A study (NEJM Dec. 23, 2005 issue “Disciplinary Action by Medical Boards and Prior Behavior in Medical School” Maxine A. Papadakis, M.D and others) had shown that bad behavior in the later years of practice appear to be related to bad behavior which had been observed while the doctor was still in medical school.
Codes of professional behavior have been written by medical schools for their students to follow during their years in school. What should codes of professional behavior contain which we present to our medical students as they start out in their medical education? My opinion is that these codes not only should look at defining acceptable and ethical behavior of these students as they work in their educational environment in the classroom and on the hospital wards but also to emphasize to them they represent a “look ahead” to how they are expected to behave years from now when they have the full responsibility for patient care.
Here are my “look ahead” criteria definitions of honesty, integrity, responsibility, reliability, accountability and respect for patients which should be incorporated into medical schools codes of behavior, hopefully making the students understand why as students these elements of professionalism are necessary to observe now, identifying and correcting bad behavior to prevent loss of patients and even medical license in the future.
Honesty and Integrity:
Honesty and Integrity means Trust and Trust is the fiduciary responsibility that we must give to our patients and for which they expect from us.
Responsibility:
Responsibility includes the care of the patient that trumps the physician's self-interest.
Reliability:
Reliability means that the patient can depend on the doctor's medical skills and behavior to meet the challenges of patient care.
Accountability:
Accountability means that the physician is in the service of the patient and outcomes including medical errors and unattained goals or promises must be told and explained by the physician to the patient and whatever personal responsibility the physician holds should be accounted for.
Respect for Patients:
Respect for Patients means respect for their welfare as well as their autonomy. In addition, there must be respect for the patient's privacy (including issues of patient modesty along with any written or spoken personal details of the patient's life). There must be respect for the patient's religious beliefs, culture, their own personal view of the quality of their life and respect that the patient may be part of a family or other community.
Let me know if you have any suggestions about other points we should be teaching our students with regard to professionalism in medicine. ..Maurice.
Thursday, August 31, 2006
Wednesday, August 30, 2006
"Going by the Numbers":When is Enough,Enough?
I received a very poignant e-mail today from a daughter about her father. Though in a number of threads, I have tried to cover the issue presented,I felt that this description brings home the concern some families have about their ill loved one and was appropriate for initiation of a new thread.
Dear Doctor,
I stumbled upon your Web site via an effort to make some moral sense of what is happening to my dad. Six months ago, at 81 years old, he was bowling three times a week, taking my 8-year-old son to school every morning because he enjoyed it and maintaining weekly bowling and lunch dates with my son and daughter, respectively. Tonight, he lies in CCU at the local hospital. It's day 19 since my mother, eldest daughter and myself made the decision to call 911. A few months previously, we tried to talk to him into seeing a doctor because of various symptoms that resembled prostate cancer and kidney disease. But, having consulted a doctor many years previous for various digestive disorders and having extremely painful, invasive and, to him, humiliating procedures, he opted out. He was adamant. He did not want to see a doctor.
... he remains hospitalized, skin and bones, enduring dialysis and tubes connected to every conceivable bodily oriface. Ironically, while he constantly expresses his fervent desire to go home, he has never questioned any of us about his presence in the hospital. His doctor initially told me that, by the numbers, he should have been dead. But as I see him beg for food and water that he can't have because of an as yet undiagnosed GI blockage...as I move his painfully cramping legs that once took him down the bowling lanes with such grace and precision...and as I see him grow progressively more angry and delusional, and not at all like himself, I can't help but wonder the futility of medical science. The doctor tells me that, of the plethora of problems my dad suffers from, none are "terminal." Yet, I know, without question, that if our beloved pet, as those in the past, was in such misery...we would feel obliged to do the right thing. Why is it that medical practitioners persist in "going by the numbers"... when is enough, enough?
Judy
Judy, I can't explain, in your dad's case, the physicians' need to continue supportive treatment. I do know that if an adult has the capacity to make medical decisions or if not, that members of the family who know the patient's desires well can request as surrogates that the physicians stop unwanted, energetic life-supportive therapy and provide only effective comfort care.
