Ethical dilemma final copy
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Transcript of Ethical dilemma final copy
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