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Ethical dilemma final copy
- 1. Disclosure vs. non-disclosure: honesty with patients Lee Dies and Jessica Glaspell Thursday, January 27, 2011
- 2. Disclosing Cancer to a Mentally Compromised Patient A 64 year old man, David, was brought to the ER after his wife found him suddenly disoriented and incoherent. David was known at the hospital for alcohol dependence, with cirrhosis of the liver. Exam in ER revealed liver enlargement including a mass (by CT scan). He was admitted to the hospital and a biopsy of the mass was scheduled. David’s mental status improved; his wife requested that he not be told if the diagnosis is malignant. David said that if he learns he has cancer, he will kill himself. The physician then cancels the biopsy procedure.
- 3. Disclosure vs. Non-Disclosure Side A: Defend the wife’s request to withhold the information.
- 4. What Needs To Be Determined? Does the wife have the right to withhold information? How does the patient being mentally compromised factor in? What is the physician’s obligation to the patient? Is the patient’s best interest served?
- 5. Presentation Goals Establish and defend the wife’s right to withhold information Explore the two main ethical principles related to this dilemma Explain the practice of therapeutic privilege Offer a plan for resolution that produces a satisfactory outcome for all stakeholders Maintain that the best interest of the patient is served
- 7. Wife
- 8. Physician
- 10. Nursing Staff
- 12. Consequences of Decision Diagnosis of cancer is withheld from patient; biopsy is canceled Patient is protected from extreme psychological harm and desperate act of suicide Suicide is avoided; wife is protected from immense despair Patient is inadvertently provided more time to come to terms with condition Physician upholds his moral obligation to “do no harm” by exercising his right of therapeutic privilege
- 13. 2 Basic Ethical Principles in Conflict Autonomy - The rights of individuals to decide on the best course of action for themselves. The legal doctrine of informed consent is based on respect for this principle. Beneficence This principle is about doing more than just not harming another person. This principle suggests that ethical behavior must “do good.” In fact, this principle in its true meaning suggests an obligation to benefit others.
- 14. ANA Code of Ethics “The Code of Ethics guides nurses when they recognize that many of the decisions they make have an ethical component and many involve conflicts among ethical responsibilities. These conflicts may involve the clash between two ethical duties such as duty to respect autonomy and duty to benefit the patient” (Preface).
- 15. Autonomy “Freedom from external constraint and the presence of critical mental capacities such as understanding, intending, and voluntary decision-making capacity (Beauchamp). “As important as autonomy rights are, no autonomy right is strong enough to entail a right to unrestricted exercises of autonomy. Acceptable liberty must be distinguished from unacceptable, but how are we to do so (Beauchamp)?”
- 16. Autonomy, Con’t. Valid ground for the limitation of autonomy The following four “liberty limiting principles” have all been defended: The Harm Principle: A person’s liberty is justifiably restricted to prevent harm to others caused by that person. The Principle of Paternalism: A person’s liberty is justifiably restricted to prevent harm to self caused by that person. The Principle of Legal Moralism: A person’s liberty is justifiably restricted to prevent that person’s immoral behavior. The Offense Principle: A person’s liberty is justifiably restricted to prevent offense to others caused by that person.
- 17. Autonomy, Con’t. “Paternalism is justified if and only if the harms prevented from occurring to the person are greater than the harms or indignities (if any) caused by interference with his or her liberty…” (Beauchamp) Paternalism defends the wife’s request to withhold the diagnosis
- 18. Beneficence This value has long been treated as a foundational value—and sometimes as THE foundational value—in medical and nursing ethics. Among the most quoted principles in the history of codes of medical ethics is the maxim primum non nocere: “Above all, do no harm.” Many current medical and nursing codes assert that the health professional’s “primary commitment” is to protect the patient from harm and to promote the patient’s welfare.
- 19. Beneficence, Con’t. The goal of all healthcare relations is to receive/provide help for an illness such that no further harm is done to the patient, especially in that patient’s vulnerable state (Beauchamp, 150). An illness is far broader than its subset, disease. Illness can be viewed as a disturbance in the life of an individual, perhaps due to many non-medical factors. Helping one through an illness is a far greater personal task than doing so for a disease. A greater, more enduring bond is formed. The strength of this bond may justify withholding the truth as well…” In this context, it is more justifiable to withhold the truth temporarily in favor of more important long-term values…(p. 150).
