Bioethics

"Telling the Truth to Patients: A Clinical Ethics Exploration," David C. Thomasma

According to Thomasma, truth-telling is important because it is "a right, a utility, and a kindness," but it can be trumped by more important values. "[T]ruth is a secondary good," he says. "Although important, other primary values take precedence over the truth. The most important of these values is survival of the individual and the community. A close second would be preservation of the relationship itself."

"Transparency: Informed Consent in Primary Care," Howard Brody

Brody observes that the theory and the practice of informed consent are far apart and that accepted legal standards send physicians the wrong message about what they are supposed to do. He thinks that a conversation standard of informed consent does send the right message but is probably legally unworkable. He proposes instead a "transparency standard," which says that "disclosure is adequate when the physician's basic thinking has been rendered transparent to the patient."

"Respect for Patients, Physicians, and the Truth," Susan Cullen and Margaret Klein

Cullen and Klein argue that deception to benefit patients is wrong because it disrespects them by restricting their freedom to make choices about their own lives. But if a patient explicitly states that she does not want to know the facts about her condition, generally physicians should respect her wishes. Those who claim that it's not possible to tell patients the truth are confusing the "whole truth" with the "wholly true." Patients cannot and need not understand the whole truth—that is, all the medical details of a disease process. But they can understand enough to appreciate the nature and seriousness of the disease and the benefits and risks of treatments. Cullen and Klein concede that in rare cases, it is permissible for doctors to deceive a patient—but only if the deception is for a short while and if the potential gain from the deception is probable and significant. By this criterion, a brief deception to save the patient's life may be justified.

Autonomy, Futility, and the Limits of Medicine," Robert L. Schwartz

Does respecting the principle of autonomy require physicians to provide any treatment that an autonomous patient requests? Schwartz says that physicians are not obligated to give scientifically futile treatment (a worthless cancer therapy, for example). More importantly, neither are they morally required to provide treatment that is outside the scope of medical practice (such as surgical amputation of a limb for purely religious reasons). In many instances (including the famous Wanglie case), the central question was not whether the treatment requested by the patient was futile, but whether the treatment was beyond the proper limits of medicine. Schwartz contends that defining the scope of medicine should be left to physicians themselves.

"Paternalism," Gerald Dworkin

Dworkin accepts the notion (famously articulated by John Stuart Mill) that society may sometimes justifiably restrict a person's liberty for purposes of self-protection or the prevention of harm to others. But he takes issue with Mill's related anti-paternalistic idea that a person "cannot rightfully be compelled to do or forbear because it will be better for him to do so." He argues that some limited forms of state paternalism can be justified, for "[u]nder certain conditions it is rational for an individual to agree that others should force him to act in ways which, at the time of action, the individual may not see as desirable." In a representative government, rational people could agree to restrict their liberty even when the interests of others are not affected. But in such cases the state bears a heavy burden of proof to show "the exact nature of the harmful effects (or beneficial consequences) to be avoided (or achieved) and the probability of their occurrence."

. "The Refutation of Medical Paternalism," Alan Goldman

Except in a few extraordinary cases, strong paternalism in medicine is unjustified, Goldman argues. Patients have a right of self-determination, a right of freedom to make their own choices. Decisions regarding their own futures should be left up to them because persons are the best judges of their own interests and because self-determination is valuable for its own sake regardless of its generally positive effects. This right implies "the right to be told the truth about one's condition, and the right to accept or refuse or withdraw from treatment on the basis of adequate information regarding alternatives, risks and uncertainties." The faulty premise in the argument for medical paternalism, says Goldman, is that health and prolonged life can be assumed to be the top priorities for patients (and so physicians may decide for patients accordingly). But very few people always prioritize these values in this way.

"The Concept of Informed Consent," Ruth R. Faden and Tom L. Beauchamp

Faden and Beauchamp distinguish two common views of informed consent and argue that only one of them reflects the true meaning of the concept. Real informed consent involves more than a patient's merely agreeing to, or acquiescing in, some suggested course of action. An informed consent is a patient's autonomous action that authorizes a course of action. The other common meaning of the term is defined legally or institutionally and does not refer to autonomous authorization. Faden and Beauchamp also believe that the tendency to equate informed consent with shared decision-making is confused. Decision-making, which has been linked historically to informed consent, is not enough.

Tarasoff v. Regents of the University of California, Supreme Court of California

In this 1976 case, the court held that the professional duties of confidentiality can be overridden when a patient poses a serious danger to others. It concluded that "the public policy favoring protection of the confidential character of patient-psychotherapist communications must yield to the extent to which disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins."

Bouvia v. Superior Court, California Court of Appeals

In this 1986 ruling, the court asserted that competent adults have a "constitutionally guaranteed right" to decide for themselves whether to submit to medical treatments, a right that outweighs the interests of physicians, hospitals, and the state. A competent patient may refuse treatments even if they are needed to keep her alive.

"Fundamental Elements of the Patient-Physician Relationship," AMA Council on Ethical and Judicial Affairs

In this section of its medical code of ethics, the American Medical Association declares that the patient-physician relationship is a collaborative alliance in which both parties have responsibilities. Physicians should serve as their patients' advocates and respect their rights, including the right to accept or refuse recommended treatment, to receive complete information about treatments and their alternatives, and to have their confidentiality protected.

