Ethical Considerations in Doctor-Patient Communication
“
THERE ARE
NO
NO
CIRCUMSTANCES
IN WHICH A DOCTOR MAY
WITHHOLD INFORMATION
”
J
ASON
T. E
RBEL
Diletta Di Marco
&
Vuk Gavrilović
WHAT IS THE DEBATE ABOUT?
Essentially, it boils down to:
AUTONOMY
vs
BENEFICENCE
(arguably)
TABLE OF CONTENTS
Theoretical
views:
Utilitarianism
Libertarianism
Kantianism
Aristotelianism
Counterargument
s to reasons why
not to disclose
Arguments
against
withholding info:
Autonomy
Trust
& Cooper.
Exceptions
UTILITARIAN VIEW
Lying to the patient is acceptable if it yields
greater utility to the patient (or the overall
population)
BUT
:
It is “acceptable” only if that patient is not
YOU
.
It is easy to want a “global” benefit when you are
part of the “globality”, but what if you are the
patient who is receiving a maleficent treatment
or being lied to?
LIBERTARIAN APPROACH
The autonomy is of
paramount importance.
It is the patient who makes all the decisions
about him/herself and therefore must have all
the necessary information to decide
autonomously (if the patient wishes it).
KANTIAN MORAL IMPERATIVES
Withholding information violates the
moral imperatives set by Kant:
You must always
tell the truth
,
whatever the circumstance
You must
treat others as ends
, not
only as means to an end.
Patients are
autonomous
and
rational
individuals, you must not do things that
hinder their autonomy
ARISTOTELIANISM
Persons are autonomous and rational
individuals, they have their
own
preferences and ability
to decide for
themselves.
Every person has his/her own idea of what
constitutes “well-being”, and is entitled to
pursue this personal idea
autonomously
.
Therefore, you must give them all the
information so they can pursue
their ideal
REASONS WHY NOT TO DISCLOSE
(COUNTERARGUMENTS)
“By disclosing all (e.g.) negative effects of a therapy,
you might cause anxiety to a patient, hopelessness,
other negative consequences or even suicide.”
BUT
:
The doctor might be making
wrong assumptions
on
patient’s psyche or not be qualified for such a decision
– or even a psychiatrist might be wrong!
And even so, what’s wrong with a rational choice to
commit suicide? One should be free to decide
autonomously if he/she wishes to end the suffering.
REASONS WHY NOT TO DISCLOSE
(COUNTERARGUMENTS
)
Giving all the information and details (about a
procedure or drug) might be impractical, or confusing
and induce into a wrongful decision.
True,
BUT
:
There is a “
standard of substantial completeness
”,
and a principle of “material relevance”.
So, minutiae or negligible effects or details may be
withheld if they are irrelevant and
only if they do not
impair
the ability to make a rational and
autonomous
decision
REASONS WHY NOT TO DISCLOSE
(COUNTERARGUMENTS)
A patient might explicitly ask about not
wanting to hear negative things. There
might be an agreement which allows/obliges
the doctor not to disclose some info.
Acceptable,
BUT
:
Only if withholding this information does
not impair the
autonomy of the patient
and the ability to make a rational and
informed decision.
ARGUMENTS AGAINST
THERAPEUTIC DECEPTION
AUTONOMY
:
Patients are rational autonomous agents.
Withholding information infantilizes them, is
disrespectful, infringes the
right to self-
determination,
and is an affront to
dignity and
autonomy.
A view that autonomy is of paramount importance
is shared among different philosophical approaches
(Kantianism, Libertarianism, Aristotelianism, and
arguably even Utilitarianism)
ARGUMENTS AGAINST THERAPEUTIC
DECEPTION
TRUST AND COOPERATION
:
Hiding the truth undermines the trust in the
doctor. It is in the best interest to be honest and
cooperative.
Only the patient knows everything about
himself, and by having
complete information
from
the doctor the patient might have relevant insight in
his condition.
Full trust = full cooperation = better results
An alliance between doctor and patient is
beneficial, and must be based on
honesty and
trust
.
EXCEPTIONS:
In case of emergency or impossibility to inform the
patient
If the patient is not fully autonomous or capable of
rational decision-making and cooperation
Temporary non-disclosure or “staged” disclosure is
also acceptable
HOWEVER:
It must always be aimed at the ultimate wellbeing
of the patient (beneficence is primary)
The medical benefits of non-disclosure must be
clear and direct
Withholding information permanently is not
acceptable
Information must not be withheld only to give
hope or to avoid a refusal of a treatment
FUNDAMENTAL
PRINCIPLES
BREACH
RIGHT TO HEALTH
Art. 32
The Republic safeguards health as a
fundamental
right of the individual
and as a collective
interest, and guarantees free medical care to the
indigent.
No one may be obliged to undergo
any health treatment
except under the
provisions of the law.
The law may not under
any circumstances violate the limits imposed
by
respect for the human person.
