Commentary on option 1
Many problems and errors in the complex field of health care are not caused by any one individual’s actions but by a “systems error”: an important lab report gets lost in a pile of paper; the nurses in the hallway are not talking about Panos but they are right outside his door so he thinks they are.
In this response to Niki’s request, the physician may very well be right. It is difficult to keep information, or misinformation, from hospitalized patients. Dr. Tyson may not be able to control every interaction between her patient and numerous health care workers but she can control what she does and says. Does invoking a “systems problem” — blaming others — absolve the physician from responding to Niki’s request? How should she respond to Niki’s complaint about gossip?
Most hospitals have policies or codes of conduct about confidentiality and similar issues. Dr. Tyson is a resident, which means she may spend a variable period of time in any one institution. She should be aware of the policies of any institution in which she works, but practically, she may not be.
Which, if any, of the four possible responses to Niki’s concern would you use, assuming that Dr. Tyson agrees to Niki’s request not to tell Panos about his cancer?
- “The people who work here are all professionals. They won’t say anything inappropriate to any patient.”
- “I will speak to the ward manager and ask her to tell everybody not to speak to your father about his condition.”
- “This hospital has a confidentiality policy. I will get a brochure on it for you to read.”
- “I will give you the contact information of the hospital’s patient advocate whom you can call to discuss your concerns.”
Commentary on option 2
In this option, Dr. Tyson gives the standard “truth-telling” response she learned in ethics classes. There is considerable literature supporting this position. There are many studies showing that patients want to know about their condition and that “not telling” results in isolation, poorer response to treatment and poorer quality of life. Sometimes families get it wrong and think that their family member would not want to know, when in fact they do. Sometimes the patient goes along with the deception in order to spare his or her loved ones the distress of talking about an impending death.
However, most of those studies were conducted in western patient populations, usually American. Studies involving patients from non-western cultures sometimes tell a different story. This depends, however, upon the patient’s acculturation to the local culture (see option 3).
Some ethicists feel that there is no difference between lying and not revealing the whole truth because the intent is the same, that is, to deceive the patient. Both instances have the same result: the patient cannot be a fully informed decision-maker. Others feel that lying is a worse decision in that, if found out, trust in the physician would be destroyed, whereas with failure to provide relevant information, the resulting decisions made by the patient would be their responsibility. It may also have something to do with the fact that for most of us, we have been taught from childhood that lying is wrong. We should at least realize that failure to reveal, even if done with beneficent intention, is not necessarily benign.
Commentary on option 3
Here, Dr. Tyson is trying to obtain information about Panos’ beliefs and values. How should she interpret the information Niki gives her? Are we getting information about Panos or about Niki and how she thinks about things? By including Maria and Sophia in the discussion, Dr. Tyson is certainly trying to find common ground between her medical beliefs and those of the family. But which set of values and beliefs should take precedence? Should she follow the medical view that in almost all cases it is best for patients to be told of their conditions or should respect for others’ cultural values prevail? Should she accept Maria’s or Niki’s assessment of the intergenerational differences in approach to truth-telling? If Dr. Tyson tells Panos about his diagnosis in spite of the family’s objection, is she behaving with respect for patient autonomy or paternalistically in deciding herself what is best? For instance, if she agrees not to tell Panos, is she denying him the opportunity to decide what to do with his life? Perhaps he might not accept treatment, believing that his condition is not so serious. If he is told, what might be the consequences of angering his family? What additional questions should Dr. Tyson ask that might be helpful in determining Panos’ wishes?
None of these questions are easy to answer but thinking them through is necessary before taking action. Broadening the discussion to include other physicians or an ethicist might be helpful.
Commentary on option 4
Many would say that this is the best course of action. We have no evidence that Panos has ever discussed how he would like information to be handled if he became sick, and it would appear that Niki is making assumptions based on what she thinks he would want. Dr. Tyson’s responsibility is to the patient first, even if this might anger the family. A number of studies have shown that physicians are poor judges of patients’ desire for and need for information and that the best thing to do is to ask directly. However, as in this case, there may not be an available interpreter and, as we saw, using a family member might not provide the information required. Also, one must keep in mind that even if asked directly, a patient might defer to family out of concern for them, feeling the family could not cope with discussing such issues with their loved one. Finding out what a patient really wants to do in these situations requires tactful exploration of their values and relationships, and cannot be accomplished with a few brief questions.
For more information on working with interpreters, see the “Working with interpreters” section of this module and “Cross-cultural interviewing.”