DISCLOSURE VS. NON-DISCLOSURE: HONESTY WITH PATIENTS

Lee Dies and Jessica GlaspellThursday, January 27, 2011

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.

Disclosure vs. Non-Disclosure

Side A: Defend the wife’s request to withhold the information.

What Needs To Be Determined?

1. Does the wife have the right to withhold information?

2. How does the patient being mentally compromised factor in?

3. What is the physician’s obligation to the patient?

4. Is the patient’s best interest served?

Presentation Goals1. Establish and defend

the wife’s right to withhold information

2. Explore the two main ethical principles related to this dilemma

3. Explain the practice of therapeutic privilege

4. Offer a plan for resolution that produces a satisfactory outcome for all stakeholders

5. Maintain that the best interest of the patient is served

Stakeholders

• Patient• Wife• Physician• Hospital Staff:• Nursing Staff• Ethics Committee

Key Factors

Mentally compromised patient

Wife is performing surrogate role

Alcoholism Presence of liver mass Suicidal Extreme emotional,

physical, and psychological duress

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

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.

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).

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)?”

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.

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

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.

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).

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)

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.”

Therapeutic PrivilegeWhat 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.”

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.”

Alternatives

Psychiatric Consult Therapy Plan for treatment and full disclosure

Alternatives, Con’t. Ethics

Committee Consult

Recap1. Does the wife have the right to withhold

information?2. How does the patient being mentally

compromised factor in? 3. What is the physician’s obligation to the

patient? 4. Is the patient’s best interest served?

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