Should Informed Consent be based on rational beliefs? A Critique:

Julian Savulsecu and Richard W Momeyer argue, “being autonomous requires … a person [to] hold rational beliefs” (Savulsecu & Momeyer 282). They make an important distinction between rational beliefs and rational choice. Rational beliefs is the knowledge of the situation regarding its accurately and validity. Rational choice is how a person acts upon the beliefs that they have. When specifically applying this to the medical world, Savulsecu and Momeyer believe that it is not enough to simply provide information to the patients; rather, the physicians should help their patients with more rational thinking and deliberations.

Overall, I do not agree with Savulsecu’s and Momeyer’s argument of rational beliefs. Autonomy does not, and should not, correlate with a persons belief – knowledge – or the rationality of choice behind it. Autonomy is very basic. It is the right or condition of self-government I would argue that a person’s autonomy should be based off the action a person takes. Being autonomous is an action – similar to the action of jumping. If you meet a set of criteria that distinguishes an action form others, then I believe that you have preformed that action. If both feet come off the ground and I elevate my body, then I have jumped. In the case of autonomy, a person would preform a self-governing action. Performing this action does not require extensive knowledge on a situation, only the person’s opinion at that moment of time, and the action itself. When the action is complete, the person has preformed acted autonomously and therefore responsible for the outcomes of their actions.

Rationality and true/false beliefs do not hold much weight when deciding whether a person is/was autonomous. Acting rationally upon true beliefs may lead to a better consequence, however the quality of the consequence should not dictate whether or not it was an autonomous decision. Take the Jehovah Witness case for an example. The doctor actions to transfuse or not, regardless of the information he knew, would be his decision and his decision alone. When a willing, conscious effort is made to preform a task, that action is autonomous; and therefore, in that moment, the performer of such action has autonomy.

I agree with the end result and the change they want. I do believe that doctors should be made to give a more conscious effort to teach and educate their patients. Not only does this help the doctor feel more at ease when making decisions mid-surgery, but also creates a more trusting relationship between the doctor and patient. None the less, I would like to stress being autonomous has more to do with the action than the belief or choice behind the action.

Alex Liu

Citations:

Savulescu, J., and R. W. Momeyer. “Should informed consent be based on rational beliefs?” Journal of Medical Ethics 23.5 (1997): 282-88. Web.

Background:

Amira gets in a car accident with her partner, Casey and her three-year-old daughter, Samantha. Amira and Casey are both in critical condition upon arrival to the hospital. Samantha comes out of the accident with only minor injuries. When in the emergency room, Casey’s health declines rapidly and the trauma team tries to resuscitate her with no success. The nurses have to figure out if, when, and how they should update Amira on her partner’s death in a timely manner. Keep in mind that Amira is due for an urgent surgery and then will be induced into a coma for a week while her body recovers.

Dilemma:

Because Amira is declining in health, any distress can affect if she will pull through the urgent surgery she needs. The doctors are not even letting the police question Amira to make sure there is no unnecessary stress.

Reasons for telling Amira about Casey’s death immediately:

Amira is entitled to know of her partner’s death as soon as possible. Moreover, the nurses, especially, have a job to develop a healthy relationship with the patient, which includes trust and assurance that the patient is not being deceived.

Reasons for telling Amira about Casey’s death after surgery:

Even though the nurses should tell Amira as soon as possible, there are factors that should allow for the nurses to stall on giving out that information. For one, if the nurses do decide to tell Amira of her partner’s death, Amira will inevitably experience increased stress. Any person who is already in critical condition and is put into a mental state of even more anxiety could worsen his or her condition. In this article it is said that, “if she is told the tragic news about her partner’s fate in the emergency room, her response may have a serious effect on her chances of survival. Her condition may deteriorate, and her condition could become even more unstable.” If Amira is told, there is a large chance that she could lose hope in surviving or become so mentally unstable that she cannot pull through the surgery.