"When is enough,enough?". Finally, the answer should be set by an informed patient or an informed surrogate. Believe it or not, simply awaiting miracles represents only wishful thinking and should not trump the desire and need for the patient's peace and comfort. ..Maurice.
Dear Doctor,
I stumbled upon your Web site via an effort to make some moral sense of what is happening to my dad. Six months ago, at 81 years old, he was bowling three times a week, taking my 8-year-old son to school every morning because he enjoyed it and maintaining weekly bowling and lunch dates with my son and daughter, respectively. Tonight, he lies in CCU at the local hospital. It's day 19 since my mother, eldest daughter and myself made the decision to call 911. A few months previously, we tried to talk to him into seeing a doctor because of various symptoms that resembled prostate cancer and kidney disease. But, having consulted a doctor many years previous for various digestive disorders and having extremely painful, invasive and, to him, humiliating procedures, he opted out. He was adamant. He did not want to see a doctor.
... he remains hospitalized, skin and bones, enduring dialysis and tubes connected to every conceivable bodily oriface. Ironically, while he constantly expresses his fervent desire to go home, he has never questioned any of us about his presence in the hospital. His doctor initially told me that, by the numbers, he should have been dead. But as I see him beg for food and water that he can't have because of an as yet undiagnosed GI blockage...as I move his painfully cramping legs that once took him down the bowling lanes with such grace and precision...and as I see him grow progressively more angry and delusional, and not at all like himself, I can't help but wonder the futility of medical science. The doctor tells me that, of the plethora of problems my dad suffers from, none are "terminal." Yet, I know, without question, that if our beloved pet, as those in the past, was in such misery...we would feel obliged to do the right thing. Why is it that medical practitioners persist in "going by the numbers"... when is enough, enough?
Judy
Judy, I can't explain, in your dad's case, the physicians' need to continue supportive treatment. I do know that if an adult has the capacity to make medical decisions or if not, that members of the family who know the patient's desires well can request as surrogates that the physicians stop unwanted, energetic life-supportive therapy and provide only effective comfort care.
"When is enough,enough?". Finally, the answer should be set by an informed patient or an informed surrogate. Believe it or not, simply awaiting miracles represents only wishful thinking and should not trump the desire and need for the patient's peace and comfort. ..Maurice.
Monday, August 28, 2006
Fertility Treatment of a Lesbian: Can A Physician Refuse?
Here is the scenario:
In the United States of America it is accepted that all physicians have a right to choose their own patients except in the case of a medical emergency.
In the United States of America , no physician receiving government funding may discriminate against potential patients on the basis of race ,color, religion or national origin and in the state of X, the anti-discrimination laws include, as do some other states, gender and sexual orientation.
Miss K.. has gone to fertility doctor F, who is a Medicare provider, with her same sex partner Miss J. requesting that Doctor F. provides fertility treatment so that Miss K. can become pregnant by artificial insemination. Both Miss K. and Miss J. explain their desire to have a child.
Doctor F. has strong personal religious views against abortion (which he would never perform) and also about inducing a pregnancy in a homosexual. He rejects her request and subsequently Miss K. sues Dr. F. in X state court charging that under state X law, Dr. F.’s refusal to treat represented illegal discrimination on the basis of sexual orientation.
That’s the story. Now what is your ethical and legal interpretation of this scenario? . What if Dr. F. is also a general internist and has been treating Miss K as his patient. for various medical conditions over the past several years prior to her making the request?
(I want to acknowledge this thread was born out of an article “May Doctors Refuse Infertility Treatments to Gay Patients?” by Jacob M. Appel in the July-August 2006 issue of the Hastings Center Report.) ..Maurice.
In the United States of America it is accepted that all physicians have a right to choose their own patients except in the case of a medical emergency.
In the United States of America , no physician receiving government funding may discriminate against potential patients on the basis of race ,color, religion or national origin and in the state of X, the anti-discrimination laws include, as do some other states, gender and sexual orientation.