RIGHT TO PERSONAL FREEDOM
Art. 13
Personal liberty is inviolable
. No one may be
detained, inspected, or searched nor otherwise
subjected to
any restriction of personal
liberty
except by order of the Judiciary stating a
reason and only in such cases and in such manner
as provided by the law.(…)
Any act of physical
and moral violence against a person
subjected to restriction of personal liberty
shall be punished
. The law shall establish the
maximum duration of preventive detention.
INFORMATION CONTENT
The information must include
:
The nature of the intervention or
examination
The scope and extent
The risks involved
The probable percentage of success
Treatment options and their risks
Any inadequacies of the structure,
therapeutic and diagnostic tools
INFORMATION ARRANGMENT
The information must be customized, according to
the type of medical treatment required and the
peculiarities of the individual patient
, so as
to place him/her under the best conditions for a
real and conscious choice
=
=
The
negligent conduct
exists for the simple
reason that the patient, because of the
lack of
information
, it has not been put in a position to
assent to treatment with conscious will of its
implications
The consent
Given by
pre-printed form
is
incomplete and erroneous
:
the consent must be the result of
a real relationship between
doctor and patient, in which the
physician is required to collect an
effective and participatory
adhesion, not just a document
with which relieving the
responsibilities.
Such written support should
therefore be thought of as
a
support to the dialogue
,
written in simple form, avoiding
as much as possible the use of
technical terms.
The doctor will be
responsible
in case of
lack of information
He/she will also be
responsible in case of
poor communication
about the risks of
discontinuation of
treatment or
omission
of monitoring
of
therapy and possible
side effects
THE BEST PROTOCOL
The essential requirements that the
doctor has to demonstrate to the patient:
The
clarity
and
comprehensibility
of his
treatments
Traceability
of who has drawn his medical
records
The
accuracy and conformity
of the data
and information
The
relevance
of the information recorded
Completeness
of all necessary data
CASE STUDY
J. goes by his doctor in order to undergo analysis for
celiac disease. In fact since few months he suffers
strange symptoms. His analysis, however, are
labeled in the wrong way by the nurse and put
through the folders to be scanned for HIV testing.
J. was negative to the text of celiac disease but
positive to the AIDS virus
.
As J. did not sign the informed consent can not be
made aware of the discovery.
Was communicated to him that the negative
outcome to celiac disease test.
What would happen if
you were J. ?
The End
SOURCES
•
Arthur L. Caplan e Robert Arp (eds),
Contemporary
Debates in Bioethics
, Wiley-Blackwell, 2013, pp. 409-427
•
Italian Costitution
•
Roberts C, Torgerson D. Randomisation methods in
controlled trials. BMJ 1998;317:1301.
•
Legal information provided by
S
tudio Legale PCMC
(Palermo)
The debate on whether a doctor should withhold information from a patient revolves around the principles of autonomy versus beneficence. Various ethical viewpoints such as utilitarianism, libertarianism, Kantian moral imperatives, and Aristotelianism are explored. While some argue for disclosing all information to respect patient autonomy, others suggest potential harm in revealing certain details. Ultimately, the key lies in striking a balance between patient autonomy and the ethical responsibilities of a healthcare provider.
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Presentation Transcript
THERE ARE NO CIRCUMSTANCES IN WHICH A DOCTOR MAY WITHHOLD INFORMATION JASON T. ERBEL Diletta Di Marco & Vuk Gavrilovi
WHAT IS THE DEBATE ABOUT? Essentially, it boils down to: AUTONOMY vs BENEFICENCE (arguably)
TABLE OF CONTENTS Arguments against withholding info: Autonomy Trust & Cooper. Theoretical views: Utilitarianism Libertarianism Kantianism Aristotelianism Exceptions Counterargument s to reasons why not to disclose
UTILITARIAN VIEW Lying to the patient is acceptable if it yields greater utility to the patient (or the overall population) BUT: It is acceptable only if that patient is not YOU. It is easy to want a global benefit when you are part of the globality , but what if you are the patient who is receiving a maleficent treatment or being lied to?
LIBERTARIAN APPROACH The autonomy is of paramount importance. It is the patient who makes all the decisions about him/herself and therefore must have all the necessary information autonomously (if the patient wishes it). to decide
KANTIAN MORAL IMPERATIVES Withholding information violates the moral imperatives set by Kant: You must always tell the truth, whatever the circumstance You must treat others as ends, not only as means to an end. Patients are autonomous and rational individuals, you must not do things that hinder their autonomy
ARISTOTELIANISM Persons are autonomous and rational individuals, they have their own preferences and ability to decide for themselves. Every person has his/her own idea of what constitutes well-being , and is entitled to pursue this personal idea autonomously. Therefore, you must give them all the information so they can pursue their ideal
REASONS WHY NOT TO DISCLOSE (COUNTERARGUMENTS) By disclosing all (e.g.) negative effects of a therapy, you might cause anxiety to a patient, hopelessness, other negative consequences or even suicide. The doctor might be making wrong assumptions on patient s psyche or not be qualified for such a decision or even a psychiatrist might be wrong! BUT: And even so, what s wrong with a rational choice to commit suicide? One should be free to decide autonomously if he/she wishes to end the suffering.