My thoughts:

Given the circumstances of Amira’s case, I would argue that the nurses should wait until after the surgery to tell Amira about Casey’s death. Although, it would seem more appropriate to tell Amira as soon as possible, there much more other factors to consider than just saying that the patient deserves to know. There are too many risks involved in informing Amira while she is in such a critical condition as it might lead to death. If Amira does not survive this condition, then Samantha, her three-year-old daughter will be affected tremendously. Hypothetically, if Amira dies Samantha is left with no parents. Samantha will have gone through a traumatic event at an age where she is still developing and very vulnerable.

Excerpt from “The Benevolent Deception: When Should a Doctor Lie to Patients?”:

“Every clinician has encountered situations in which being too bluntly honest about a diagnosis can actually be harmful to the patient, and so we employ what is euphemistically referred to as “benevolent deception.” Consider mentally fragile patients with whom full disclosure of a devastating diagnosis may cause excessive anxiety, abandonment of ongoing therapies, or total loss of hope. In these circumstances, strict adherence to the clinical virtues of truthfulness and candor risks violation of the core ethical principle to do no harm”

This excerpt relates to this case because Amira is a mentally fragile patient

where there is “devastating” information that she needs to receive at some point

but the negative risks of knowing in her state are too high. So in some aspect,

according to this article, it is ethical for the nurses to not tell her, because it

would be causing Amira mental and, in turn, physical harm if told about

Casey’s death.

Works Cited:

Agronin, Marc E. “The Benevolent Deception: When Should a Doctor Lie to Patients?” The Atlantic. Atlantic Media Company, 24 Oct. 2011. Web. 30 Jan. 2017.

RD Yeo, M., A. Moorhouse and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics.

Understanding in the medical setting is a very important, and goes beyond what the PBE book was discussing, in terms of understanding and its relationship to informed consent. There is a need for a level of understanding between the patient and the health professional at hand, in order for the most optimal care to be administered and received and thus adhered to. Some questions might arise when one looks at what level of understanding should a patient have in a medical setting, and are their factors, circumstances, or situations to which a limited understanding on the patient side is ok?

This can be seen from our discussions that we had in class about the anesthesia case and the cancer trial case, in which we discussed whether or not a full disclosure should have been given to the patients about the components and risks of their treatment. We looked at potential benefits and risks of a patients full understanding, and some of the benefits/concerns that we looked at were more along the lines of what the effect of that full disclosure could mean for the research, whether or not the patient was harmed without the full disclosure, and the necessity of the full disclosure in the first place. Some potential areas of concern when looking at the effects of not communicating risks, the effect that the patient’s beliefs, education, and status might have on their understanding, and how the patient might not be able to understand due to emotional state, education level, health status, and circumstance.

In the medical field, there should be a level of transparency, with the doctors and health professionals ensuring that the patient knows enough about their diagnosis, condition, ect. to where there is an adequate level of understanding between the patient and the health professional. In Case 3, we see a situation in which the level of patients’ understanding is hindered by an ethical concern. This case questions whether or not the same duty of transparency applies in a situation where a full level of understanding might bring harm to the patient. Amira’s nurses have an obligation to stand by their patient and to ensure a level of understanding. But given Amira’s current medical state, considering how she is in a life or death situation, that obligation might be affected by their obligation to ensure no harm on their patient. The question for this case is whether the harm of not telling Amira is greater than the harm of telling Amira of her partner’s death.

The situation can play out in many different ways. If they tell her, she can die from stress induced trauma or a complication from the news or have an increased will to live for their 3-year-old daughter. If they decide not to tell her, she can survive her injuries and feel deceived by her nurses and lose trust and thus hinder her recover and treatment, die without knowing, or survive and not realize that the information she asked for was not disclosed to her. I think taking the patients health into consideration, the information should be disclosed to her, because the nurses can then encourage her to fight hard for their daughter.

References:

Beauchamp, Tom L., and James F. Childress. “Understanding.” Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 1994. 131-137 Print

Yeo, M., A. Moorhouse and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics.