"On a Supposed Right to Lie from Altruistic Motives," Immanuel Kant

Kant asks whether we could ever have a duty to lie if lying was the only way to prevent harm to ourselves or to others. His answer is an emphatic no. We must speak the truth no matter what injuries befall people. In fact, the act of lying itself causes injury: "For [a lie] always injures another; if not another individual, yet mankind generally, since it vitiates the source of justice." For Kant, to be truthful is an "unconditional command of reason."

"Informed Consent: Some Challenges to the Universal Validity of the Western Model," Robert J. Levine

Levine says that since different countries and cultures may have vastly different perspectives on the nature of persons, and since the point of informed consent is to show respect for persons, it is not possible to provide a definition of informed consent that is universally applicable. The rules of the Western model of informed consent are not appropriate for many cultures. The ethical principle of respect for persons is universally applicable, but applying it to specific cultures with varying notions of person can be problematic. Levine suggests that instead of insisting on sticking to the rules, we use practical procedures to deal with the cultural differences when they arise.

"On Telling Patients the Truth," Mack Lipkin

Lipkin urges a decidedly paternalistic attitude toward truth-telling. He argues that because the stress of being sick can distort patients' thinking and because they lack understanding of medical concepts, it is usually impossible to convey to them the full medical truth. Many times, telling the whole truth can do more harm than good. Moreover many patients prefer not to know the full details about their condition. "Often enough," Lipkin says, "the ethics of the situation, the true moral responsibility, may demand that the naked facts not be revealed." The critical question is not whether deception occurs, but whether the deception is meant to benefit the patient or the physician.

"Why Doctors Should Intervene," Terrence F. Ackerman

Respect for patient autonomy is distorted when autonomy is understood as mere noninterference, says Ackerman. On this prevalent hands-off view, "[t]he doctor need be only an honest and good technician, providing relevant information and dispensing professionally competent care." But this approach fails to genuinely respect autonomy, he argues, for it does not recognize that many factors can compromise autonomy, including illness and a host of psychological, social, and cultural constraints. At times, true respect for autonomy may require the physician to intervene, to deviate from the patient's stated preferences. The goal of the physician-patient relationship should be "to resolve the underlying physical (or mental) defect, and to deal with cognitive, psychological, and social constraints in order to restore autonomous functioning."

"Should Informed Consent Be Based on Rational Beliefs?," Julian Savulescu and Richard W. Momeyer

Savulescu and Momeyer maintain that being autonomous requires that a person hold rational beliefs. In informed consent, what passes for respecting autonomy often consists of little more than giving the patient information. But "[b]eing fully autonomous requires not only that we are informed , but that we exercise our theoretical rationality." Thus to ensure true informed consent, physicians should not only provide relevant information but "assist patients to think more clearly and rationally. [Physicians] should care more about the rationality of patients' beliefs."

"Confidentiality in Medicine—A Decrepit Concept," Mark Siegler

Siegler points out that in this age of high-technology health care, the traditional ideal of patient-physician confidentiality does not exist in practice. Modern health care involves teams of specialists—medical, financial, governmental, social, and more—and they all require access to, and dissemination of, a great deal of confidential information about patients. These developments seem to be in response to people's demand for better and more comprehensive care. But they also are changing our traditional concept of medical confidentiality. Confidentiality is important because it shows respect for the patient's individuality and privacy and nurtures the bond of trust between patient and doctor.

"Informed Consent—Must It Remain a Fairy Tale?," Jay Katz

The ideal of informed consent with its presumptions of autonomy and joint decision-making is yet to be fully realized in practice, says Katz. The concept has been legally recognized, but genuine patient self-determination is still not the norm. Physicians acknowledge it but are likely to see it as a perfunctory fulfillment of legal requirements or as an enumeration of risks. The goal of joint decision-making between physicians and patients is still unfulfilled. Physicians must come to see that they have a "duty to respect patients as persons so that care will encompass allowing patients to live their lives in their own self-willed ways."

Canterbury v. Spence, United States Court of Appeals

This 1972 case helped settle the question of what standard should be used to judge the adequacy of disclosure by a physician. The court ruled that adequacy should not be judged by what the medical profession thinks is appropriate but by what information the patient finds relevant to his or her decision. The scope of the communication to the patient "must be measured by the patient's need, and that need is the information material to the decision."

Code for Nurses," American Nurses Association

This statement of ethical principles details the moral responsibilities of nurses to patients, themselves, fellow health care professionals, and the larger community. It enjoins nurses to respect patients' dignity, values, beliefs, and rights of self-determination (autonomy), informed consent, and privacy. When conflicts arise between the patient's preferences and those of others, the nurse's primary duty is to the patient.

"Whose Body Is It Anyway?,"AtulGawande

Through a series of vignettes drawn from actual cases, surgeon and writer AtulGawande offers a compelling meditation on the real-life conflicts between patient autonomy and physician duty. Autonomy is an important value, he says, "[b]ut there are times—and they are more frequent than we readily admit—when a doctor has to steer patients to do what's right for themselves." He believes that ethicists err when they promote patient autonomy as the ultimate value, when it is actually one moral consideration among many. Often patients want kindness, not autonomy, or they may want doctors to decide for them. Gawande maintains that sometimes the compassionate thing for a doctor to do is to push a reluctant patient toward an option that she herself believes is in her own best interests.

. "Why Privacy Is Important," James Rachels

Why should we care so much about privacy?,Rachels asks. He notes that we have a sense of privacy that cannot be fully explained by our fear of being embarrassed or our concerns about being disadvantaged in some material way. He argues that "privacy is necessary if we are to maintain the variety of social relationships with other people that we want to have, and that is why it is important to us." To manage the relationships that we have with people, we must have "control over who has access to us."