Dilemma
In this case Mr. Joe Mulroney had a fatal reaction to an angiogram. The dilemma lies within the anaesthetist’s decision to not tell Mr. Mulroney about all of the possible risks of the procedure, which leads one to question if there was truly informed consent. After Mr. Mulroney died, his son was critical of the doctor’s morality. The son believed it was the doctor’s duty to tell his father of all possible risk factors. The doctor claimed that the risk of death from this procedure was so small therefore in his opinion it wasn’t necessary to disclose that to patients. The dilemma is whether or not the doctor ought to disclose patients of rare risks in a procedure (Thomas 276-277).
Discussion
In this case the doctor was working under the idea of intentional nondisclosure. He claimed that since the risk was so small there was no need to “burden” Mr. Mulroney with the small possibility because no benefit would come of disclosing the information. Intentional nondisclosure can justified by the principle of nonmalificance “if and only if the patient’s knowledge of the information would have serious health related consequences” (Beauchamp 128). This can be specified into the rule of “disclose all information regarding the situation except if it will cause serious health related consequences”. The doctor claimed that the possible risk of death may cause a patient to opt out of the procedure which would cause more harm to the patient than proceeding with it. In this case the doctor balanced the principles of autonomy and nonmalificance. He believed that telling the Mr. Mulroney could cause more harm to him than withholding the information therefore he chose nonmalificance. In my opinion the doctor did not adequately factor in Mr. Mulroney’s autonomy therefore preventing him from giving informed consent. Informed consent not only requires that the patient is aware of all of the information and understands it but also the ability for a doctor to give their opinion and help the patient make theirs. When the doctor was speaking with the patient’s son he described Mr. Mulroney as a “reasonable man”. If the doctor truly believed that he was a reasonable man then he would have been able to mention the very small risk of death to the patient. After mentioning the risk, the doctor could then further the conversation and help Mr. Mulroney understand that the probability of death is very low and the benefits of the procedure will outweigh that risk. The doctor ought to disclose this risk to his patients because it aids them in making an informed decision.
Similar Case
Another case that involved nondisclosure was Pauscher v Iowa Methodist Medical Center. In this case Mrs. Pauscher had an intravenous pyelogram six days after giving birth. In her medical records it stated that she had no allergies and she was not told of the risk of death from this procedure. She ended up going into anaphylactic shock (Towsley 86). If she was aware of the possible risks of the this procedure she may have been able to recall important information about her allergies and been able to survive. The court ruled that it was not the hospitals fault. This relates to Mr. Mulroney’s case because with rare risks the doctor is usually not held responsible if someone has an adverse reaction therefore it does not pose a threat to the doctor to inform his patient. Doctors ought to disclose all information to their patients and help them fully weigh the risks and rewards when making their decisions.
Sources
Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 5th ed. New York, NY: Oxford UP, 2001. Print.
Thomas, John E., and Wilfrid J. Waluchow. Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Toronto: Broadview, 2014. Print.
Towsley-Cook, Doreen M., and Young, Terese. Ethical and Legal Issues for Imaging Professionals. 2nd ed. Maryland Heights, Missouri: Mosby, 2007. Print.
I agree that in both Mr. Mulroney’s case and Ms. Pauschner’s case, the patient should have been told the risks of the procedure. Even if the possibility of death/complication was extremely small, the doctors should have at least mentioned the risk while immediately following the warning with an assurance of the doctor’s/procedure’s excellent track record. Neglecting to do so not only ended up contributing to the nonmaleficence the doctors were trying to prevent, but could also be seen as a violation of autonomy and justice, since the physicians had an unfair advantage over the patients in that they possessed but intentionally decided not to disclose important risks that could have factored into an informed decision (or, in the case of Mrs. Pauschner, the divulgence of critical information.
I agree with the above commentator as well. It is the duty of the doctor to provide all information including the risks to the patient. Completely neglecting to mention the possibility of death to the patient absolutely undermines the autonomy of the patient. Regardless of if the risk has a very low chance of occurring, there still is a probability that it could occur. Hypothetically, if the patient died, the doctor would be held accountable because he did not verbally state all possible effects of the procedure. Lastly, who is the doctor to decide whether or not a patient is has the capacity to reason? Regardless of reasoning capabilities, one should know everything that they could potentially consent to, including the risk of death.