The use of a placebo as a legitimate treatment in both a medical and research setting has been under scrutiny based on the nontraditional nature of the treatment. The Lichtenberg paper focused primarily on the controversy of whether or not physicians should be allowed to offer their patients “knowingly ineffective remedies … in order to assuage the patient’s discomfort” or if it is unethical to offer a placebo if alternative, traditional medications will suffice (Lichtenberg, Heresco-Levy, Nitzan 2004). In order to address this issue, it is first important to decide what exactly constitutes an effective treatment. Most people would deem medication as a sufficient treatment to virtually any medical condition due to its explicit physiological mechanisms and tangible effects, but is this the only “legitimate” form of treatment? The argument against the use of a placebo in medicine comes from a standpoint in which sufficient treatment is “purely biomedical” while all other alternatives are inadequate (Lichtenberg, Heresco-Levy, Nitzan 2004). Although modern medicine is both impressive and reliable, it is not the only means of recovery.

In some cases, such as depression, medicine has been observed to be equal or even less successful compared to some alternative methods, such as cognitive therapy. There is empirical data to support that therapy is “as efficacious as antidepressant medications at treating depression” and appears to have lasting effects (DeRubeis, Siegle, Hollon 2009). Cognitive therapy consists of identifying the cause or belief behind the depressive episode and then separating and questioning the reasons behind the belief. Antidepressant medication is also effective in managing or treating depression, but cognitive therapy provides an equally qualified treatment that does not require prescription drugs and also offers a protective method to prevent future depressive episodes (DeRubeis, Siegle, Hollon 2009). Unlike a placebo, the physiological mechanisms behind the success of cognitive therapy are known and respected among the healthcare field. However, is cognitive therapy, as well as other behavioral therapies, considered to be a biomedical treatment? If not, is it still considered to be a justified alternative treatment to medicine?

Another treatment that has been shown to reduce depressive symptoms is a method called Deep Brain Stimulation (DBS). DBS consists of implanting and stimulating electrodes in the brain. Although the mechanisms of these stimulations are not well understood, it seems to “improve mood and give the people an overall sense of calm” (Taylor 2016). Although it is recommended that patients try both therapy and antidepressants before DBS, it is still a viable option for patients.

Considering medication, therapy and DBS, which treatments are considered an effective treatment? Therapy is not considered purely medical, but the physiological mechanisms are well understood, while the mechanisms of DBS are not understood, but proven to be effective. Should either of these methods be considered an effective form of treatment? If so, I return to my initial question of what constitutes an effective treatment, both ethically and physically? Is it necessary for the physiological mechanisms to be explicit or is it just enough for positive outcomes to be observed? Although all of these treatments are different from the use of a placebo, I believe the same underlying principles apply in terms of effectiveness. While the controversy of deception is also part of the picture, it is important first to determine whether or not the treatment in it of itself is rendered effective enough. Based on the same underlying principles of cognitive therapy and DBS, I believe that although the mechanisms for why placebos work is not explicitly known, if it has positive effects and does not impose risks to the patient, it should be deemed a viable option for effective treatment.

DeRubeis, Robert J., Greg J. Siegle, and Steven D. Hollon. “Cognitive Therapy vs. Medications for Depression: Treatment Outcomes and Neural Mechanisms.” Nature reviews. Neuroscience 9.10 (2008): 788–796. PMC. Web. 4 Feb. 2017.

Lichtenberg, P., U. Heresco-Levy, and U. Nitzan. “The Ethics of the Placebo in Clinical Practice.” Journal of Medical Ethics 30.6 (2004): 551-54. BMJ, Dec. 2004. Web.

Taylor, Mara. “Deep Brain Stimulation (DBS).” Healthline. N.p., 10 Aug. 2016. Web.

https://xkcd.com/1526/

One of the most pertinent questions in medical ethics is balancing physician autonomy with patient trust.  Giving physicians full authority over all action at the expense of the patient’s autonomy and trust is a unsettling notion for most patients.  The use of placebo as a treatment may act to break this trust.

