When you screw up...

[aKGDH]

Intouch: Whatever. Honestly, the point of bringing up ethics questions is to spark debate, seeing as how there will always be different opinions. What I got out of everyone else's posts is that the truth should be always be told. I gave exceptions to when the truth should not be told, which no one supported. That, in case you are a bit of an idiot, was the entire point of my argument --Truthtelling IS NOT BLACK AND WHITE. If that's also what everyone else thinks, then I guess there's nothing left to argue about. I simply wanted to highlight the complexities of truthtelling and how its not just a one-liner of 'Yes, I would always tell my patient the truth' when asked such a question in an interview.

[rmorelan]

Intouch: Whatever. Honestly, the point of bringing up ethics questions is to spark debate, seeing as how there will always be different opinions. What I got out of everyone else's posts is that the truth should be always be told. I gave exceptions to when the truth should not be told, which no one supported. That, in case you are a bit of an idiot, was the entire point of my argument --Truthtelling IS NOT BLACK AND WHITE.

 

I would agree with that - I feel the base position to take is one of full disclosure and only if one of the those exceptions I mentioned apply can a doctor (with full consultation where possible with other doctors) employ any form of deception.

 

I was trying to move the debate along a bit actually. Take the case you originally presented from doing right (which the court had to make a LEGAL finding on, rather than a ethical one):

 

For example, if surgery is done and the surgeon accidentally leaves something inside the patient that does not belong but does not pose any danger to the patient's health, he does not need to tell the patient. The point is to prevent any unnecessary concern on the patient's part. However, if the situation is one in which the patient may be harmed if he is not made aware of the truth, the truth should be told, but tactfully such that the physician-patient relationship is not tarnished. Trust between the two should still be maintained in order to provide the patient with the best possible follow-ups.

 

Of the four possible considerations for using deception only therapeutic privilege could possibly apply here. However I would argue there is no serious mental or physical harm that would result from truth telling in this case, so the doctor cannot decide not to tell the patient. Further more eventually the material left in will likely be discovered (you may not know yet but all sponges for instance have radio marking on them that appear in an exam, so they will be very likely discovered in the future.). How will the doctor trust relationship be affected by subsequent discovery that a mistake was made? How will it be made worse if it is discovered the doctor knew about the error? How does this withholding of information help the profession, or does it appear that doctors routinely "cover their asses" by not revealing the truth?

 

This being said I am sure we can construct and debate the types of scenarios deceptions might be ethically employed. Good practice for interviews

[Leon]

In addition, metal stuff in the body may be picked up by metal detectors at US airports.

 

 

I can't even begin to imagine the consequences of THAT.

[Jochi1543]

In addition, metal stuff in the body may be picked up by metal detectors at US airports.

 

 

I can't even begin to imagine the consequences of THAT.

 

I am generally unsure of how you could be 100% confident that leaving a specific item inside a patient will be absolutely harmless. It's not like they have a dozen peer-reviewed studies on that, lol.

[A-Stark]

Originally Posted by aKGDH

 

No, you missed the point of my example. The patient has Alzheimer's, meaning he may be considered to be an incapable patient. The role of a physician is to do what he can to encourage patient autonomy (which the patient lacks if he is mentally unstable) and if this involves telling the nurse to surreptitiously give an uncooperative patient his meds, then so be it. Of course, it is necessary to explain this action and obtain consent from his family as well. But in this instance, the truth does not work when the patient is obviously not capable of understanding it.

 

So if the patient is not competent to consent to treatment, does that mean you'd avoid telling the family if you left a sponge or packing forceps inside him after closing? To avoid worrying them?

[aKGDH]

I don't know. I suppose it would be necessary to inform the family. Excessive worry is only cited as a reason not to tell the patient when you think there is a reason the truth may cause harm to the self or to others.

[aKGDH]

aKGDH, you are the one missing the point if you think that we all believe that truth telling is black or white. OBVIOUSLY there are shades of gray. OBVIOUSLY. I simply feel that you are giving it more shades of gray than should be merited, and feel that sometimes it is made black and white by the medico-legal dimension.

lol well obviously you don't seem to agree with the shades of grey that I've pointed out. I don't think they are 'too' grey since they are valid scenarios that you still have not refuted.

 

Mistakes happen, and I am pretty sure a lot of patients would have respect for a doctor of s/he came out honestly and said we left something in and have to go back and get it. If that isn't enough, the mere fact that it is completely unprofessional to just go "oops" and sweep your problems under the rug (so to speak), should be enough impetus to have you tell the truth.

Yes most patients would want to be told mistakes if they were made. Most does not equal all. I'm talking only about the few patients who would rather not know or cannot handle the truth due to mental instability.

 

 

Anyway that's the last say for me on the matter. I still feel that some are not understanding my point and I don't really feel like repeating my points or getting called 'thick' for having a different opinion. So tootles until the next ethics debate.

[MSc-microbiology]

Never did I say that was what physicians had the right to do. I am merely pointing out situations where truthtelling is not the best option.

 

 

Your example has nothing to do with the examples that I gave. In the examples that I gave, the physician does his best to ensure that the patient gets honesty and respect, and if this involves withholding some or all of the truth FOR THE BETTERMENT OF THE PATIENT, then that's what should be done. Should you tell the truth to an emotionally unstable patient whom you believe may commit suicide or go on a killing spree should they learn the truth? Should you tell the truth to a patient who has previously expressed not wanting to know the entire truth?

 

Not telling the truth DOES NOT equate disrespecting a patient. Rather, it's thinking outside the box and understanding that "always tell the truth" is not just some rule to blindly follow.