Miss K.. has gone to fertility doctor F, who is a Medicare provider, with her same sex partner Miss J. requesting that Doctor F. provides fertility treatment so that Miss K. can become pregnant by artificial insemination. Both Miss K. and Miss J. explain their desire to have a child.
Doctor F. has strong personal religious views against abortion (which he would never perform) and also about inducing a pregnancy in a homosexual. He rejects her request and subsequently Miss K. sues Dr. F. in X state court charging that under state X law, Dr. F.’s refusal to treat represented illegal discrimination on the basis of sexual orientation.
That’s the story. Now what is your ethical and legal interpretation of this scenario? . What if Dr. F. is also a general internist and has been treating Miss K as his patient. for various medical conditions over the past several years prior to her making the request?
(I want to acknowledge this thread was born out of an article “May Doctors Refuse Infertility Treatments to Gay Patients?” by Jacob M. Appel in the July-August 2006 issue of the Hastings Center Report.) ..Maurice.
Saturday, August 26, 2006
Playing Doctor vs Being a Doctor
When we all started playing doctor around the time we were in Kindergarten, it was all about curiosity. We learned how our bodies were the same as some and different than others. There was no responsibility for our actions or for our “patient”. The requirements for a licensed physician are much different. Curiosity and self-interest without responsibility is not acceptable. Unfortunately there are some physicians who are in practice, as reported by angry patients on this blog, where curiosity and self-interest trump professional behavior and patient responsibility. In essence, these physicians are only playing doctor.
Students are selected to enter medical school by admissions committees. I have never participated on admissions committees (my only experience was being interviewed by one many years ago). However, there are general criteria which are used including amongst others, college grades both science and non-science courses, medical school admission test scoring, references, social activities including humanitarian and medically oriented participation, how the student communicates their understanding of medicine and their interest in the profession and the general behavior of the student during the interview. But despite all the screening, wrong students are selected and finally end up only playing doctor not being one. Perhaps, the committees are looking at the wrong factors or asking the wrong questions.
I would like to challenge my visitors (most likely experienced patients) to provide us with their own criteria that they think would be very important ones for medical school admission committees to consider when they are evaluating a medical student for admission. Any suggestions? ..Maurice.
Students are selected to enter medical school by admissions committees. I have never participated on admissions committees (my only experience was being interviewed by one many years ago). However, there are general criteria which are used including amongst others, college grades both science and non-science courses, medical school admission test scoring, references, social activities including humanitarian and medically oriented participation, how the student communicates their understanding of medicine and their interest in the profession and the general behavior of the student during the interview. But despite all the screening, wrong students are selected and finally end up only playing doctor not being one. Perhaps, the committees are looking at the wrong factors or asking the wrong questions.
I would like to challenge my visitors (most likely experienced patients) to provide us with their own criteria that they think would be very important ones for medical school admission committees to consider when they are evaluating a medical student for admission. Any suggestions? ..Maurice.
Friday, August 25, 2006
“Physician, Heal Thyself”: But Is That Possible?
My visitor, Jaine, in response to the last thread asking for contributions of topics, presented a topic that I have touched upon in various threads but I think is worthy of devoting one specifically to this issue here and now. Jaine wrote:
A topic of interest to me is whether doctors are capable of monitoring their own profession, in an ethical manner, in a punitive system? Only extremely ethical people are capable of remaining objective and honest in a system that punishes members for being honest about mistakes. It is ridiculous, in my opinion, for doctors to promote themselves as being capable of self-governing in an ethical manner in a punitive system, when doctors are subject to human nature, as well as suffering from such things as personality disorders, to the same degree as the rest of the population. The approach encourages setting the standard of care very low to protect even the least skilled doctors instead of demanding doctors develop and maintain a high skill level.
“Critics of the current system say it discourages medical staff from honestly admitting errors, for fear of lawsuits.” Link.
