Putting Ethics on the Spot in Neurology

Erle C.H. Lim; Amy M.L. Quek; Raymond C.S. Seet

Disclosures

We were queuing for crullers and coffee after a grueling ward round when our eyes were drawn to the choreiform movements of the woman ahead of us. Despite our feeble attempts not to stare, our eyes were drawn to her excruciatingly slow attempts to insert a straw into a glass, extricate cash from her purse, and, balancing her tray precariously, wend her way to a nearby table. Against our better natures, none of us made any real attempt to assist, lest we cause offence or embarrassment. She sat down, adjusted her perfectly positioned spectacles, and began to eat. Later, comfortably ensconced in the doctors' lounge, we began to discuss the phenomenology of her movement disorder, even postulating that adjusting her spectacles was a voluntary maneuver to mask her involuntary choreiform movements.

In medicine, the art of making a spot diagnosis is much lauded; indeed, William Osler, doyen of clinical medicine, declared, "There is no more difficult art to acquire than the art of observation."[1] In 1817, James Parkinson wrote a monograph on his eponymous disease after examining Londoners whose stooped posture and shuffling gait caught his attention.[2] Many of his observations hold true to this day, bearing testament to his prescience and clinical acumen. Legend has it that Christian Billroth would start the academic year by sticking his finger into a foul-tasting liquid while informing his students of the two qualities necessary for becoming a doctor: namely, freedom from nausea and the power of observation. He would then enjoinder his students to copy his actions and would smile at their stoic discomfiture, telling them that they had passed the first test but not the second, for he had dipped the index finger and licked the middle finger.

Neurology is unique among the medical specialties in that much of the clinical examination can be appreciated visually and taught by use of video recordings.[3,4] Since 2003, we have conducted a 'neurological localization course', during which participants are taught correct clinical examination techniques with the help of patients.[5] Trainees are often impressed by the wealth of clinical information that can be gleaned by observation alone; for example, how the externally rotated, slightly plantar-flexed attitude of the lower limb of a supine patient can hint at the possibility of an underlying footdrop, or how muscle atrophy, diabetic dermopathy and trophic changes can not only provide clues to an underlying peripheral neuropathy, but can even indicate the level of the stocking paresthesia.

Several weeks after our encounter with the woman with choreiform movements, we were enjoying another post-rounds breakfast-cum-discussion when our attention was drawn to a colleague whose subtle neck and facial movements were accompanied by grunting noises while eating—phenomena indicative of complex motor tics, rather than the more facile explanation that he was really enjoying his morning porridge. When he had left, the medical student attached to our team asked the obvious question: with the evidence staring us in the face, why did no one inform him of the diagnosis and proffer appropriate treatment? Having acknowledged the proverbial 'elephant in the room', we launched into an animated discussion about a physician's duty of care, asking whether the ethical imperative to treat exists only in a medical emergency or after the establishment of a formal doctor–patient relationship.

Few would argue that doctors have a moral and legal obligation to render assistance in the event of a medical emergency.[6] A formal doctor–patient relationship likewise provides a doctor with the moral and legal imperative to practice 'good medicine'. Hence, a neurologist seeing a patient for diabetic polyneuropathy would not hesitate to enquire about symptoms of hyperthyroidism when the patient has a noticeable goiter, despite its apparent irrelevance to the case. Indeed, the same doctor would be thought negligent if he were to ignore or fail to notice a goiter in a patient with myasthenia gravis, in view of the known associations between these two conditions.

Was our group remiss because we did not inform the stranger with choreiform movements or our colleague with tics of their diagnoses, simply to avoid embarrassment? It might be argued that to offer an unsolicited medical opinion to a stranger reeks of bad taste, akin to canvassing patients or ambulance chasing. Some might comfort themselves that failing to inform a woman with a goiter and ophthalmopathy or a man with bilateral ptosis of their probable diagnoses of Graves disease and myasthenia gravis, respectively, is not an egregious or harmful omission. Yet the potential consequences of such inaction could be the development of atrial fibrillation resulting in an embolic stroke, or myasthenic crisis with respiratory failure. As Einstein perceptively pointed out, "The world is a dangerous place, not because of those who do evil, but because of those who look on and do nothing." We had hoped that, being in a hospital, the woman with choreiform movements had already consulted (or was on her way to consulting) a doctor. It was, however, just as probable that she was merely visiting a patient, and that, like us, other doctors had steered clear of broaching the subject.

Could we have helped the woman? The answer is an emphatic yes. We could have ascertained the cause of her chorea, performed a clinical examination for a cardiac murmur to exclude rheumatic fever and Sydenham chorea, examined her eyes under a slit lamp for Kayser–Fleischer rings, treated any underlying conditions such as hyperglycemia or thyrotoxicosis, recommended neuroimaging, and instituted genetic testing if Huntington disease was suspected. If she had Parkinson disease and unrecognized levodopa-induced dyskinesias, we could have recommended adjustment of her medications or the addition of amantadine, sedatives or nootropics to ameliorate the chorea.[7] Likewise, dopamine depletors or atypical antipsychotics could lessen disabling choreiform movements,[8] thereby increasing her quality of life. It is possible, however, that unsolicited advice could prove unwelcome. In the case of a diagnosis of Huntington disease, for example, the patient would be forced to face the prospect of an incurable and heritable disease that could render her unemployed and without medical insurance.

What, then, is our duty of care to the 'man in the street'? Are physicians morally and legally obliged to render a medical opinion at all times? More importantly, could we be held liable, in the absence of a formal doctor–patient relationship, for failing to point out to a would-be patient that they might have medical conditions requiring attention? Although we are morally obligated to render assistance in a life-or-death situation, even being protected under the 'Good Samaritan Act',[9] there is no legal liability should a physician 'do nothing' in an emergency involving a stranger, as long as the physician "is not under a pre-existing duty and has not created a risk of harm to the stranger".[10] The absence of an emergency situation does not, however, preclude longer-term deleterious consequences, as illustrated by the scenarios described above. For this reason, the issue of our duty of care is worthy of further debate and discussion.


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