Interesting scenario for you #2

[Guest Kirsteen]

Hi there,

 

Here's one ethical question that I received during a medical school interview. I'd be interested in hearing your take(s) on it:

 

You are working in the ER and a girl and her boyfriend are wheeled in, both having been hit by a car while crossing a road. The girl is 14. Before trying to treat the girl, you go through her purse in an attempt to find any medical information, e.g., Jehovah's Witness cards, etc. While doing so, you find a set of sexual paraphernalia: edible panties, a vibrator, chocolate body paint, numerous multicoloured condoms... Shortly after admission, both the girl, and her boyfriend die. The girl's mother is called and you are required to speak to her to recount exactly what happened and hand over the girl's possessions. You are notified that the girl's mother is in the building and heading down the hall to see you. You have the purse in hand and 20 seconds to decide what to do with the sex toys, etc. You know that it is illegal to take possessions of others, but you are considering throwing them out so that the mother does not see them.

 

What do you do?

 

Cheers,

Kirsteen

 

P.S. Yes, the interviewer did list all of those sexual recreational materials off during the interview.

[Guest mydream88]

I am 100% positive that I would have turned bright red and break into a sweat once they started reading this ethical scenario, YIKES :eek .

 

After the initial shock (which I would make every effort to conceal as I beleive that is part of this excercise, they are trying to see how you react to things), I think I would answer the following:

 

The girl was your patient. She deserves to have her privacy, autonomy and dignity upheld. As well, this information could only hurt her mother and may disrupt her grieving process as she may be unaware of her daughter's choices and thus so many questions will be left unanswered. Thus, I would not give the mother her daughter's sex toys. I think it may violate the principle of beneficience to do so.

 

What, per chance, did you say Kirsteen?

 

mydream88:)

[Guest QCnut]

Whoa! that is an odd one..

 

As a scenario it's tough because I don't really see what kind of choices you have to explore. Since they told you outright that it would be illegal to take the toys, then throwing them away seems unwise.

 

I wonder if it was posed to see if you could get over the awkward/shockingness of finding the sex toys and focus on the more important and difficult task of telling the mother how her daughter died.

 

I think I might have approached the scenario like that .. because your primary role in the situation was to provide medical care for the girl. An important part of that is conveying information to her family in a sensitive way. But I don't think you should go as far as censoring her belongings.

 

It could be an extreme example of how you approach honesty in medicine? Just my thoughts.

[Guest mydream88]

I completely agree with QCnut that it would be more important to ultimately realize that you have to tell the mother that her daughter died and how. This should be your primary focus. I guess I can see that it would not be ethical for one to decide what her parents can and cannot know about their daughter HOWEVER, the daughter is your patient, and she didn't give permission per se to divulge this information about her. thus I will still stick with my original answer. I think that as long as you recognize the DIlemma on your hands and what QCnut mentioned about first and foremost dealing with the fact that you have to be there for this parent who just lost her child, it does not matter what conclusion you ultimately came to regarding giving her mom the sex toys.

 

mydream88

ps. though Im eager to see what you guys would do in this case.

[Guest chemgirl]

I don't know if I'd worry about the sex toys that much. I think that if my child had just died, her memory would not be denigrated in any way by finding out these "secrets." It's all water under the bridge at that moment. And who knows, maybe the parents knew she was sexually active, maybe the contents weren't hers, maybe it wasn't even her bag but was just in the car, how do you really know? I think that everyone else is right when they say it is more important to focus on telling the parents about the death in a sensitive and caring manner. If it was me, I would probably hand over the bag to the parents intact, as if I hadn't gone through it, and make no reference to the contents. I think it is up to the parents to decide what to do with that information, and, if they decide to throw out the contents and not think about what they would mean, they still have the right to make that decision themselves. I would be stark raving mad if someone at the hospital decided what possessions of my dead relative I did or didn't want to have or be told about, so in this case I am putting myself in the parents shoes.

[Guest chemgirl]

Mydream88, I agree with your original answer if the patient was going to recover, but since she isn't, I just wouldn't feel comfortable deciding for the parents what they do and do not want to know. I see you bring up the principle of benificience in that case, but too me, that borders on being paternalistic, and deciding for people what information they need to know, and that is why I don't agree with that scenario in this case.

[Guest QCnut]

I just thought of something else - what if it turned out that there was some kind of criminal aspect to this case.

 

I know that I'm taking it to an extreme, but imagine having to explain that you had thrown away evidence in order to "protect" the mother...

 

just another possible dimension?

(I think it came to mind because of that recent horrible child porn case that the Toronto police dept. helped to solve)

[Guest mydream88]

good point chemgirl. I can definitely see what you mean. The last thing one would want to do is to come across paternalistic, that's for sure.

 

I guess from that perspective, it is very logical to give the parents all their child's belongings. even though it's not pretty information, it is ultimately not up to the doctor to decide what information a parent should have on their child.

 

hmm, this is a tough question.

 

mydream88

[Guest byjude]

The other thing is, if she's got sex toys in her purse, chances are she has more at home.