Using placebos is an absolutely essential part of the medical research process, as controlling patient test groups under varying conditions is a requirement set forth by the Food and Drug Administration (Clinical Trials and Human Subject Protection).  In this circumstance, a placebo treatment is legally required for determining the efficacy of a drug or procedure.  However, placebos may offer their own therapeutic benefits in some circumstances (Daniel E Moerman, 472).  Because placebos can result in real symptom improvement, prescribing a patient a placebo is now considered by some to be a viable option.

However, when the placebo becomes a possible treatment option remains uncertain.  There are a few requirements that govern the discretionary usage of a placebo as treatment.  First, the physician must be acting in the best interest of the patient.  In cases of moderate pain treatment, placebo may be seen as a good medical decision, especially if the pain is not indicative of more severe physical problems.  In fact, using placebo over opioid pain relievers offers reduced side effects, albeit at the expense of euphoria and sedation.  Second, the patient must be consistently monitored so that standard treatment can be administered if there is no improvement.  Third, the physician must be honest if the patient decides to inquire about the specifics of treatment.  While those in favor of placebo usage argue that physicians do not have to initially disclosure it, they concede that physicians must guarantee a basic level of trust in the patient relationship.

The article’s second case presents a dilemma that extrapolates on the third point made above: Is the physician’s initial deception of the patient unethical?  While certain benefits — or lack of problems — make placebo a viable option, choosing this treatment runs the risk of diminishing trust in the patient-physician relationship.  In cases that do not absolutely require negative-control patient groups, I see the use of undisclosed placebo as a violation of trust by the physician.  Patients seek out medical professionals to receive the best advice and treatment.  Therefore, it is my opinion that medical professionals should not use placebo treatments, as doing so undermines the trust between the two parties.    

While placebo should not be rejected as an outright useless treatment, the patient’s trust in their physician relies on knowing that the doctor is acting honestly, transparently, and in their best interest.  Knowing this allows patients to put more confidence in the actions of their doctor, thereby strengthening the relationship and improving health outcomes (Lynda A Anderson).  Despite this, there is little room for arguing against use placebos in clinical trials, especially phases II and III.  Unless a patient is being studied and compared to groups with different variables — like authentic treatment or placebo — physicians should not consider using placebos and must value honesty with their patients.

Citations

Clinical Trials and Human Subject Protection, accessed 3 Feb 2017, http://www.fda.gov/ScienceResearch/SpecialTopics/RunningClinicalTrials/

Daniel E Moerman, Wayne B Jonas. “Deconstructing the Placebo Effect and Finding the Meaning of Response,” Annals of Internal Medicine 136 (2002): 471-476.

Lynda A Anderson, Robert F Dedrick. “Development of Trust in Physician Scale: A Measure to Assess Interpersonal Trust in Patient-Physician Relationships,” Sage Journal 67 (1990).

This case tells the story of Amira Mullens, a woman hit by a drunk driver in a multi-vehicle accident while driving with her partner, Casey, and three-year-old daughter Samantha. While suffering the repercussions of the accident including extensive blood loss, discoloration of the face and lips, a collapsed lung, compromised breathing, and kidney damage, Mullens inquires about the state of her family members. Unbeknownst to Mullens, Casey past away. Afraid of negatively impacting Mullens’ surgery and post-operative care, the Nurses are hesitant to tell Mullens of Casey’s recent passing (Yeo). Should the nurses tell Mullens about the death of her partner, or should they refrain from doing so in an effort to increase her probability of survival?

Last week we read a case on Joe Mulroney, an individual that suffered a fatal reaction to an angiogram, a routine procedure with an extremely high success rate. Mulroney’s son argued that while the procedure may be wildly successful, his father deserved to know the complications prior to consenting to surgery (Thomas et al., 300-301). Like Mulroney’s son, I too thought that Joe deserved to know. I cited an example from my QTM class this past semester in which the professor asked us if we would like to know our risk of contracting cancer whether it be a 30% chance of risk or a 5% chance. The majority of the class said 5%. I argued that while I don’t think it would change my decision to go through with the procedure considering the alternative is death, I would like to make an informed decision.