- 20. Court Decisions Two exceptions to the general rule of disclosure have been noted by the court. It is recognized that patients occasionally become so ill or emotionally distraught on disclosure as to foreclose a rational decision, or complicate or hinder the treatment, or perhaps even pose psychological damage to the patient Where that is so, the cases have generally held that the physician is armed with a privilege to keep the information from the patient, and we think it clear that portents of that type may justify the physician in action he deems medically warranted. (Canterbury v. Spence, U. S. Court of Appeals, 1972)
- 21. Therapeutic Privilege “The practice of withholding pertinent medical information from patients in the belief that disclosure is medically contraindicated is known as “therapeutic privilege.” “It creates a conflict between the physician’s obligations to promote patients’ welfare and respect for their autonomy by communicating truthfully.”
- 22. Therapeutic Privilege What if the truth could be harmful and when is it justified to withhold information? “If the physician has some compelling reason to think that disclosure would create a real and predictable harmful effect on the patient, it may be justified to withhold truthful information.” “…if the physician has compelling evidence that disclosure will cause real and predictable harm, truthful disclosure may be withheld. Examples might include disclosure that would make a depressed patient actively suicidal.”
- 23. AMA Code of EthicsOpinion 8.08 Informed Consent “In special circumstances, it may be appropriate to postpone disclosure of information.” “Physicians need not communicate all information at one time, but should assess the amount of information that patients are capable of receiving at a given time and present the remainder when appropriate.”
- 24. Alternatives Psychiatric Consult Therapy Plan for treatment and full disclosure
- 25. Alternatives, Con’t. Ethics Committee Consult
- 26. Recap Does the wife have the right to withhold information? How does the patient being mentally compromised factor in? What is the physician’s obligation to the patient? Is the patient’s best interest served?
- 27. Works Cited Contemporary Issues in Bioethics, Beauchamp, Walters, Kahn, Mastroianni, 2008 http://books.google.com/books?id=XxfjqF1A0TkC&pg=PA48&lpg=PA48&dq=do+family+members+have+the+choice+to+not+disclose+medical+information+to+patients&source=bl&ots=MsA46R3HNo&sig=rFO4PatZvkOp0PmQYy6sa5KWQOE&hl=en&ei=sBo-TYywKoXcgQfk09WbCA&sa=X&oi=book_result&ct=result&resnum=7&ved=0CEUQ6AEwBg#v=onepage&q&f=false American Medical Association Code of Ethics ANA Code of Ethics Article: Truth-Telling and Withholding Information: Ethical Topic in Medicine, University of Washington School of Medicine Study guide definitions from Dottie Landry, MSN, RN
Notas do Editor
- establish that the wife does have the right to request the information be withheld and why explain the practice of therapeutic privilege explore ethical principles that relate to this dilemma offer a plan that helps to resolve the dilemma and produce a satisfactory outcome for all stakeholders maintain that the best interest of the patient is servedFor our presentation, our goals are to: establish that the wife does have the right to request the information be withheld and why explain the practice of therapeutic privilege explore ethical principles that relate to this dilemma offer a plan that helps to resolve the dilemma and produce a satisfactory outcome for all stakeholders maintain that the best interest of the patient is served
- Mentally compromised/Surrogate role of wife – Pt’s mental capacity is temporarily challenged; wife is acting in surrogate role as decision maker-a right established by the fact that upon admission, she signed the consents as the patient was disoriented and incoherent. This is common practice in health care facilities. If the patient were mentally incompetent, that would bring in a whole other set of issues, namely legal, that would not support the wife’s right to act as decision maker unless there were legal provisions in place such as Advanced Directives and Power of Attorney. But mentally compromised infers to conditions when temporarily, the patient is unable to give informed consent, such as the case of David. The AMA’s Code of Ethics Opinion 8.081, Surrogate Decision Making, states “ In the absence of state law specifying either appropriate surrogate decision-makers or a process to identify them, the patient’s family, domestic partner, or close friend should become the surrogate decision-maker.” This establishes the wife as the surrogate. Now let’s take a look at the patient: Patient experienced physical manifestations of altered mental status. He learns he has a mass on his liver—he is scared, anxious and overwhelmed. Alcoholism also affects his physiological and psychosocial status. Patient understands how a possible diagnosis of cancer will affect his ability to drink, and is unable to cope with having to fight that battle along with the cancer, so patient decides that if he learns he has cancer, he will forgo it all and just end his life. The patient is under extreme duress emotionally, physically, and psychologically.
