What Would You Do? Test Yourself on This Ethical Dilemma

Kenneth W. Goodman, PhD

August 08, 2012

Editor's Note:
This interactive case follows 1 patient and pinpoints some of the ethical issues that her physician encounters. How would you deal with these issues? Did you choose the best option? Read through the case, select the options that best reflect your own views, and read what bioethicist Kenneth W. Goodman, PhD, Professor and Director, Bioethics Program, University of Miami, Florida, has to say about the choices.

Introduction

Kenneth W. Goodman, PhD

Ethical challenges or dilemmas may arise at any time during medical practice. You might even face several ethical issues during the care of a single patient. Some major ethical dilemmas may involve life-or-death issues, whereas others involve small instant decisions that weigh on your conscience.

These unheralded daily decisions ultimately define you as a person and illuminate your standards and stances toward patient care and the role of a devoted physician.

Look at this patient-care case, which involves several ethical decisions; then, take the self-test at various points. See how your responses compare to those of your colleagues, and look more deeply into the reasons why you chose as you did.

Situation: The Case of Anne R.

Your longtime patient, Anne R., is a relatively frail, 85-year-old woman who has lived more or less successfully at home since her retirement 20 years ago. Paul, her husband of 47 years, died 10 years ago. In many respects, she is still mourning his loss. Her life is generally solitary, inactive, and boring.

Anne has 2 daughters who live with their families in Houston and Toronto, both 3-hour plane rides away. They try to visit for holidays, and each daughter attempts to arrange to have her visit at least once a year. They seem to be a dedicated and loving family, albeit separated by nontrivial distance. However, Anne is increasingly reluctant to travel.

Anne has several maladies that you have been managing: atrial fibrillation; an arteriovenous malformation that causes occasional, and sometimes severe, gastrointestinal bleeding; chronic obstructive pulmonary disease; and osteoporosis. She has fallen twice but suffered only minor bruises.

Nine years ago, you partly convinced Anne of the importance of advance directives, although she winced and turned away when you raised the issue. In a designation of surrogate, she named both her daughters to make decisions for her if she became unable to do so, but she also declined to complete a living will. "I can't think about that right now," she said.

One night at 11:50, you receive a call from a hospitalist at General Medical Center, where you have privileges. Anne apparently had begun to feel very poorly and called 911. A workup in the emergency department showed atrial fibrillation. She is currently stable but uncomfortable. Her daughters do not yet know of this episode. You need to decide what to do.

What Should You Do?

Decision Point: Should You Go to the Hospital to See Anne?

Pro: You know Anne better than the doctors at the hospital do, and she is frightened and alone, with several comorbidities. You know it would be supportive and helpful to go, and you might be able to provide some information or help in some way.

Con: It is late and you're tired. You tell yourself that your presence would add very little. Anne could be transferred to the floor or admitted to the critical care unit, in the capable hands of others, until tomorrow.

Would you go to the hospital?

Would you wait until the next morning?

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Cite this: What Would You Do? Test Yourself on This Ethical Dilemma - Medscape - Aug 08, 2012.

In a very narrow view of doctoring, there is no medical need for you to go to the hospital. This patient in this case is not likely to die or experience any additional morbidity because you chose to stay home. But such a view of what it means to be a physician is not merely practical or strategic; it raises diverse issues for medical ethics and medical professionalism. If you reject the notion that physicians are replaceable technicians -- your answer suggests that you do -- then you are probably aware that it is not merely scientific know-how that you bring to the bedside. You bring a detailed medical history, an awareness of how your patient lives, and a foundation of trust. In other words, you have a relationship with the patient. By going to the hospital, you are keeping your end of the bargain. You are caring, as well as curing (or trying to cure), your patient. Moreover, the foundations of medical ethics and professionalism make clear that good doctors are self-effacing. They promote their patients' interests ahead of their own. Patients need physicians for more than medical knowledge and competence. They need them as guides, sources of customized advice, and homes for caring and compassion. After all, your patient is sick, and she is scared. If someone else could hold up your end, fine. But in this case, only you can. Note also that it was a colleague who called, not the patient, who might not even know of the call. The hospitalist's call was a kind of courtesy "heads-up," probably engendered in part by concern for the patient. Your arrival at the hospital signals the kind of physician you are -- and how lucky your patients are for it.

You aren't a social worker, babysitter, or hand-wringing relative. You have many patients who would like you to be available at midnight, but they do not call or have hospitalists to call for them. Surely you cannot be expected to get dressed and go to the hospital every time you get a nighttime call, especially given current reimbursement levels. Indeed, why did this hospitalist call in the middle of the night? Surely he could do all that was necessary for the treatment of the patient (or had access to others who could). He should just take care of this patient, and in any event, you will go there in the morning. You became a physician to provide medical care, not to hold hands. Your medical utility in the current situation is limited. You are impatient with do-gooders who somehow have come to think of physicians as servants. It is late, you are not dressed to go out, and you are tired. How does your patient's condition confer any kind of obligation to be so inconvenienced?