At first glance, I thought that the case at hand mirrored Mulroney’s case, and that the physicians was obligated to tell Mullen’s the wealth of information they possessed. Mullen’s case is unlike Malroney’s in that Mullens’ case falls under the category of an emergency. Emergency, incompetence and waiver are the three categories in which health professionals are allowed to proceed without consent. In addition, “a physician may legitimately withhold information based on a sound medical judgement that divulging the information would potentially harm a depressed, emotionally drained, or unstable patient” (Beauchamp et al., 127). Since Mullens not only experienced a dramatic car crash, but is in dire need of surgery, she most definitely meets the qualifications to be considered as an unstable patient. Furthermore, numerous studies have investigated the effect of psychosocial factors, such as depression, social support, stress, etc. on surgical outcomes and have discovered a clear relationship between the two.

While it is true that nurses and physicians must build trustworthy relationships and that truth telling is important, I think that deception can be argued for if it falls in line with the patients’ best interests.

Beauchamp, Tom L., and James F. Childress. “Respect for Autonomy.” Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 1994. 125-31. Print.

Thomas, John E., Wilfrid J. Waluchow, and Elisabeth Gedge. “Case 10.3 Should Patients Be Informed of Remote Risks of Procedures?” Well and Good: A Case Study Approach to Health Care Ethics. 4th ed. Peterborough, Ontario: Broadview, 2014. 300-02. Print.

Yeo, M., A. Moorhouse and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics.

Dilemma:

In the case of Amira’s and Casey’s  car accident, the moral dilemma is whether to inform Amira of her partner’s death before she loses consciousness. It is the conflict between the patient’s autonomy, including her understanding of the situation, and nonmalefiecense, avoiding harm to the patient.

Analysis:

Amira ‘s right to know about the condition of her family is important. They should tell the truth and respect the patient’s autonomy, not limit the understanding of the patient. Trust between a physician and patient is essential. It is similar to the case, “Integrity and Nurses’ Relationship with Colleagues and Employers”. Nurses are expected to develop therapeutic, honest relationships. By telling the truth, according to Edwin in his medical journal, the doctor will help the patient “understand and deal with the difficult situations they may be facing thereby benefiting them and upholding the ethical principle of beneficence”.

In this case, it is important to specify the moral norm of “tell the truth”. Timing in disclosures must always be considered. Poor timing of difficult conversations may have a deleterious effect. Specifically, one should tell truth, at the right time. Another way to specify this moral norm is to “tell the truth unless the physician has compelling evidence that the consequences may cause severe harm to the patient”. With this specification, it is important for the nurses to balance the idea of whether the news will “cause severe harm to the patient”.

In this specific case, Amira is in a critical state and fighting for her life. Any more stress could “impair her capacity to survive the surgery and post- operative care in a coma” (Moorhouse and Khan 233). It is important to specify that the medical staff should avoid causing harm that is long- term and on a more serious degree. The nurses may be going against her right to understand the situation and causing some harm by performing the surgery, but they are doing so to increase the likelihood of her survival during and after the surgery.

Anxiety is common before surgery and causes mild symptoms, like irregular heartbeat and shortness of breath. According to Evans, anxiety before surgery is common, yet “excessive preoperative anxiety is associated with unfavorable physiologic responses, such as tachycardia, hypertension, cardiac arrhythmias, hyperventilation, and postoperative pain”. It is important for the surgeon and his or her team to be fully active and engaged with the patient during the surgery to ensure a safe procedure. An anxious patient may distract the staff or unintentionally answer questions incorrectly, thus misdirecting or misleading the staff during pre-and post-operative care. This could worsen the outcome. (Dr. Joseph M Rosenwald)

Another ethical concern to consider is the nurses’ role in informing Amira. The nurse may feel it is out of his or her focus of practice to release the information to the patient. It is up to the primary doctor of Casey to inform Amira. As Amira’s healthcare provider, the nurse may call upon the doctor to inform Amira herself or himself. In this case, the time is limited, so it may be more likely that the news would be handled after the surgery.

Finally, a therapist, has an overriding duty to give their patients the best chance of surviving a medical crisis. Informing the patient of the death of a loved one, while seeming urgent to the patient, may threaten their chances of survival in a difficult procedure. Disclosing information of that sort is best done by one professionally trained and in the most optimum fashion. It is important to mitigate the harm this news can cause. Moments before a critical surgery is probably not the right time for that conversation.