“In Sweden, when a patient suffers avoidable injury, whether through gross negligence, such as a botched surgery, or through a more understandable but avoidable mistake, such as a misdiagnosis or medication error, the patient—usually with help from the doctor's office—fills out a form requesting compensation.” Link.
If anyone has a subscription to the New England Journal of Medicine I’d appreciate being able to read the article offered at entitled “Medical Errors and Medical Narcissism”
The case of Dr. Michael Swango, who is suspected of murdering between 35-60 patients, provides an example that begs questions be asked around what the priority and mindset of the medical system is. Is it to protect doctors or protect patients?
“After Swango's arrest, Stewart told the New York Times, "(His) case shows that the medical establishment will blindly trust the word of a fellow doctor over the word of other witnesses and that the medical profession cannot adequately police itself." Link.
So the issue Jaine brings up is essentially what I summarized in the title of this posting: “Physician Heal Theyself”: But Is That Possible? “Physician Heal Thyself” is a biblical proverb meaning that people should take care of their own defects and not just correct the faults of others.: But do any of my visitors think that physicians have the strength of professionalism and ethics to do that on their own? ..Maurice.
A topic of interest to me is whether doctors are capable of monitoring their own profession, in an ethical manner, in a punitive system? Only extremely ethical people are capable of remaining objective and honest in a system that punishes members for being honest about mistakes. It is ridiculous, in my opinion, for doctors to promote themselves as being capable of self-governing in an ethical manner in a punitive system, when doctors are subject to human nature, as well as suffering from such things as personality disorders, to the same degree as the rest of the population. The approach encourages setting the standard of care very low to protect even the least skilled doctors instead of demanding doctors develop and maintain a high skill level.
“Critics of the current system say it discourages medical staff from honestly admitting errors, for fear of lawsuits.” Link.
“In Sweden, when a patient suffers avoidable injury, whether through gross negligence, such as a botched surgery, or through a more understandable but avoidable mistake, such as a misdiagnosis or medication error, the patient—usually with help from the doctor's office—fills out a form requesting compensation.” Link.
If anyone has a subscription to the New England Journal of Medicine I’d appreciate being able to read the article offered at entitled “Medical Errors and Medical Narcissism”
The case of Dr. Michael Swango, who is suspected of murdering between 35-60 patients, provides an example that begs questions be asked around what the priority and mindset of the medical system is. Is it to protect doctors or protect patients?
“After Swango's arrest, Stewart told the New York Times, "(His) case shows that the medical establishment will blindly trust the word of a fellow doctor over the word of other witnesses and that the medical profession cannot adequately police itself." Link.
So the issue Jaine brings up is essentially what I summarized in the title of this posting: “Physician Heal Theyself”: But Is That Possible? “Physician Heal Thyself” is a biblical proverb meaning that people should take care of their own defects and not just correct the faults of others.: But do any of my visitors think that physicians have the strength of professionalism and ethics to do that on their own? ..Maurice.
Tuesday, August 22, 2006
Visitor Generated Bioethical Issues: Find One, Research One and Post It Here
As someone really interested in the discipline called bioethics, I keep looking around me and looking for ethical issues, which have been popular but not fully resolved, or ethical issues about which many in society are not really aware. Then there are the ethical dilemmas which over the years has been settled by consensus but as social and political and technologic properties within society have progressively changed, these issues are reopened like a almost healed wound that is again abraded. So I keep thinking, what would be interesting next to put on my blog. There are many possibilities but then these are my possibilities. I can state with certainty that I cannot think of all the issues that are perplexing others. This is a democratic blog (notice the small d), therefore I thought now, maybe I should change the format of this blog a bit at times and have my visitors generate a new, yet undiscussed, bioethical issue; a matter of visitor creativity.
Skim through my archives or use the “Search This Blog” service provided by Google located at the top left hand corner of the page to see if the topic was covered previously. If you have a new topic or a new twist of a previously posted topic, post your comments here after you have done a bit of preliminary research on the topic. I might just start up a new thread with your commentary as the lead text of the thread. ..Maurice.