There is nothing wrong with a physician making a recommendation -- even a strong recommendation -- if it is evidence-based and in the patient's best interest. But no procedure is without risks, and there is broad agreement that patients should understand and appreciate the most significant ones. It is often a challenge to determine how much information a patient can understand and appreciate, and it requires careful judgment by a physician. However, deemphasizing risks might be a corner-cutting measure that increases the chance that a patient might be harmed without understanding why. Put differently, informed consent requires that patients or surrogates have enough information to make a reasoned decision. It is true that "enough information" is vague and provides little guidance. However, the information needs of decision-makers vary with their education and emotional state, the facts of the case and its complexity, and other factors. Moreover, that a patient disagrees with a physician does not make her wrong or incompetent or unreasonable. Any such disagreement should be managed with more information, not less. To be sure, there are circumstances in which patients delegate or try to delegate all decisions to their physicians or family members. Although one can attempt to honor such requests, doing so raises additional challenges related to the accuracy of the surrogate's communication of patient values.

Complete neutrality is good for football referees, journal editors, and news reporters. It is not a virtue for physicians. Nothing about informed consent entails that physicians should keep their mouths shut. Reasonable patients value their doctors' advice. It can sometimes be a good idea to include family members in the decision-making process; some patients should be encouraged to consult trusted kin. But knowledgeable physicians should not be shy about making solid recommendations -- being mindful, of course, that a patient might choose otherwise. This is an important point about informed consent. The consent process demands much from physicians and other clinicians. At the end of the day, however, the process is hollow and useless if a patient or surrogate does not have the right to refuse treatment. Worse still is the physician who views him- or herself as a mere technician, competent in the skills of the profession but unable or unwilling to help patients sort through detailed evidence and arrive at a conclusion. Most patients want recommendations. They should get them.

Medical pros and cons are rarely of equal status, but when they are, it is permissible to present them equally. Unless a delay introduces additional or greater risks, it can also be reasonable to wait, watchfully. A firmly held medical opinion, however, is a valuable commodity; in general, it should be shared (perhaps gently, and without being overbearing) as a key part of the informed consent process. It is sometimes thought that patient "autonomy" requires that all reasonable alternatives be presented equally, leaving patients to sort them out. But this view of autonomy confuses the right to self-determination with restaurant-menu-style decision-making. Patients should not be pressured or forced, but this does not entail a laissez-faire stance toward selecting among medical alternatives when one is preferred. If it is medically acceptable to wait, then it can be good practice to revisit the issue in a set period.

You have several options when patients or family members request treatment that you believe is unreasonable. First among these is to find out why. What are their hopes and expectations? Do they accept the diagnosis and prognosis? If not, why not? The daughters now have a duty to make decisions for their mother -- to consent to or refuse medical treatment. There is broad and uncontroversial agreement that surrogates have the power to direct another's care and, as important, they are required to direct that care as the patient would if she could communicate. That is, surrogates must not express their wishes; they must express the patient's. For these reasons, it is not yet a matter of acceding to the request for full treatment. It is a matter of helping the daughters work through the complexities of their mother's impending death.

If the diagnosis and prognosis are accurate, then hospice is the right way to go. However, it is not unreasonable for the surrogates to need some time to come to terms with their mother's forthcoming death. Recommending hospice is better than insisting on it. Moreover, this provides an opportunity to make clear both that the patient will die, come what may, and that hospice will provide the most comfortable passing. The daughters' divided opinions in this case are an additional challenge. Remember that the patient appointed both as equal surrogates; this has proved to be a complication. Remember also that their duty is to consent only to treatments that their mother would want if she could communicate, and there is at least some reason to believe she would not value aggressive treatment given the prognosis. This is not a credible opportunity for the physician to impose his or her beliefs or values on grieving family. The physician's job is to make clear that there is nothing medicine can do to restore her, not to judge that there is no value in the life she has now. The cost of care should rarely, if ever, be invoked in such cases. The physician's job is to practice high-quality medicine, not provide financial advice. One exception might occur when the costs of caring for one patient impede care of another. On a daily basis and in most ordinary circumstances, this is rare.

The daughters must speak for their mother. That they disagree is meaningful only if they disagree about what their mother would want. If they simply disagree with each other about what each wants for their mother, that disagreement carries no ethical weight. It is about the patient and what she would want. Because there is some evidence that the mother -- indeed, any reasonable person -- would not like to be maintained in an unconscious state until death, there is an opportunity to provide gentle advice in that direction. The daughters need to hear that nothing more can be done medically except to provide a pain-free death. Done right, that is an opportunity, not a problem. Good doctors will make the time needed to advise and counsel. The model of shared decision-making is always superior to alternatives; ideally, it provides a sound medical opinion, careful communication, and a decision that everyone can support.

Seeking legal advice is a good idea only if one actually needs legal advice. That is not the case here. Most US jurisdictions provide clear guidance in cases such as this: Work with the surrogates. Although this patient's case involves several challenging ethical issues, the hospital lawyer is not the one to ask for guidance. Asking the institutional ethics committee to weigh in might be an option if there is either (1) confusion, ignorance, or disagreement about the ethical issues on the table or (2) a need for mediation. Ethics committees should be competent to provide both. Make sure that the hospitals at which you practice have a functioning ethics committee or other ethics resource; if they do not, they are falling behind in meeting the established standard. The physician should not be seeking an ally in a lawyer or ethics committee to win over or bully patients or family members into agreement.

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