Theraputic Privilege: An Ethical Dilemma

[Bhebe55]

I have to defend a point in my Bioethics class, and I was hoping to pick the brain of the smartest forum community around. Just looking for brain storming ideas on how to defend this position using ethical principles. Ok here is my sceneraio:

A 65 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 alchol 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.

My project is to defend the physician's decision to cancel the biopsy.

Any insights or personal experiences would be great. Thank You in advance for any and all replies.

[Altra, BSN, RN]

No ethical reason to withhold information from a now mentally competent adult - he has the right to self-determination. Even if his spouse holds medical power of attorney, that is not applicable while he is alert & oriented.

The physician has no duty to perform the test - s/he can only offer it to the patient and attempt to obtain his consent to perform it. A spouse has no power to override a patient's wishes unless there is a clinical diagnosis regarding the patient's altered mental status.

[elkpark]

I'm not sure I'm fully understanding your scenario. Did the physician cancel the biopsy because "David" indicated that he didn't want the biopsy? Or did the physician cancel the biopsy without discussing this with anyone?

In order for the biopsy to be done, ethically and legally, "David" would have to consent to the procedure (presuming that the reference to "David's" mental status having "improved" means that he is again making decisions for himself). If he doesn't want the biopsy done, the physician was completely correct to cancel the procedure. If it is the case that the wife consented to the biopsy during the interval when "David" was considered too impaired to make decisions for himself, then I would think it's v. appropriate to go "back to the drawing board" once "David" is again making his own choices, and start the process all over again. A biopsy is not an emergency, life-or-death procedure, and there is time to pursue the usual "informed consent" process with "David."

[Bhebe55]

I was very confused about the consent issue myself. I quoted the problem exactly as written so that is all the information I have. I know ethically the Dr. can withold information if he believes the news would cause him to commit suicide. I dont know if he can just decide to not even offer the biopsy procedure? On the other hand there is no way to perform the procedure without the patient finding out. If he says i dont want to know if it comes back cancer there are only two options. If it isnt he tells david and he knows the results. If it is he dosent tell him and he still knows the result. Not telling him would be the same as a confirmation. So does this justify just cancelling the procedure without even talking to David?

My assignment is to defend the doctors actions. I personally dont feel I have enough information to do that. What do yall think?

[Altra, BSN, RN]

I don't think this is really so complicated:

If David is currently mentally competent, then his consent must be obtained for the procedure. Period.

To get David's consent requires a discussion with him of the findings of the CT scan (which may have occurred during David's period of altered mental status) and the possible implications.

In light of the concerns of the patient's wife, I can totally see the hospital physician turfing this one to the patient's PCP for follow up.

And ... stuff like this happens more commonly than you may think.

[canoehead, BSN, RN]

I think the doc can choose not to involve himself in a situation that is so likely to cause harm. Once he does the biopsy, if it is cancer he has placed himself between a rock and a hard place...no matter how the doc handles the family there could be consequences to his career.

I also think he should be truthful with the family, that he can't go ahead if that means he causes his pt to choose suicide, or if it means he becomes involved in deception. Sounds to me like if it is cancer the patient would still not receive/choose treatment. At this point there is no benefit to the patient from a biopsy result and it could cause harm. So one could argue the doc's ethical choice is to hold off until the family can talk about constructive steps they can take if it is cancer.

(On the other hand) if it isn't cancer would they possibly be delaying useful treatment for some other disease? What's the differential diagnosis list?

If I was the doc I'd be open with the family- their statements make this a no win situation for them and for me, so let's treat symptomatically unless we think there is information from the biopsy that would prolong the patient's life or improve his quality of life. At this point even the small risk of a needle biopsy is not worthwhile. At that point they can stay with the same doc and hopefully get some practice using positive coping skills, or they can move on to another physician.

[PetiteOpRN]

Doc's options are:

1. Do the biopsy. If the patient has cancer he dies, if not he's fine, but for a little scar.

2. Don't do the biopsy. If the patient has cancer he dies, if not he's fine.

Since the patient's not going to get treatment, regardless of bx results, it does not benefit the patient at all to get the biopsy. The MD can refuse to do the surgery if the patient states they will refuse care. If a patient refuses blood transfusion, the surgeon can refuse to treat.

If the patient really wants the bx, despite the fact they will refuse treatment. SOMEONE out there will take their money. Surgeons are not bound to perform futile surgery on noncompliant patients.

[Debra ACRN]

I've actually refused to HIV test a patient who stated that they would commit suicide if the test was positive. We got the patient some psych assist prior to testing. Your first duty is to do no harm. If the results of a biopsy would or could cause suicide it would be the physician's responsibility to postpone the proceedure until there could be some assurance of benefit to the patient. I think ethically you would need to inform the patient that there is a mass on his liver and why you would be concerned over exploring that further.

I would fully support the physician.

[caroladybelle, BSN, RN]

Why do the procedure if we cannot/won't treat the issues that are found? It is amazing how much money is wasted in health care, doing tests/scans/procedures when the results will not change the outcome/plan of care.

The MD cannot ethically withhold any data that he finds from the test. And if the MD does tell the pt, he may be responsible for the pts death. Thus it is quite ethical to refuse to do the procedure.

[MunoRN, RN]

Biopsies should only be done if the outcome could contribute to decision making or guide a course of treatment. The patient's declaration that he'll kill himself if he has cancer adds an interesting wrinkle, but really he just falls into the general group of patients for whom a biopsy won't be beneficial in guiding treatment, so the test gets cancelled.

If the patient demanded that he have the biopsy done so that he would know if he should commit suicide due to cancer, that would make the question more interesting.

[dudette10, MSN, RN]

I've actually refused to HIV test a patient who stated that they would commit suicide if the test was positive. We got the patient some psych assist prior to testing. Your first duty is to do no harm. If the results of a biopsy would or could cause suicide it would be the physician's responsibility to postpone the proceedure until there could be some assurance of benefit to the patient. I think ethically you would need to inform the patient that there is a mass on his liver and why you would be concerned over exploring that further.

I would fully support the physician.

There it is. You can defend the physician's actions at this time by using the ethical principle of nonmaleficence. In a very convoluted way, you can also uphold the principle of autonomy. For example, the patient wants to kill himself if he has cancer. Nonmaleficence=do no harm (avoid a situation in which the patient will kill himself), but also autonomy=he chooses to not kill himself because of the doctor's choice of nonmaleficence.

If the goal of the ethical dilemma is to keep the patient alive, the doctor MUST postpone the procedure until further discussion can take place. It does not strip the patient of autonomy to do so.

[MunoRN, RN]

So heres a related ethical question. Assisted suicide is legal in my state. One of the requirements is that the patient has a prognosis of 6 months or less. Because of this, my hospital has in the past done MRI's, PETs and biopsies to obtain an accurate predicted survival. Could Physicians a refuse inform the patient of the results if they didn't agree with their decisions? The hospital I work for is Catholic, so we don't provide assisted suicide (we refer patients to "specialists" in assisted suicide who seem to find that everyone has a prognosis of 6 months or less).

I suppose we could abstain from the process even more my refusing any care that may contribute to them fulfilling the legal requirements of the law, which may just end up encouraging patients to end their life outside of the legal requirements meant to protect them (psych consult, confirmed terminal condition, etc).