Doctors should inform their patients on whatever it is they are planning to do with them, but as discussed in class and the readings, how much information is too much? In terms of this specific case, I believe that the doctor was required to discuss with the patient the purpose of the procedure, and the correlating symptoms that were used to back up the claim, but I do not believe the doctor had to inform his patient of the minute risk of the procedure (especially when they had thousands of the same surgery over the last decade with no fatalities). Risk is everywhere, it’s when your in the plane flying miles about the ground, and its on the walk to class every morning. Everything carries risk, but does that mean the doctor has to inform you that checking your temperature might have a risk of you dying for whatever reason? And even if the doctor did inform you of that ridiculously small risk, are you going to turn down getting your temperature taken? While this might seem like a bit of an exaggeration, I think it aptly gets the main point across.
So yes, I believe that for the most part doctors should inform their patients on everything, but in terms of small risk cases like this one I do not feel that it is all that necessary. The heavy question now is where is the line drawn for “small risk”, and who’s the person to draw it.
I definitely do agree that it is important to try to not violate the patient’s autonomy. However, I also believe that, as a physician, you never know how your patient will react to this piece of information. In this case, assuming he is a “reasonable man,” then yes, he probably would have understood the minimal risk and consented anyway. However, what if a patient overreacts and completely refuses to go through with a life-saving procedure because of a doctor bringing up this small risk? At that point, the patient may be harmed as a result of this overreaction. Thus, it can be argued that the physician is violating the nonmaleficence principle by providing the patient with this information that leads to him or her panicking and making a poor decision.
I think that the doctor was respecting the patient’s autonomy, even when he did not disclose the miniscule risk of death to the patient. Surely, the physician did reveal the more relevant risks of the procedure. The risks of this procedure, including an allergic reaction to the iodine used as well as the risk that the procedure dislodges clotted blood or fat that could block blood supply to the brain or heart, are actually quite substantial. Indeed, allergic reaction and blood blockage can often be fatal. Perhaps the mistake the doctor made in this case, while obtaining informed consent, is that he incorrectly assumed the transitive property of consent. O’Neill argues that consent is intransitive. It is possible that the doctor assumed, though he did not intend maleficence and only beneficence, that the patient would understand that the physiological risks of the procedure could result in severe effects, including death, if they did occur. However, by the transitive property, almost every activity can result in death. Consequently, in this case, I think the doctor morally is only obligated to present the direct, known risks of the procedure and then ask if the patient has any questions. This is a good way to gauge if the patient understands or not. If he or she has any questions, of course the patient should ask. Most likely, the common risks of the procedure would alarm certain members of the population more than others. If the patient was a member of that population, he or she would also most likely inquire about the likelihood of death. Of course, then, the physician would have to disclose the information.
I think it’s important to remember that doctors possess pasts filled with different training regimens, procedures, and experience with disease similar to the different pasts patients have related to disease and illness. In this particular case of the anesthesiologist, the hospital in which they had worked had no fatalities within the past ten years. Current neuroscience tells us that people make decisions based on present-moment happenings and past experience. We rationalize our choices using previously acquired information. There was no precedent of death for the physician, so why logically would one think to present it as a risk during a routine procedure.
This comes back to O’Neill’s article and her point that patients should be able to choose the amount of information they wish to access. The patient here asked no questions about their procedure. One could argue they made a choice about how much information they wanted access to. I think Alexi makes a great suggestion for improving the consent process in this case by requiring the doctor to ask the patient if they have any questions, but I think it’s unfair to blame the doctor regardless. Truthfully, even the most benign procedures have a risk of death. As Alexi said above, “risk is everywhere”. If we informed every patient about the risk of death for finger pricks, routine blood draws, etc., is that information really useful to patients or does it place an undue burden on them? I realize that may sound paternalistic, but I think it’s unreasonable to expect a doctor to remember to list every single risk for every single procedure.
Hey, Rebecca. Thank you for your post, for I enjoyed reading about the comparison between the two cases. To begin with, physicians should disclose all information to patients. However, I agree with the reading that articulates that physicians should not inflict excess stress on the patients by informing them about remote risks. Thus, the full disclosure should exist in written form. As a result, the patients can read all of the information, and they can raise concerns about the stated possibilities of death. Furthermore, if the patients do not have any concerns about the minimal risk of death, then the “risk” to not inform the patient verbally would be worth it. Moreover, the aforementioned protocol of including the remote risk of death in the written papers and only including pertinent information about the procedure in the verbal discussion applies to the case with the angiogram. On the other hand, however, the case with Mrs. Pauscher slightly differs. For example, the physician assumed that the Mrs. Pauscher did not have any allergies due to the lack of notation in her medical chart. As a result, the physician did not have reason to inform the patient of the anaphylactic shock. Again, however, the physician should include the risk of anaphylactic shock in the written consent forms, so the patient can clarify information. Thus, the physician did not fail to disclose any necessary information in this case.