Physician Paternalism: Not Telling the Truth

To give you some insight into what represents physician paternalistic behavior, I can present the following scenario, which is only an example representing that which has been practiced in the past and may still be practiced.



A) The physician has found, on routine x-ray of the chest of his patient, a shadow which to the physician is suspicious for cancer of the lung. When describing the chest film to the patient, the doctor, however, does not mention the abnormality rationalizing that since he had yet to review the film with a radiologist, which might take a day or two, he would keep his suspicions to himself until the finding was confirmed. The physician felt that until the radiologist confirmed his suspicions it would be beneficent for the patient if unnecessary emotional upset could be avoided.



Would you find this rationale acceptable? If not and you were the physician, what would you say to the patient? If you were the patient, how would you feel about the physician if you discovered that the physician did not tell the truth?



B. Scenario A continues. On consultation with the radiologist several days later, the radiologist could not explain the shadow and advised that the patient obtain a CAT scan of the chest for clarification of the finding. The physician, considering that if a repeat chest film does not show the shadow and realizing that the CAT scan study might cost the patient $1000, decides on his own to order a repeat chest film which costs perhaps 20 times less. He feels that he is doing good for the patient by saving the patient the expense. Also he decided that if no shadow appears, a CAT scan would have been unnecessary. If the shadow was still present then a CAT scan could be ordered later. The physician calls the patient and simply tells him that another chest film is necessary, since on reviewing the film again, he felt the film was of poor quality but does not describe the consultation or advice by the radiologist.



Is the physician doing good for the patient by saving the patient money for a procedure which the physician, himself, feels may not be necessary? Should the physician have now informed the patient about the shadow on the first film and his review with the radiologist? How should the physician explain his previous lack of disclosure? Should the physician have revealed to the patient the advice of the radiologist before ordering another chest film? Who should be making the decisions regarding cost vs. effectiveness of diagnostic tools?