Skim through my archives or use the “Search This Blog” service provided by Google located at the top left hand corner of the page to see if the topic was covered previously. If you have a new topic or a new twist of a previously posted topic, post your comments here after you have done a bit of preliminary research on the topic. I might just start up a new thread with your commentary as the lead text of the thread. ..Maurice.
Saturday, August 19, 2006
Not Telling Bad News: An Ethical Dilemma
In my now inactive "Bioethics Discussion Pages", I presented a scenario which provides a true dilemma with regard to the telling of bad news to a patient. The conflict is between the ethics of a patient's culture and the law and ethics and standards of practice in the "American culture". The most recent responses by visitors to the "Pages" are at the top of the posting. What would be your response? ..Maurice.
Not Telling Bad News
The patient, Mrs. F., is a 66 year old female mother of 4 sons and 5 daughters, who was born in Italy and lived there until 2 years ago when she moved to a northern city in the USA to be closer to 7 of her children who are now residents in America and live not far from each other. The patient is now living with her eldest daughter. The patient’s husband died some 10 years ago. The patient speaks and understands some English but is not at all fluent.
In the past several months, the patient has developed abdominal pain, nausea and a 15-pound weight loss from her usual 150 pounds. She was taken to a physician, Dr. G., the private physician of her daughter. Dr. G. examined Mrs. F, ordered tests and finally requested a gastro-intestinal specialist consultation. With the understanding by Mrs. F. that some tests needed to be done to find out the cause of her pain, she accepted the tests. By these tests including a biopsy, Mrs. F was found to have an ulcer in the stomach that was a cancer. According to the gastroenterologist the cancer could be surgically removed but the patient needed a surgical consult to determine how much of the stomach needed to be removed.
Before Dr. G spoke to the patient, the elder daughter talked to him and requested the diagnosis. He told her about the suspected stomach cancer. She then insisted that he not tell her mother that she had a cancer. She said that in her Italian culture these serious matters belonged to the knowledge and decision of the family and that the patients were not told since they might be harmed by the information through emotional fright and worries and as a consequence might not try to get better. She said she and the rest of the family would be the ones to be informed about the prognosis and treatment and the family would decide and give informed consent for the treatments. She was very emphatic about this directive she gave the physician. Two other family members present at the time confirmed what their sister said. The physician told them that Mrs. F was no longer in Italy and that in this country it was ethically and even legally wrong not to tell the patient what she had and not to get her own informed consent for the surgery and subsequent treatments. After much discussion with the family, Dr. G. suggested he go and ask the patient how much she wanted to know about her illness and what needs to be done. The daughter and family refused for the doctor to speak to the patient about this matter since they feared their mother might infer a bad diagnosis.
What should Dr. G. or any other doctor responsible for this patient do?
---- THE DISCUSSIONS ----
Date: Fri, Jul 16, 2004 1:40 PM From: monicawiest@shaw.ca To: DoktorMo@aol.com
It is true that the context of practice is North America, not Italy. Consequently, the law and ethics that guide clinical practice here must be seriously considered. As such, we cannot forget the principles of patient autonomy, beneficence, disclosure, and consent: the patient has a right to information to make informed choices. The patient also has the right to forego information and I think that the doctor's responsibility is to delicately find out how much the patient wishes to know. Autonomy also means respecting and working with a patient's beliefs and culture as much as possible. Relating to beneficence, would telling the patient cause her more harm? Most commentators don't think so, but if they don't have the same point of reference as the patient, how do they know? It strikes me that the challenge is not what the doctor should do, but HOW she or he finds out what the patient wants. Hopefully this doctor was taught some communication skills. The children may be right and so be it, or they may be wrong and then patient can be informed.
Date: Sun, Aug 4, 2002 12:27 AM From: cody_carlson@msn.com To: DoktorMo@aol.com
At first glance there may seem to be a dilemna here for Dr. G. After a moments thought, however, any such dilemna proves illusory. Mrs. F is the patient, not her family. Dr. G is the physician, not Mrs. F's family. Mrs. F has rights to the information regarding her health. The physician has the right to inform his patient as well. I'm not sure that any mentally stable person would want to be ignorant about their illness. Though one may not want bad news, it's certainly better than no news.
