt medical attention to preserve life and provide comfort, delay should never be hidden but always explained and promptly attended to resolve.