Citations

Davis-Evans, Chassidy. “Alleviating Anxiety and Preventing Panic Attacks in the Surgical Patient.” AORN Journal 97.3 (2013): 354-64. Association of PeriOperative Registered Nurses.AORN Inc., Mar. 2013. Web. 30 Jan. 2017.

Edwin, AK. “Don’t Lie but Don’t Tell the Whole Truth: The Therapeutic Privilege – Is It Ever Justified?” Ghana Medical Journal. Ghana Medical Association, Dec. 2008. Web. 30 Jan. 2017.

Moorhouse, Anne, Pamela Khan, and Patricia Rodney. “Case 3: Emergency and Trauma Nurses: When to Give Bad News.” Concepts and Cases in Nursing Ethics. By Michael Yeo. 3rd ed. Peterborough, Ont., Canada: Lewiston, NY, USA, 1991. 232-42. Print.

Rosenwald, Dr. Joseph M., DDS. “Anxious Patients in Surgery.” Telephone interview. 29 Jan. 2017.

Beauchamp and Childress talk about how we make decisions based on facts and values, but sometimes decision making becomes complicated when we consider abstract principles such as autonomy and non maleficence (Beauchamp and Childress, 13). The complication becomes whether we make the decision with autonomy as the ruling factor or non maleficence.  In “Emergency and Trauma Nurses: When to Give Bad News,” the ethical concern presented in this case is “when to tell the truth in situations when, given, the physical and psychological conditions, delivering devastating news might jeopardize the patient’s life, and possibly life” ( Yeo, Moorhouse, and Khan 232).  Presented is Amira and Casey and their daughter who were involved in a car accident. The daughter and Amira survive, but Casey did not. Amira is in critical condition and needs to go into surgery. Doctors and nurses are afraid that any upsetting news will worsen her conditions. While in this state, Amira asks the nurses about her daughter and her partner. Do they tell Amira that her partner died and risk losing her too? Or do they wait to tell her after her surgery? How do the nurses decide? Do they make the decision based on protecting Amira’s health? or do they make a decision based on their obligation to answer Amira’s question?

One side of the argument is that Amira should be told the truth because honesty is the best policy. Lying to Amira is not only unethical but it creates a dishonest relationship between her and the nurses. There is a possibility that Amira will be upset with the nurses for lying to her. As a result, Amira may no longer trust the nurses. She may shut down and never cooperate with the nurses and doctors during her recovery.  In addition, if the nurses do not tell Amira, then they are denying her information she requested. Withholding information from Amira is acting upon paternalism–not respecting her autonomy. Amira has every right to know about what happened to her family. Failing to tell the truth, is taking those rights away from her. Although the truth will indeed hurt Amira, the nurses who told her will be there to support her through the process.

The other side of the argument is to not tell Amira because the news may cost her her life. Amira’s conditions are already worsening ,so telling her the news will cause even more distress. Nurses are taught the principle of non maleficence, to chose the option that will cause little to no harm. Choosing to not tell Amira the truth is for the sake of protecting her health status and possibly saving her life . If Amira is told the truth about her partner’s death, there is a chance that the news will also kill her. Furthermore, Amira’s conditions deem her incompetent ; she is not in the right frame of mind to understand the news about the death of her partner.  Another aspect that needs to be take into consideration is the child. If Amira dies, then the daughter will be left with no parents.

I think the question of when to give  bad news depends on the state of  the patient. The news will hurt regardless, but the mental and physical state does play an important role. If I were to decide, I would chose to not tell Amira the truth because her life is at stake. Waiting to tell Amira when she is more stable is the best option because she can make sense of the situation a little better. In saving her life, Amira gets to live not only for her, but for her daughter too.

Works Cited

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford UP, 2009. Print.

Yeo, M., A. Moorhouse and P. Khan “Case 3: Emergency and Trauma Nurses: When to Give Bad News” Concepts and Cases in Nursing Ethics.