REASONS WHY NOT TO DISCLOSE (COUNTERARGUMENTS) Giving all the information and details (about a procedure or drug) might be impractical, or confusing and induce into a wrongful decision. True, BUT: There is a standard of substantial completeness , and a principle of materialrelevance . So, minutiae or negligible effects or details may be withheld if they are irrelevant and only if they do not impair the ability to make a rational and autonomous decision
REASONS WHY NOT TO DISCLOSE (COUNTERARGUMENTS) A patient might explicitly ask about not wanting to hear negative things. There might be an agreement which allows/obliges the doctor not to disclose some info. Acceptable, BUT: Only if withholding this information does not impair the autonomy of the patient and the ability to make a rational and informed decision.
ARGUMENTS AGAINST THERAPEUTIC DECEPTION AUTONOMY: rational Patients Withholding information infantilizes them, is disrespectful, infringes determination, and is an affront to dignity and autonomy. A view that autonomy is of paramount importance is shared among different philosophical approaches (Kantianism, Libertarianism, Aristotelianism, and arguably even Utilitarianism) are autonomous agents. the right to self-
ARGUMENTS AGAINST THERAPEUTIC DECEPTION TRUST AND COOPERATION: Hiding the truth undermines the trust in the doctor. It is in the best interest to be honest and cooperative. Only the patient knows everything about himself, and by having complete information from the doctor the patient might have relevant insight in his condition. Full trust = full cooperation = better results An alliance between doctor and patient is beneficial, and must be based on honesty and trust.
EXCEPTIONS: In case of emergency or impossibility to inform the patient If the patient is not fully autonomous or capable of rational decision-making and cooperation Temporary non-disclosure or staged disclosure is also acceptable HOWEVER: It must always be aimed at the ultimate wellbeing of the patient (beneficence is primary) The medical benefits of non-disclosure must be clear and direct Withholding information permanently is not acceptable Information must not be withheld only to give hope or to avoid a refusal of a treatment
FUNDAMENTAL PRINCIPLES BREACH
RIGHT TO HEALTH Art. 32 The Republic safeguards health as a fundamental right of the individual and as a collective interest, and guarantees free medical care to the indigent. No one may be obliged to undergo any health treatment provisions of the law. The law may not under any circumstances violate the limits imposed by respect for the human person. except under the
RIGHT TO PERSONAL FREEDOM Art. 13 Personal liberty is inviolable. No one may be detained, inspected, or searched nor otherwise subjected to any restriction of personal liberty except by order of the Judiciary stating a reason and only in such cases and in such manner as provided by the law.( )Any act of physical and moral violence against a person subjected to restriction of personal liberty shall be punished. The law shall establish the maximum duration of preventive detention.
INFORMATION CONTENT The information must include: The nature of the intervention or examination The scope and extent The risks involved The probable percentage of success Treatment options and their risks Any inadequacies of the structure, therapeutic and diagnostic tools
INFORMATION ARRANGMENT The information must be customized, according to the type of medical treatment required and the peculiarities of the individual patient, so as to place him/her under the best conditions for a real and conscious choice = The negligent conduct exists for the simple reason that the patient, because of the lack of information, it has not been put in a position to assent to treatment with conscious will of its implications
The consent Given by pre-printed form is incomplete and erroneous: the consent must be the result of a real relationship doctor and patient, in which the physician is required to collect an effective and adhesion, not just a document with which responsibilities. between participatory relieving the Such written support should therefore be thought of as a support to written in simple form, avoiding as much as possible the use of technical terms. the dialogue,
The doctor will be responsible in case of lack of information He/she will also be responsible in case of poor communication about the risks of discontinuation of treatment or omission of monitoring of therapy and possible side effects
THE BEST PROTOCOL The essential requirements that the doctor has to demonstrate to the patient: The clarity and comprehensibility of his treatments Traceability of who has drawn his medical records The accuracy and conformity of the data and information The relevance of the information recorded Completeness of all necessary data
CASE STUDY J. goes by his doctor in order to undergo analysis for celiac disease. In fact since few months he suffers strange symptoms. His analysis, however, are labeled in the wrong way by the nurse and put through the folders to be scanned for HIV testing. J. was negative to the text of celiac disease but positive to the AIDS virus. As J. did not sign the informed consent can not be made aware of the discovery. Was communicated to him that the negative outcome to celiac disease test.
What would happen if you were J. ?
SOURCES Arthur L. Caplan e Robert Arp (eds), Contemporary Debates in Bioethics, Wiley-Blackwell, 2013, pp. 409-427 Italian Costitution Roberts C, Torgerson D. Randomisation methods in controlled trials. BMJ 1998;317:1301. Legal information provided by Studio Legale PCMC (Palermo) The End