Let us not forget the gravity of the term, "rights" in this context. How often do we confuse rights with sole privilages? Remember that our duties and responsibilities in addition to our privilages give us our rights. Our right to act is not always just something we have the choice of doing, but also duties we must perform and responsibilities we must be held accountable for.
Having to disregard family/cultural tradition may not be easy, but Dr. G's responsibility as a physician is clear.
Date: Tue, Jul 23, 2002 9:59 AM From: mstern777@yahoo.com To: DoktorMo@aol.com
The doctor has an ethical dilemma. Is his responsibility to the patient or to the family of the patient? I would answer that in this case it is to the patient, (sometimes families have bad intentions or are ignorant or both). His obligation is to inform the patient. His skill as doctor to do so in a kindly supportive and understanding way is now put to the test. This meeting may be had with the family present, if the patient wants that.
Ultimately we are all prisoner's of our culture. If it was an ethical requirement to treat people form a different culture in the same manner that they would be treated were they still in that culture well... you can imagine the doctor putting on the voodo feathers and killing a chicken because that the way it was done in the patients old country.
This particular patient is not described as mentally incapacitated in any way only having a language fluency problem. This can be over come with a translator or by bringing in a doctor fluent in Italian. Bad news is bad news and no amount of cover up will make it go away. I believe some studies have show that the not-knowing the sense that things are going badly but nobody is telling me what is going on is more stressful, ultimately, than knowing the bad news and moving on to dealing with it or making peace with the outcome.
Michael Stern
Date: Tue, Jul 2, 2002 8:48 PM From: r_l_eaves@icehouse.net To: DoktorMo@aol.com
Of course the doctor should tell the patient of the situation that she is in...he should have told her before he told her daughter...then there would be no dilemma to begin with!!!!
Date: Tue, Jul 2, 2002 1:44 PM From: JeriNrich@aol.com To: DoktorMo@aol.com
Under the umbrella of veracity and autonomy (self-determination)the patient must be told. There are precious few times that I could think of where the patient should be lied to. Throw in the concepts of least harm/ most good as well as cultural relativism serve to strengthen my resolve. Richard Cherrin
Not Telling Bad News
The patient, Mrs. F., is a 66 year old female mother of 4 sons and 5 daughters, who was born in Italy and lived there until 2 years ago when she moved to a northern city in the USA to be closer to 7 of her children who are now residents in America and live not far from each other. The patient is now living with her eldest daughter. The patient’s husband died some 10 years ago. The patient speaks and understands some English but is not at all fluent.
In the past several months, the patient has developed abdominal pain, nausea and a 15-pound weight loss from her usual 150 pounds. She was taken to a physician, Dr. G., the private physician of her daughter. Dr. G. examined Mrs. F, ordered tests and finally requested a gastro-intestinal specialist consultation. With the understanding by Mrs. F. that some tests needed to be done to find out the cause of her pain, she accepted the tests. By these tests including a biopsy, Mrs. F was found to have an ulcer in the stomach that was a cancer. According to the gastroenterologist the cancer could be surgically removed but the patient needed a surgical consult to determine how much of the stomach needed to be removed.
Before Dr. G spoke to the patient, the elder daughter talked to him and requested the diagnosis. He told her about the suspected stomach cancer. She then insisted that he not tell her mother that she had a cancer. She said that in her Italian culture these serious matters belonged to the knowledge and decision of the family and that the patients were not told since they might be harmed by the information through emotional fright and worries and as a consequence might not try to get better. She said she and the rest of the family would be the ones to be informed about the prognosis and treatment and the family would decide and give informed consent for the treatments. She was very emphatic about this directive she gave the physician. Two other family members present at the time confirmed what their sister said. The physician told them that Mrs. F was no longer in Italy and that in this country it was ethically and even legally wrong not to tell the patient what she had and not to get her own informed consent for the surgery and subsequent treatments. After much discussion with the family, Dr. G. suggested he go and ask the patient how much she wanted to know about her illness and what needs to be done. The daughter and family refused for the doctor to speak to the patient about this matter since they feared their mother might infer a bad diagnosis.