 

Once again YOU are deciding what is for the "betterment of the patient" instead of the patient (or their proxy decision maker) which IS paternalistic. You might want to think about the points many of these folks are bringing up. Many of these people are Residents, Clerks, Med Students, as well as pre-Meds. Some have practical experience with this topic already.

 

When and if you become a physician you WILL eventually have to weigh what YOU think is best for the patient versus what the PATIENT might think is best. More often than not, the patient may not agree with you and except for very rare circumstances it is your responsibility to respect their decision. It is exceedingly rare to be able to justify not telling the truth, from a legal, ethical, and moral standpoint.

 

By not disclosing a mistake, despite your believing the mistake is harmless, you are both LYING to the patient and robbing them of their right to know/decide their healthcare.

[scrub]

intouch, I think you nailed it with:

 

"I think some of what you are missing is the distinction between practical outcomes, and the moral obligations we have to one another as human beings."

 

Can anyone think of an example where deception surrounding a hospital error is beneficial (or perhaps least detrimental) to a patient? One that utilizes the beneficence over autonomy argument? (assuming competent patient)

 

I tried writing out a scenario but by the end I wasn't convinced it was justified...

 

Edit: The problem I run into when approaching this is - If the error is no big deal then the pt won't freak out, therefor you tell them because there is no question of negative beneficence. If it IS a big deal then you HAVE to follow up ("I forgot ______ so now you might be at risk of _____") so what are you going to do something further to the patient without them knowing why? That OR you don't follow up and they get an MRI and a pair of forceps comes flying out of their stomach. Any ideas of when deception regarding an error would be justifiable?

[dr_horrible]

Never did I say that was what physicians had the right to do. I am merely pointing out situations where truthtelling is not the best option.

 

 

Your example has nothing to do with the examples that I gave. In the examples that I gave, the physician does his best to ensure that the patient gets honesty and respect, and if this involves withholding some or all of the truth FOR THE BETTERMENT OF THE PATIENT, then that's what should be done. Should you tell the truth to an emotionally unstable patient whom you believe may commit suicide or go on a killing spree should they learn the truth? Should you tell the truth to a patient who has previously expressed not wanting to know the entire truth?

Not telling the truth DOES NOT equate disrespecting a patient. Rather, it's thinking outside the box and understanding that "always tell the truth" is not just some rule to blindly follow.

 

I understand your concern regarding telling an already emotionally unstable patient something that might drive them to react in an adverse manner that could possibly threaten their recovery.

 

But I don't think that classifying someone as emotionally unstable, or even suicidal, waves their right to their own autonomy. Which is what you are doing when you decide that they would be better to not know about a mistake made during surgery.

 

If you are so concerned about your patient that you believe they may go on a killing spree, or kill themselves, after heading about the mistake, I think it may be time to talk to the patient about entering counseling, or finding other type of psychiatric help for them. It could also be wise to talk to the patient's family about your concerns over their well-being. With these actions, you may be able to make sure the patient has enough support to avoid taking such extreme measures, while still being comfortable with disclosing your mistake to the patient (and a mistake such as leaving something within a patient during surgery does not seem like a small or harmless one!)

 

Your last question about whether you should tell a patient who previously expressed his or her wishes to not be informed about how he or she is doing is another scenario entirely, and in this case, does not involve you making a decision for the patient.

[scrub]

If a patient is at risk of going on a killing spree or killing themselves they should be arrested. They very likely waive their right to autonomy in this case (relevant to our ethical duty, which would actually be trumped by our legal duty here) which means this example isn't relevant to the initial discussion.

 

I think we lost track of the topic - it isn't just deception we're talking about here (which in itself is already a big debate) but deception following a medical error. This isn't "Maybe we shouldn't tell Grandma her symptoms aren't Alzheimer's but Glioblastoma Multiforme and she has a couple months to live".

 

Perhaps you'd have a case if the patient clearly stated prior to a procedure that they don't wan't to know about any medical errors that occur during the course of their care. This would probably involve some conditions i.e. "If you, doctor, don't think its a big deal then just don't tell me, I understand the implications and wish not to know". If you could demonstrate they understood the implications (not just take their word) and it was clearly outlined then you could think about omitting your errors from your post-treatment debriefing.

[aKGDH]

But I don't think that classifying someone as emotionally unstable, or even suicidal, waves their right to their own autonomy. Which is what you are doing when you decide that they would be better to not know about a mistake made during surgery.

That's actually not true...A person deemed incapable and not in his right frame of mind (which can present from someone with Alzheimer's to someone who is suicidal) has no autonomy. I mean this in the sense that the person doesn't even understand himself and what he truly wants. Thus as a doctor you see to it that the patient gets the treatment that he would have wanted if he were capable, or the treatment that his relatives wishes him to get.

 

If you are so concerned about your patient that you believe they may go on a killing spree, or kill themselves, after heading about the mistake, I think it may be time to talk to the patient about entering counseling, or finding other type of psychiatric help for them. It could also be wise to talk to the patient's family about your concerns over their well-being. With these actions, you may be able to make sure the patient has enough support to avoid taking such extreme measures, while still being comfortable with disclosing your mistake to the patient (and a mistake such as leaving something within a patient during surgery does not seem like a small or harmless one!)

I'm not suggesting to completely ignore the situation such that you carry on with your duties without making an effort to talk to the patients family, or seek a psychiatric consult. I'm just saying that telling someone who has tried to kill themselves a piece of information about their health that you suspect would cause themselves bodily harm or harm to others is not a wise decision. If you deem this person to later be capable again, then of course the entire truth must be told and the patient's autonomy must be respected.

 

Basically, deceiving the patient is never the right thing to do, under any circumstance. But there are times when the truth will do more harm to the patient than good, and those situations must be carefully evaluated.