An article in this month’s issue of Health Affairs shows that, among a sample of about 1,800 physicians questioned on whether they had “sometimes or often” misrepresented the facts to patients or otherwise carried out arguably unethical acts in speaking with or about the care of specific patients,
- 11 percent had told an adult patient or a child’s guardian something that wasn’t true
- 55 percent had described a patient’s prognosis in terms that were “rosier” than those warranted by reality
- 10 percent had failed to disclose potential conflicts of interest
- 20 percent had failed to fully disclose information about a mistake because of fear of being sued
- 28 percent had intentionally or unintentionally disclosed information to an unauthorized person
In another article published today on Medscape, a well-known bioethicist discusses the implications of the original survey data and (despite the heading given to his article; “Lying to patients: no huge ethical failure, says bioethicist”) he is very clear about the following:
- Lying to patients about mistakes is “inexcusable and inappropriate” — and stupid too.
- Patients “have a right to know about” financial conflicts of interest — but how much they want to know is up to the patient, and it is perfectly reasonable for the physician to “simply offer the patient the opportunity to know” about such conflicts without immediately jumping into all the details.
We can also see that there are times when (in our opinion) it may be perfectly reasonable to break the law and intentionally disclose information to an unauthorized individual. (As an example, we offer the situation when the healthy, long-time partner of an unmarried couple may need to know that his or her partner has a serious health problem and no longer has the capacity to make decisions for him- or herself.)
Other issues may become much more difficult to deal with. When is it appropriate to tell a patient with a terminal illness that, “We are going to solve this problem and get you back home with your family as soon as we can.” We can probably all imagine circumstances when we might do this if we were doctors. The bioethicist describes this as “an ethical grey zone.” It’s probably a fair description. In the end, the truth needs to be told, but maybe it should sometimes come out over time rather than immediately.
But there is something deeper here that should concern us all. We should be appalled that 20 percent of physicians have failed to disclose that they (0r some other health care professional) had made a mistake. This is a deeply troubling finding. It says much about us as a society — both in terms of our willingness to cover up such mistakes as individuals and our apparent inability to understand and accept that mistakes happen and to think that legal action is the only reasonable recourse.
Regular readers of this blog will be aware that the inability to fully and accurately disclose information about the risks associated with the various forms of treatment for prostate cancer is commonplace. Whether clinicians like this or not, it is a form of lying. Can we imagine times when it may be an appropriate course of action? Yes we can. But the principle should always be full disclosure if at all possible. How else is the reasonable patient to make reasonable choices about his care?
Filed under: Diagnosis, Living with Prostate Cancer, Management, Risk, Treatment Tagged: | bioethics, lies. lying
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I think that denial by the doctor that his/her treatment caused the observed side effects should be added to this list.
Dear Joe:
I think that is more complicated. One would need to know whether there is good evidence that a specific treatment was in fact associated with occurrence of the actually observed side effects. If it is, then the doctor should be advising the patient of this before the patient decides to accept such treatment.
One ethical notion seems to be missing from the talk and, I guess, the survey. I was given two treatment options and explicitly excluded from a third, with a quickly-stated reason that did not satisfy me. This occurred because of a failure (perhaps not intentional) to inform me of a condition under which the third option would be applicable. No lie was involved, just a sort of incompleteness. I obtained a second opinion in another country, in secret. I was right. (1) The third technique was applicable, given that condition. (2) The third technique is part of a combination treatment that seems to be at least as effective as the two I was offered. I was informed as to why this is so, and told which oncological papers were used to motivate the doctors’ advice to go for the combination. I did, and further reading, on this site and elsewhere, supported the advice.
I don’t know what this sort of incomplete range of choice is called in ethics. I do know, that in the current state of scientific uncertainty and insufficiency of statistical data in prostate cancer research, full discussions of all applicable options is desirable. Where I came from, however, the private insurers and health ministry limit “discussions” with patients to 10 minutes, making extensive conversations nearly impossible. In my present country of residence, each discussion lasted for at least half-an-hour, and others were held when I felt they were needed. All were highly informative.
Aloha Sitemaster,
The initial conditions were such that localized treatment of the prostate would leave potential prostate cancer that might exist outside the prostate. There was no discussion of potential side effects. Three weeks into the 8-week treatment, I tried to quit as going to the toilet (both #1 and #2) was very painful. Was persuaded to continue and given pain meds by the radiation oncologist. During the following months my log shows a max of 44 trips to toilet in 48 hours. Bladder bleeds wherever it is touched inside. Two and a half years and several cauterizations later to control rectal bleeding, extreme pain began whenever I needed to urinate; I was on pain management for 1.5 years. The radiation oncologist was in denial of the problem. I have been using a suprapubic catheter since October 2010 to bypass the urethra. The urethra appears to have a wound that will not heal. When bleeding got bad, I started mild HBOT; 6 months later I was able to stop pain management. Now, preparing for uro-ostomy. The mild HBOT helped a lot but is not healing the open wound. The urologist feels that bladder is not usable for the long term.
Long story, short story, still feel that other treatment options would not have been a better option to keep me alive.
Should have made the decision for plumbing realignment earlier.
Joe
Dear Joe:
While I sympathize with your problem, I don’t think this is really an ethical issue as much as it is one of less than high quality medical practice at several point along your journey.
When I was a boy back in the day, the nuns told us that there were two forms of lying (and indeed sinning) — by omission and by comission. The latter referred to the actual bending of the truth; the former to omitting aspects to lead the listener to a different version of the truth.
I believe that many doctors are guilty of incorrectly informing their patients by omission rather than commission. I am always hesitant to ascribe motives to people I don’t know, but I believe in many cases these omissions are because “doctor knows best”. There was a lovely old urologist in Cape Town who brought the concept of prostate cancer support groups to South Africa. So he was certainly a caring man, but he argued that men should not seek second opinions because it only confused them, so he would certainly have not provided a menu of options to men he diagnosed.
Of course many prostate cancer activists are also guilty of these offences. Much of what is published is misleading because of omissions. In discussions and arguments, when I have pointed this out to the activists, they inevitably accept what I say but do not change their attitude, saying that men need to be frightened into action. I don’t agree with that.
Perhaps Paternalism Rules!!