alek0

1) Do you think it is ethical for medical care practitioners not to disclose full information about proposed treatment?

2) Do they have the right to perform medical procedures without patient's consent and sometimes against patients wishes?

3) Is it ethical to refuse all treatment if patient disagrees with what physician proposed to do and would prefer (and prepared to give written confirmation) less effective but less invasive option?

4) Finally, do different guidelines apply to pregnant women? Do you think that ob/gyn has the right to override mother's wishes if he thinks he is acting in the interest of the fetus? For example, performing episiotomy against woman's wishes?

sacrod

No one has really replied to this post, so I thought I'd give some articles that you might be interested in... sorry I don't have the complete bibliographical information for some of them. Sorry, I also don't really feel like replying to all of the questions for several reasons... 1. I don't know what the heck I'm talking about 2. Even if I did, it would be too long and take way too much time, as philosophical discussions always do... sometimes if I'm in the mood or the question is specific enough, I might have something to say, but most of the time I'm just ignorant so I don't say anything! 3. Would be much better if you read it from the experts yourself .... These are taken from a course packet from a class that I am TAing for.

Beauchamp and Childress, "The Meaning and Justification of Informed Consent," Principles of Biomedical Ethics, Oxford, 1994. p. 142-146.

Arras, John D., "Antihypertensives and the Risk of Temporary Impotence: A Case Study in Informed Consent," Foundations of the Health Professional-Patient Relationship

Katz, Jay, "Informed Consent - Must It Remain a Fairy Tale?", [i}Journal of Contemporary Health Law and Policy[/i], Vol. 10-67.

Brody, Howard, "Transparency: Informed Consent in Primary Care," The Hastings Center Report, Vol. 19, No. 5, Sept/Oct 1989, p.5-9.

DMB

As a sometime patient, I have struggled with this problem in the past. The real question is: how many practitioners know enough to be able to disclose full information? I have found that practising medics (as opposed to researchers) are often incapable of giving statistics which IMO ought to be the foundation of many medical decisions. I would like to know things like what are the probable consequences of doing nothing for the condition under consideration? what are the different possiblities for treatment? and what are the success rates for the different treatments? Plus, obviously a lot of others. I remember getting sensible statistical information like this only once, when I was pregnant and about to undergo amniocentesis to check for chromosomal and other abnormalities. I was told what the probability was for a woman of my age of a Down's syndrome pregnancy and I was also told what the risk was of the procedure itself causing a miscarriage.

In an emergency, where the patient is unconscious or otherwise incapable of making his/her wishes known and where there is no pre-knowledge of the patients views, then I would say that action should be in favour of saving the patient's life.
It gets very difficult if the patient is clearly incapable of making a rational decision or is considered to be too young to be in full control of his/her own life. In general, however, I think the choice should lie with the patient.

There may be all sorts of reasons why the physician believes the treatment proposed by the patient is inappropriate. If, however, the alternative treatment is a medically recognised procedure, the physician, after doing his/her best to persuade the patient to take the recommended treatment, should either undertake the alternative or refer the patient to another doctor who is willing to do it.

If, however, the proposed alternative has no medical standing and could fall into the category of dangerous quackery, then the physician could not in all conscience do anything to help the patient undertake the treatment and should explain clearly why. It is then up to the patient as a competent adult to make the choice and go to the quack if that is what he/she really wants.

The mother is a competent adult; the foetus isn't. So the rights of the mother in this situation should be exactly the same as in any other medical procedure. A case in the UK a few years ago was decided specifically on this issue by the Court of Appeal. It was agreed that even if the mother's decision meant that either she or the baby, or both, would die as a result of her decision, she still had the right to refuse treatment (in this case a caesarian).

[ March 09, 2002: Message edited by: DMB ]</p>

Mostly Lurking

No, it is not ethical. There should be no "lies by omission" when it comes to medical treatment. If a medical practitioner wants to perform a procedure on somebody it is his/her duty to disclose what could reasonably be viewed as pertinent information, as well as be prepared to fully answer any questions the patient may have.

I'd say that any adult has the right to refuse any medical treatment he/she wants to, as long as the medical practitioner at least tried to explain why a procedure was performed. So, no, I'd say that medical procedures should not be allowed to be performed without the patient's consent.

Now, in the case of children, it gets a lot more tricky. Namely, when are people old enough to override their parents' wishes? Should it even be based on age, or some other criteria? Once this is determined, parents should be able to make medical decisions on their children's behalf until they are able to decide for themselves.

I don't think that a doctor should be required to provide treatments that (s)he thinks would not be in the patient's best interests. So, I'd say it's up to the doctor's discretion whether or not to refuse to treat a patient under these circumstances.

I agree with DMB's answer to this one.

alek0

Let me clarify what I meant with number 3.

