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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
8c* Confidentiality - Withholding Information
[C8:1] A patient who only speaks Chinese but with decisional capacity is admitted into the hospital with nonproductive coughing. Medical communication has been conducted through the use of a medical interpreter. An MRI was conducted. Before the test results came back, family members requested that any negative information be withheld from the patient, as informing the patient of negative test results would not help the patient but would only emotionally harm the patient. The interpreter communicates this conversation with the patient, and the patient agrees with not being informed. The MRI showed a peripheral lung tumor with a diagnosis of probable adenocarcinoma. What would be the most appropriate response to the family members?
[C8:2]
- A. I’m sorry, but the patient must always be provided their test reports.
- B. I will not inform the patient, but if I cannot inform the patient, then I cannot inform family members either.
- C. Call for an ethics consultation to resolve this issue.
- D. The patient has the right to have the family informed of the test results, but not themselves.
- E. It is morally unaccepted for the patient not to be engaged in their decision-making, and therefore I cannot do what you are requesting.
- F. Therapeutic privilege gives the practitioner the authority not to reveal the test reports.
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TAC: Think - Assess - Conclude
I. Think: What is the question?
[C8:3] Does a patient have the right not to be informed?
II. Assess: Specify & Balance the four principles of medical ethics
Patient: 1) Autonomy - Informed Consent
[C8:4] The patient has the legal right and moral obligation to exercise individual autonomy as manifested through the process of informed consent. All legal rights are of two types: negative rights and positive rights. A negative right is when others have an obligation to not interfere. A positive right is when others have an obligation to provide something.
[C8:5]
[C8:6] Inform consent is both a negative and a positive right. Informed consent is a positive right in that the practitioner is legally, professionally, and morally obligated to provide the patient with 1. treatment or available procedural options, 2. goals or purposes of the treatment, 3. risks of harm and benefits of the various treatment options, 4. available alternatives including no treatment, and provide the patient with the 5. opportunity to ask questions and to withdraw from the research or treatment at any time. Informed consent is a negative right in that the practitioner is obligated to not interfere with a patient’s decision to consent to a treatment option, refuse a treatment option, or withdraw from treatment. However, just because a patient has a legal right to be autonomous does not mean that the patient is legally bound to exercise that right. If the practitioner has explained their legal and moral right to be informed and make medical decisions on their behalf, the patient is not bound to exercise that right if the patient so decides. The thought is that the individual patient is usually the best individual for determining what treatment options would best reflect their own goals, values, and priorities. Morally, most western ethicists would also argue that the patient has a moral obligation to be as active as possible in making personal decisions regarding their well-being, as moral activity is what determines the moral worth of an agent. However, this case is a bit different in that the patient and the family have all agreed that it would be in the patient’s best interests for the family to be substantially informed, but not the patient. Although medical autonomy is usually exemplified and put into practice by getting a patient’s informed consent, this case is an exception. The patient’s autonomous decision is exemplified here by not getting informed consent from the patient but rather from the family.
[C8:7] Perhaps it would be wise in this case to encourage the patient to fill out a living will that would legally indicate accepted treatment options for various circumstances and conditions if they were ever to occur, as well as a durable power of attorney for legally determining whom the patient wants to make medical decisions on their behalf which in this case would probably be the family by consensus.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[C8:8] Although the patient and family both believe that the test results information would only emotionally harm the patient, this case still does not seem to be at the level of therapeutic privilege. Therapeutic privilege is the legal and professional permission for a practitioner not to reveal information to a patient if such information would pose serious and immediate harm to the patient, such as suicide or inciting the patient to harm someone else. In this case, revealing the test results to the patient would not be a serious psychological threat or medically contraindicated.
However, if the patient and family all agree that it would not be in the patient’s best interests or well-being for the patient to provide informed consent for treatment, and it is the patient’s legal and moral right to make such a judgment, then it would seem that professional beneficence (do good) and professional nonmaleficence (do no harm) would obligate the practitioner to abide by that decision.
Public Policy: 4) Justice
[C8:9] The principle of social justice provides the patient with civil rights and moral opportunities to make their own medical decisions. The opportunity of filling out a living will, is so that the patient can provide the legal information of what treatment options would be accepted to the patient under varying circumstances. A power of attorney could also be filled out, legally determining what individual or family members would have the authority to make medical decisions on the patient’s behalf.
[C8:10]
III. Conclude: Nationally or Professionally True Answer
[C8:11] Respect the patient’s decision to allow the family to provide informed consent for medical treatments on the patient’s behalf. In this case, it would be wise to encourage the patient to fill out a living will and a durable power of attorney. The living will provide direction for treatment options should the conditions ever arise, and a power of attorney would indicate what individual or family members would have authority to make medical decisions on the patient’s behalf.
Answer Options: [C8:12]
(Choice A) I’m sorry, but the patient must always be provided their test reports.
A is the wrong answer. There are several different circumstances in which the patient cannot or should not be provided their test results. Some examples are if the patient were to be unconscious, without decisional capacity, therapeutic privilege, and in this case, because of autonomous choice.
(Choice B) I will not inform the patient, but if I cannot inform the patient, then I also cannot inform family members.
B is the wrong answer. The patient has the legal and moral right to determine whom they wish to make medical decisions on their behalf.
(Choice C) Call for an ethics consult to resolve this issue.
C is the wrong answer. Ethics consultations are primarily invoked when there is disagreement among family members. Ethics consultation are advisory only, not decision-makers.
(Choice D) The patient has the right to have the family informed of the test results, but not themselves.
D is the correct answer. The patient has the legal and moral right to have the family informed of the test results, but not themselves. Not being informed also means that the patient would no longer be able to provide informed consent. This no information disclosure decision, in effect, also is making the family into the surrogate decision makers.
(Choice E) It is morally unaccepted for the patient not to be engaged in their decision-making, and therefore I cannot do what you are requesting.
E is the wrong answer. Although many moral philosophers believe that patients with decision-making capacity have a personal moral obligation to be active decision-makers in their medical treatment, patient morality in itself does not necessarily determine the practitioner’s professional conduct. Civil law and professional responsibilities have given patients the authority to be autonomous, including choosing others to make decisions on their behalf.
(Choice F) Therapeutic privilege gives the practitioner the authority not to reveal the test reports.
F is the wrong answer. Therapeutic privilege is the legal and professional permission for a practitioner not to reveal information to a patient if such information would pose serious and immediate harm to the patient, such as suicide or inciting the patient to harm someone else. This case does not reach that level of consequence.
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Civil Rights
- • Obligation of others to Not Interfere
Negative Right
- • Obligation of others to Provide something
Positive Right
Assessment
Do Not Inform
Principles
X
Autonomy
X
Beneficence
X
Nonmaleficence
X
Justice