- Now we will explain why this is the best course of action for the time being. In order to do that we have to look at the ethical principles.
- In the textbook, Contemporary Issues in Bioethics, autonomy is upheld as…This principle provides the basis for the right to make decisions. But, it also states that …
- The textbook teaches that there exists valid ground for the limitation of autonomy and outlines 4 outlining principles that have all been defended.
- Because the harm prevented (suicide and extreme psychological and emotional duress) is greater than the harm of not being told his diagnosis, paternalism in this case is justified. The essence of paternalism is an overriding of a person’s autonomy on grounds of providing that person with a benefit—in medicine, a medical benefit. Examples given in the text include, among others, involuntary commitment to institutions for treatment and intervention to stop rational suicide—as in David’s case. We’ve already established the wife’s right to act as surrogate. Paternalism defends her request to withhold the diagnosis.
- In the case of David,the wife and physician exert the ethical principle of beneficence over autonomy.
- Here I want to expand on the concept of the patient’s welfare and defend the choice of beneficence over autonomy. I think these statements help us to step into the broader picture. The disease is a mass on the liver, which most likely is cancer. The concept of illness encompasses a more holistic view of David’s condition…taking into account his emotional, physical, and psychological manifestations as well as the physical. Later on you will see that the resolution of this dilemma is based on the treatment of his illness in the fullest context.
- Two exceptions to the general rule of disclosure have been noted by the courts.Each is in the nature of the physician’s privilege not to disclose. (Read the two bullets)When risk disclosure poses such a threat of detriment to the patient as to become unfeasible or contraindicated from a medical point of view, the physician can exercise something known as therapeutic privilege.Portent = An indication of something important or calamitous about to occur; an omen. 2. Prophetic or threatening significance
- The AMA defines therapeutic privilege as…. (read first bullet)In Opinion 8.082, the code of Medical Ethics address the conflict of autonomy vs. beneficence. (Read second bullet)
- The document Truth-telling and Withholding Information: Ethical Topic in Medicine, University of Washington School of Medicine defends the principle of Therapeutic Privilege. The document addresses the questions of…
- The previous document is supported by the AMA Code of Ethics which acknowledges there are circumstances when non-disclosure is appropriate.In this opinion, the AMA while acknowledging therapeutic privilege, also introduces that the patient be continually monitored, that a plan is developed for full disclosure, and that a consult with an ethics committee is warranted.
- So in light of everything we have learned in our research, we have come up with a scenario with what happens next so that all of the interests of the stakeholders are considered and protected.Psychiatric Consult – a referral can be made to help the patient deal with his medical condition and suicidal ideations. It can provide a professional diagnosis concerning his psychological status. With therapy, the patient and wife can determine whether or not they wish to hear the different treatments available for a diagnosis of cancer. A plan can be made for scheduling the biopsy and for full disclosure.
- A consult with the Ethics Committee of the hospital is also warranted. This consult can be initiated by the nursing staff, social services staff, or hospital patient representative.The Ethics Committee can ensure the patient’s rights are protected and exercised and protect the interests of all stakeholders involved. A hospital Ethics Committee is a multidisciplinary team represented by an Administrator, Board Certified Social Worker, Nurse, Physician, Chaplain
- Let’s quickly revisit our questions. Have we answered them and defended them? We feel that we have.Through the admit process and in keeping with the principles of the AMA, we have established the wife’s right to be the surrogate decision maker.The patient being mentally compromised factors in the decision making process, the right to autonomy, defends beneficence, and the alternatives.The physician’s obligation is to prevent harm, do no harm, act in the best interest of his patient, treat the patient holistically within the entire context, and protect the patient’s health. His decision to cancel the biopsy was within his right of therapeutic privilege justified by the patient’s emotional, physical, and psychological status.The patient’s best interest was served in that he was given time to come to terms with his situation; the client-physician relationship was preserved, and the appropriate referrals and consults were made.