Couple of years ago, before I found out how to control my endometriosis problems, I was frequently in awful pain. As it happened, my regular doctor was on holiday so I went to see another doc, after she found out I don't want kids she recommended hysterectomy. I didn't think that was a good idea (and still don't), so I refused. And she told me there is nothing she can do for me. Not even painkillers, even though I could barely walk from pain. Is this ethical behavior?

And concerning number 4, my sister recently had a baby and had a number of routine interventions against her explicit wishes. The baby wasn't in distress, the reason why she got all those interventions is simply because they do it to all first time mothers there. For some, like episiotomy, there is no proof of benefit. n the contrary, there is plenty of proof that it does harm. Why are those things done?

Alonzo Fyfe

To provide 'full information' would take years -- and would require training the patient to become a doctor.

By necessity a medical practitioner can provide only a small subset of the available information. And must decide which subset is relevant -- a matter about which rational people be disagree.

Only if the patient is determined to be incompetent or unable to express his/her wishes.


My first impression is that this question carries assumptions that could be misleading. Whose opinion are we going on here that the alternative is "less effective but less invasive"? And there are other problems -- potential side effects.

Pain killers, for example, should be addictive? What should a doctor do if she believed a patient was selecting a more painful alternative because the patient had an addiction to pain pills? Or would likely acquire one?


In an emergency situation, possibly. In a non-emergency situation, not without a court order.

alek0

Another clarification: pain killer in question was ibuprofen which is to my knowledge non adictive. Before I found a solution (alternative med) to my endometriosis problems, I used to take it for a first day or two of period, that is once a month. A pack of 20 pills would last me 4-5 months. Is this an addiction? It didn't eliminate pain but it was sufficient to prevent me from fainting from pain and waking up in ER. Anyway, it was all in my chart which was faxed to the other doc. I really think that sort of regime is far less drastic and with fewer side effects than full hysterectomy at 27 would have been.

Another thing about item 1): why do you think that it would take years to give fill information about certain treatment or medication? Why I risks deliberately minimized? Why is it so difficult to give honest information and let patient decide, because after all the patient has to live with possible consequences of that decision? I am just saying that if there are proven risks, no matter how small, patients should be told.

scigirl

All right, can't resist posting here! (going to med school in august. . . )

No, the truth is best, even if it hurts. However, I do feel that doctors can emphasize the positives (like if a patient is going to die in two months, the doctor should try to be optimistic anyway).

I would say no, except under certain circumstances such as the following:

1) Quarantining of patients who have very contagious diseases (like ebola).
2) Under emergency situations when determining the patients wishes is impossible. In these cases, the doctors should always err on the side of life - give the blood transfusion even if you think they might be against it. NOTE - if people are that worried about this, they can get a living will drawn up.
3) Doctors can - and do - get court orders to force certain treatments for children. Like the Christian Scientists who refuse to give their five-year-olds antibiotics. IMHO - the kids should at least be allowed to reach a certain age and choose the religion for themselves. Then they can refuse all the treatments they want.
4) If the patient is deemed incompetent to make medical decisions (for instance a suicidal patient is not exactly in the best position to make healty decisions on his behalf), than decision-making should go (and does go ) to the appropriate person i.e. wife or parent.

I don't think this should happen - that example you posted about your endometriosis problem is really sad, and I'm sorry that had to happen. I don't think the AMA encourages this type of behavior (at least I hope not!)

But a doctor is not obligated to perform treatments or prescribe drugs that he/she feels are unnecessary.
I would say usually, no. But what if the mother was addicted to crack? In this case putting her in a treatment center may be against her wishes, but is good for her AND the baby. So again I say not usually, but there may be cases where I would say yes.

scigirl

[ March 10, 2002: Message edited by: scigirl ]</p>

ohwilleke

[QUOTE]Originally posted by alek0:
<strong>1) Do you think it is ethical for medical care practitioners not to disclose full information about proposed treatment? </strong>

No, so long as it is practicable to make the disclosure.

<strong> 2) Do they have the right to perform medical procedures without patient's consent and sometimes against patients wishes? </strong>

If they are about to die and you can't know what their wishes are and they can't consent, this is ethical. If consent could easily have been sought, this is unethical.

<strong> 3) Is it ethical to refuse all treatment if patient disagrees with what physician proposed to do and would prefer (and prepared to give written confirmation) less effective but less invasive option? ]</strong>

No, assuming that a less effective but less invasive option is available, and that the doctor beileves that the refusal is motivated by a reason based on the procedure, rather than, for instance, doubt about problems with this particular doctor and fear of considering a new doctor.

<strong> 4) Finally, do different guidelines apply to pregnant women? Do you think that ob/gyn has the right to override mother's wishes if he thinks he is acting in the interest of the fetus? For example, performing episiotomy against woman's wishes?</strong>

No. The woman is a better natural guardian for any interests of the fetus than a doctor who has no personal stake.

Edited to change answer to 3 after realizing what was being asked.

[ March 13, 2002: Message edited by: ohwilleke ]</p>