Withholding Information: An Introduction to the Moral Issue

Issues of truthfulness and disclosure are among the most difficult and delicate ethical issues for healthcare professionals. Nurses in trauma centers face distinct ethical challenges as questions arise about whether withholding information to patients is ever justified. After reading Tom L. Beauchamp’s “There Are Circumstances in Which a Doctor May Withhold Information” from Arp and Caplan’s Contemporary Debates in Bioethics, I will present the paternalistic and therapeutic privilege approaches to this case to suggest that trauma nurses and other healthcare professionals have an obligation to manage information in a way that “sometimes withholds information and at other times stages disclosures over time” (Arp and Caplan 409).

The Case

“Case 3: Emergency and Trauma Nurses: When to Give Bad News” explores the question of when to tell the truth in situations when, given the patient’s physical and psychological condition, delivering devastating news might potentially jeopardize a patient’s health, and possibly life. In this case,  Amira is driving on the highway with her partner, Casey, and their daughter, Samantha; they are hit by a drunk driver in a multi-vehicle accident.  Casey’s vital signs are absent, while Amira, unaware of her partner’s death, is in the trauma room in need of surgery. When she asks about Casey, the nurses fear that stress may further impair her capacity to survive the surgery; they are also afraid that she may die in the operating room without knowing the truth about her partner (Yeo, Moorhouse, and Khan).

The Best Response:

A. Paternalistic Approach

Paternalism is the intentional overriding or limitation of one person’s autonomous choices or actions by another person or institution, where the latter justifies the action-a nurse’s withholding information-by appeal to the goal of providing a benefit or of preventing or mitigating harm to the person whose choices or actions are limited or overridden (Arp and Caplan 413). The motivation is therefore “the beneficent promotion of physical or psychological health and welfare of those whose autonomous choice is limited or overridden” (Arp and Caplan 414).  The moral thesis is that as risk to Amira’s welfare increases, the likelihood that withholding information is justified correspondingly increases.

B. Caring for Patients Who Have Received Bad News: Therapeutic Privilege

The primary concern of emergency and trauma nurses should not at the onset be the disclosure of all available pertinent information. While some information can be delayed, some of it may justifiably never be mentioned (Arp and Caplan 415). The trauma nurse’s fundamental obligation at the beginning of the process of disclosure is to calm down and reassure Amira, while engaging sympathetically with her feelings and conveying the presence of a caring, knowledgeable medical authority (cf. Quill and Townsend, 1991). The nurse’s emotional investment in the feelings of the Amira should be joined with a detached evaluation of what the patient’s medical and informational needs are; cases in which the risk of harm and burden will be substantially increased if all pertinent information is disclosed call for a “skilled management of each item of information” (Arp and Caplan 415). Moreover, how should the trauma nurses decide how and when Amira should be told the bad news about her partner?

Based on the therapeutic privilege, there is a commonly understood and “morally intuitive difference” between lying to someone with the intention to deceive and withholding the truth from someone to “avoid a perceived negative, detrimental, or painful physical or psychological consequence” (Arp and Caplan 404). Considering Amira’s best interest, can disclosure of Casey’s death therefore be delayed justifiably?

Contemporary Issues: Skilled Management of the Truth — Not Always Justifiable

Harvard University’s Justice with Michael Sandel presents “A Lesson in Lying.” Sandel discusses the realm of freedom and the realm of necessity as well as the carefully worded denials in the Monica Lewinsky affair of Bill Clinton (~16 minutes).  Although skilled management of the truth is not always justifiable, in the case of Amira, the decision of a trauma nurse to withhold information is founded on the best interest of the patient. As Sendel discusses, in the light of Kant, is there something morally at stake in the distinction between a lie and a misleading, but true evasion? If so, is this adequate for rendering information withholding by healthcare professionals morally impermissible?

Works Cited

Arp, Robert, and Arthur L. Caplan. Contemporary Debates in Bioethics. Chichester, West Sussex: Wiley Blackwell, 2014. Print.

