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.

[Kooky Korky, 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.

However, a doctor is not free, I believe, to just dump the pt. He must give the pt notice that he will no longer be involved in the pt's care, provide at least some explanation of why, and remain at the pt's service until replacement is found. I think. I would think that dumping the pt is unethical and I don't understand why the doc doesn't explain to pt and spouse his reason for wanting to be off of the case, why he doesn't get a Psych consult, refer for counseling for the suicide threats (religious or secular counseling or whatever the pt is comfortable with). I think the doctor needs to do everything to handle the situation openly, fully, and in a way that demonstrates his concern for his patient.

OP, why not seek some clarification from your teachers if you have questions (as you said above that you do)?

[mentalhealthRN]

I think its interesting that we are taking the word of the wife regarding this statement of --"he will commit suicide if he has cancer". So we are going to take the word of someone not trained to assess lethality? I mean I know she is his wife and maybe he has indeed said this to her, but having worked with a lot of psych patients with fatal dx, I have found they can sometimes say this but not really mean it. They may think that but when a real assessment is done and they are asked if they would follow through with this --plan? intent? etc. that they may want to commit suicide be couldn't do it. So just saying having done a lot of lethality assessments in the Psych ER-- a psych consult is not a crazy thought. Our docs in the psych ER get called often with consults just like this one. So just putting that thought out there. I know it doesn't give a defense to the docs actions as the assignment is asking you to do, but just some food for thought as you muffle through and come up with answer. Good luck.

[elkpark]

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?

I don't see how a physician could possibly agree to do the procedure and then refuse to disclose the results to the client because of her/his personal views -- the appropriate action in that situation would just be to decline to do the procedure in the first place, and, as you note, refer the client to someone else.

[OldNurseEducator]

It sounds to me as if the doc cancelled the procedure because he knew he wouldn't get consent from the patient without the patient knowing the possible diagnosis. The doc disagreed with the wife's choice. It's not her choice now that the patient is lucid. Doc did the right thing. Consent MUST be given...he can't get consent. Why bother? I agree that the doc has an ethical responsibility to tell the patient he no longer will take his case. If the doc puts it in the attending's hands, the attending is responsible to tell the patient the diagnosis. Whoever said it happens a lot is correct. This kind of ethical dilemma does happen a lot. :snowman:

[interleukin]

He's already killing himself.

[Altra, BSN, RN]

I have great respect for educators who are able to develop thought-provoking assignments that do not omit critical pieces of reality, such as the legal (and ethical) responsibility to obtain informed consent for procedures.

Those educators are like gold.

And OP, I don't know if this helps your thought process or not ... but in my experience the days of families & physicians collaborating to shield diagnosis & treatment options from the adult patient are largely gone. Families do make decisions for patients who lack the ability to do so at the moment due to their illness, but current medical, nursing, and allied health culture emphasizes an individual's right to self-determination.

Edited to add:

Here's a column I found with a quick google search on therapeutic privilege. It notes that it is a rare situation. And the patient scenario it presents does not involve the necessity of obtaining informed consent for an invasive procedure. (though it is a skillful handling of a psychiatric patient :) )

http://virtualmentor.ama-assn.org/2004/02/msoc1-0402.html

[nohika]

I think its interesting that we are taking the word of the wife regarding this statement of --"he will commit suicide if he has cancer".

No, it says in the prompt that he (David) said it, not the wife.

Regardless...I took biomedical ethics last semester and so I can kind of understand this whole funstuffs. Basically...if he has the ability to consent, and "qualifies" to do so, then it's his business what he does/wants. Autonomy vs do no harm.

[canesdukegirl, BSN, RN]

I think that the doc was correct in canceling the biopsy. I think that the next steps that the doc should take would be to schedule an appt with social work and get a psych consult.

My rationale to get SW involved is a. This pt is known for alcohol dependence, and if cirrhosis is evident, this pt has had a long hx of ETOH abuse. b. SW can offer both the pt and the wife resources to enable them to get therapy/counseling. They may not take the offer, but the offer should be extended.

My rationale for a psych consult is very much tied into the request for a SW consult. There are obviously problems that have gone unresolved for David since he is abusing ETOH. The blanket statement that David made "If I learn that I have cancer, I will kill myself." immediately labels him as a danger to himself. The problem here is that we don't know WHEN David said this. Did he say it when he was disoriented? Did he say that off-handedly (sort of like if someone says, "If I have to endure one more procedure/IV start/X-ray, I will kill myself.) in a conversation with friends one night? Did he say this when he was drunk? Did he say it to the doctor after he was oriented? We don't know. A psych consult would get to the bottom of David's statement and thus enable the doctor to have a more evidenced-based view of what steps he should take.

I believe the doc made a good decision here. He needs more information FIRST in order to proceed with diagnosing David's liver mass. I think that the wife was thrown into the mix to confuse the real focus: David's mental state. She can ask the docs all day long not to give him the dx, but that is a moot point now. Unless she has POA, she has no authority over his medical care EXCEPT if David is mentally incapacitated, and then the law (depending on your state) defines the next of kin (his wife) as the legal POA if he did not already designate a different person to hold his POA.

This is a great assignment! This does happen quite often in the real world. Kudos to your professor for giving you such a thought provoking scenario.