Truth-telling in Medicine And: The Justification of Paternalism.
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Transcript of Truth-telling in Medicine And: The Justification of Paternalism.
Truth-telling in Medicine
And: The Justification of Paternalism
Critical Analyses
Difficult question!! Veatch: As a rule is strongly in favor of
almost unlimited patient autonomy-- BUT this reading was taken from a case book where Veatch was trying to lay out both sides of the issue and not take a stand himself
Critical analyses cont.
Gawande: Several “mixed signals”– Title of paper– “Lazaroff” example– Mammogram example– “Mr. Howe” example
Which is the “real” Gawande?
Critical Analyses: take home message Need to read the article at least once
without a highlighter (don’t ignore specific words and phrases but rather put them in overall context)
Be sure to ask how each paragraph fits into overall scheme of author’s argument
TRVTH
Traditional approaches to truth NO general duty to disclose Truth as medicine; bad news can be
harmful or fatal Subsumed under general duty of
beneficence or “do no harm” (nonmaleficence)
How culturally bound is current US view? Only a tiny slice of the entire history of
medicine is dominated by an autonomy ethic of truth-telling
Majority of other world cultures still seem reluctant to embrace this ethic
BUT at least some traditional cultures are moving in a “Western” direction (e.g. Japan)
“Truth-dumping”
Violation of beneficence-- usually perceived by patient as cruel and uncaring
Violation of autonomy?– Does cruel disclosure make patient a
better (freer) decision-maker?– Does patient get a voice in how truth is
told?
Reasonable Mix of Beneficence and Respect for Autonomy?
Robert Buckman, How to Break Bad News (Baltimore, Johns Hopkins U. Press, 1992)
Truth Protocol (Buckman)
Pick a good time and setting and assemble right people
Find out how much the patient already knows
Find out how much the patient wants to know
Protocol (cont.)
Share the information the patient seeks – in sensitive manner– in appropriate “chunks”
Respond to patient’s feelings Planning and follow-through
Lessons from Buckman
Effective truth-telling is heavy on listening and light on talking
Most patients want to know more and can handle it; a few don’t want to
Giving patient greater role in setting agenda is respectful of autonomy and is also compassionate and caring
Seldom the Question
“Should we tell the patient the truth, or conceal it from her?”
Usually the Questions
“When to tell?” “How much to tell?” “What exact words to use?” “Whom should be there with the
patient?” “What comes next?”
When Can Paternalism Be Justified?
Atul Gawande, “Whose Body Is It Anyway?” New Yorker, Oct. 4, 1999
“Weak” Paternalism
Patient lacks important dimensions of capacity to make autonomous decisions– Child– Dementia– Mentally ill
Generally easier to justify
“Strong” Paternalism
Patient appears to have full capacities for autonomous decision-making
Provider nevertheless feels that decision is mistaken and will cause great harm
Usually seen as much harder to justify-- threat to respect for autonomy
Gawande’s defense of strong paternalism Dependent upon arguments in: Carl E.
Schneider, The Practice of Autonomy (Oxford U. Press, 1998)
Schneider’s Approach
Read ethics literature Read legal cases Read books written by people about
their own experiences with illness (pathographies)
Interviewed patients in a chronic renal unit
Schneider’s Conclusions
Some people wish to exercise autonomy as per the “ideal case” in ethics literature today
Many do not wish to and would wish to defer or delegate part or all of major health decisions to others including physician
Schneider (cont.)
The people who wish not to choose often have very rational reasons for this preference– Weakness and fatigue– Lack of knowledge or understanding– Awareness of problems in own thinking
process– Avoidance of guilt
What Does “Respect for Autonomy” Require?
Forcing each patient into “ideal autonomy” mold regardless of preferences?
Allowing each patient to select the degree to which she wants to be informed and to participate?
Gawande’s “Mr. Howe”
Traditional argument often offered as justification for strong paternalism-- “Thank you” test
Is this an adequate ethical justification? Is Gawande a “good physician” or an
arrogant, paternalistic physician (or both)?