Quill, T, and Townsend, P. (1991). Bad news: Delivery, dialogue, and dilemmas. Archives of Internal Medicine, 151, 463-464.

Yeo, M., A. Moorhouse and P. Khan. “Case 3: Emergency and Trauma Nurses: When to Give Bad News.” Concepts and Cases in Nursing Ethics.

The question presented by Case 10.3 “should patients be informed of remote risks of procedures” seems to appeal to the “obvious” answer: yes, patients should be informed. The elements of the situation, however, are not so simple. I would like to consider the points: (1) risk of death and (2) full disclosure and trust.

What poses risks of death?

Many daily activities and interactions are likely to have some “remote risk of death” (Thomas, 300). There are common medical procedures that can cause death, things in your household that can kill you and your daily choices such as diet and exercise can lead to fatal chronic diseases. To name a few: walking, drinking alcohol, smoking cigarettes, taking the stairs, choking, getting bit by a dog, vehicular accidents, and exposure to forces of nature. According to Medical News Today, the top 10 reasons for death in America are heart disease, cancer, chronic respiratory diseases, unintentional injuries/accidents, stroke, Alzheimers, diabetes, influenza and pneumonia, kidney disease and suicide. There is even a show called 1000 Way to Die, which narrates silly, yet real, causes of death. So, what poses risks of death? Pretty much anything and everything.

Is there such thing as full disclosure?

What is the practicality of full disclosure? Realistically, is it feasible to truly explain to patient(s) a procedure or treatment to a level of comprehension comparable to the comprehension of a medical professional, who has dedicated years to studying and understanding these procedures/treatments? The complexity of health and medicine is so immense and great; this is a reason why within medical professions there are many different specializations. It is not feasible to expect one person to know everything. The act of going to professionals and seeking health care requires an automatic certain level of trust. We trust healthcare workers to act in the patient’s best interest, take care of our loved ones, fight infectious diseases, and “save” patients. We rely on these people with specialized profession because they know and understand their role better than those with less knowledge in their field of study.

In the case of Joe and the anesthesiologist, I believe the anesthesiologist did give full disclosure. Precondition threshold elements of competence and voluntariness are fulfilled, and consent elements of decision and authorization are also fulfilled. The only division under debate would be information elements including elements of disclosure and understanding. Yes, “patients have a right to be given full information about any procedure to which they are subjected,” (Thomas, 301) and yes, healthcare workers are “obligated to disclose a core set of information” (Beauchamp 125). But, the key word is CORE. In the case of Joe, death was not a CORE part of information. I disagree with Joe’s son that the anesthesiologist “show[ed] lack of respect for patients as persons” (Thomas, 301). Healthcare workers such as the anesthesiologist do their best to inform patients while “consider[ing] the burden of fear and distress placed on patients” (Thomas, 310). Restaurants do not warn customers the risk of choking and dying before they order. Car dealerships do not give statistics of vehicular death before selling you a car. The anesthesiologist does not overwhelm patients by listing every bullet point of information about a procedure. Plans, unfortunately, do not always proceed as planned, and unexpected events cannot always be anticipated.

So the big question: who is right—Joe’s son or the anesthesiologist? I wouldn’t go so far as to say one party or the other is “right”, but rather, the anesthesiologist is not in the wrong.

Questions (for us) to consider: would you rather be imposed with burden of fear or remain blissfully ignorant? Have you ever withheld information from someone else? Is Joe’s son merely looking for someone to blame in his mourning and sadness? How can healthcare professionals, patients, and their families better communicate with more compassion?

Citations:

Beauchamp, Tom L., and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York, NY: Oxford UP, 2001. Print.

“Danger of Death!” The Economist. The Economist Newspaper, 01 Sept. 2014. Web. 29 Jan. 2017.

Nichols, Hannah. “The Top 10 Leading Causes of Death in the US.” Medical News Today. MediLexicon International, 21 Sept. 2015. Web. 29 Jan. 2017.

Thomas, John E., and Wilfrid J. Waluchow. Well and Good: Case Studies in Biomedical Ethics. Peterborough: Broadview, 1987. Print.