What should Dr. G. or any other doctor responsible for this patient do?
---- THE DISCUSSIONS ----
Date: Fri, Jul 16, 2004 1:40 PM From: monicawiest@shaw.ca To: DoktorMo@aol.com
It is true that the context of practice is North America, not Italy. Consequently, the law and ethics that guide clinical practice here must be seriously considered. As such, we cannot forget the principles of patient autonomy, beneficence, disclosure, and consent: the patient has a right to information to make informed choices. The patient also has the right to forego information and I think that the doctor's responsibility is to delicately find out how much the patient wishes to know. Autonomy also means respecting and working with a patient's beliefs and culture as much as possible. Relating to beneficence, would telling the patient cause her more harm? Most commentators don't think so, but if they don't have the same point of reference as the patient, how do they know? It strikes me that the challenge is not what the doctor should do, but HOW she or he finds out what the patient wants. Hopefully this doctor was taught some communication skills. The children may be right and so be it, or they may be wrong and then patient can be informed.
Date: Sun, Aug 4, 2002 12:27 AM From: cody_carlson@msn.com To: DoktorMo@aol.com
At first glance there may seem to be a dilemna here for Dr. G. After a moments thought, however, any such dilemna proves illusory. Mrs. F is the patient, not her family. Dr. G is the physician, not Mrs. F's family. Mrs. F has rights to the information regarding her health. The physician has the right to inform his patient as well. I'm not sure that any mentally stable person would want to be ignorant about their illness. Though one may not want bad news, it's certainly better than no news.
Let us not forget the gravity of the term, "rights" in this context. How often do we confuse rights with sole privilages? Remember that our duties and responsibilities in addition to our privilages give us our rights. Our right to act is not always just something we have the choice of doing, but also duties we must perform and responsibilities we must be held accountable for.
Having to disregard family/cultural tradition may not be easy, but Dr. G's responsibility as a physician is clear.
Date: Tue, Jul 23, 2002 9:59 AM From: mstern777@yahoo.com To: DoktorMo@aol.com
The doctor has an ethical dilemma. Is his responsibility to the patient or to the family of the patient? I would answer that in this case it is to the patient, (sometimes families have bad intentions or are ignorant or both). His obligation is to inform the patient. His skill as doctor to do so in a kindly supportive and understanding way is now put to the test. This meeting may be had with the family present, if the patient wants that.
Ultimately we are all prisoner's of our culture. If it was an ethical requirement to treat people form a different culture in the same manner that they would be treated were they still in that culture well... you can imagine the doctor putting on the voodo feathers and killing a chicken because that the way it was done in the patients old country.
This particular patient is not described as mentally incapacitated in any way only having a language fluency problem. This can be over come with a translator or by bringing in a doctor fluent in Italian. Bad news is bad news and no amount of cover up will make it go away. I believe some studies have show that the not-knowing the sense that things are going badly but nobody is telling me what is going on is more stressful, ultimately, than knowing the bad news and moving on to dealing with it or making peace with the outcome.
Michael Stern
Date: Tue, Jul 2, 2002 8:48 PM From: r_l_eaves@icehouse.net To: DoktorMo@aol.com
Of course the doctor should tell the patient of the situation that she is in...he should have told her before he told her daughter...then there would be no dilemma to begin with!!!!
Date: Tue, Jul 2, 2002 1:44 PM From: JeriNrich@aol.com To: DoktorMo@aol.com
Under the umbrella of veracity and autonomy (self-determination)the patient must be told. There are precious few times that I could think of where the patient should be lied to. Throw in the concepts of least harm/ most good as well as cultural relativism serve to strengthen my resolve. Richard Cherrin
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