 

So if you're going to remove these paraphernalia from her purse, there's still a good chance that the mother will find more later when she goes to clean out her daughter's place. Yes, she may have had time to deal with her daughter's death before she finds this other shocking sight, but you're not necessarily saving her from anything except a double shock. And who knows, maybe she has her own collection at home, or is aware of her daughter's behaviour (not that likely, but you never know..)

 

I would put the stuff back into the purse and hand it back to the mother as is. It's not your job as a physician to impose your own value system onto what you think the families of your patient can or cannot handle, especially when it involves tangible personal items. I would think that in comparison, finding out a daughter keeps a handy supply of sexcessories (granted, it would appear she's being safe!) would be small potatoes in light of hearing that she has just died. If the mother has trouble accepting this, she can impose her own rationalization to deny the existence (eg, buying for a friend's birthday, etc) but it should be up to those individuals to do the censoring, not up to the doctor.

[Guest Dunes]

very interesting Scenario indeed

 

I agree with both chemgirl and byjude. I don't think the parents would care too much about this because their daughter just died! I wouldn't even think twice about giving them everything that belongs to the girl since it might be of sentimental value to them, and maybe they did know about her sexual activity, so who am I to say what and what not to give. As a physician I would concentrate on how to sensitively convey the fact that their daughter just died and not that she was sexually active.

 

If the girl hadn't died, that would be a different case of course.

 

I'm curious to see what you answered Kristeen

 

Dunes

[Guest tweep0]

Very interesting scenario. Here are a couple of things I would consider:

 

I would first explain the accident to the mother, the daughters condition, and console the mother. This is most important. Now comes the purse...

 

After a death, a will basically dictates who has new ownership of the victim's possessions. I would try to see if the daughter had a will and if it states, for example, that all her possessions go to her uncle (for some reason) then I wouldn't give the purse to the mother (in a polite way ofcouse).

 

If no will exists or the will proclaims that all possessions are to be transfered to the parents, then the issue becomes the daughter's prior wishes. If the daughter previously stated to the doctor or in a living will that she does not want her parents to know that she is sexually active or uses sex toys, then I would not give the parents the toys.

 

If there is no will and no previous request from the daughter, the situation becomes tricky. It boils down to what the daughter would have wanted vs. the rights of the parents to know. The possibility exists that the parents already knew about it and by not telling them, they lose trust in you as a doctor. It is also possible (but highly unlikely) that the sex toys were a loaner to the daughter from the parents and they would feel angered if you didn't return them.

 

Knowing that keeping the possessions is illegal and that no will exists or that the prior wishes of the daughter are unknown, i guess i would give the mother the purse, but I would warn the mother that there are some materials in the purse that may suggest the daughters lifestyle that you [parent] are unaware of. If the mother still wants to take the purse, then I would also let her know that there may be a lot of reasons explaining the contents of the purse and if she wanted to talk about it later on, she could come in.

 

Im still conflicted about whether it is okay to assume that a 14-year-old girl would not her parents to know she is sexually active. If the assumption is true, then I wouldn't give the mother the sex toys. TOUGH QUESTION though.

 

Tweep

[Guest physiology]

Hey Kirsteen,

 

I'm gonna reply without reading anyone else's posts to simulate the interview experience.

 

These personal belongings, no matter how incriminating, are a part of this person. The fact that so many pieces of sexual paraphernelia were there, indicates that they were for a reason, hapharzardly or not.

 

Because they are her possessions, I would not try to hide or conceal or throw away any of these. They do not belong to me and as such I have no jurisdiction over her belongings.

 

Perhaps she was buying these for a friend? Or perhaps they were for herself? If she was having sex, at least it was presumably safe (multicoloured and edible condoms?). Moreover, perhaps the mother already knows that her daughter is sexually active and her mother has taken a pragmatic approach, and allowed her daughter to engage in sex, knowing full well her daughter would rebel if told otherwise, provided that it was safe.

 

I mean this type of question lends itself to myriad hypothetical situations and question upon question. The possibilities are endless. However, bottom line, these possessions are not mine, and therefore I have no right tampering with them.

 

I would give the purse to the mother and let her decide what to do with it. If the mother questioned me on this I woudl say "They were inside the purse while I was searching for identification" and leave it at that.

 

It's not my job to draw conclusions and impose my set of values/morals on the mother (that sex at age 14 is bad, etc). This is the mother's job and she can do or think what she likes with those sexual objects.

 

Now that I've read the other posts, I can edit mine.

 

Kirsteen, which school presented this question to you?

 

And of course, approaching the mother with a good "bed-side" manner would be important too. That's my catch all phrase for being affable, warm, and supportive to all patients, regardless of the situation.

[Guest Kirsteen]

Hi there,

 

It's an interesting question, eh? I assume that it was directed my way given my years as a sexual/reproductive health counselor; nonetheless, I found it tricky.

 

Like many of you have said, you'd concentrate on what the mother would feel. My response echoed this. I noted that the girl's possessions were not mine, that the primary concern of the mother at that time would probably be the death of her daughter, and I would give the mother the purse. However, I suggested that prior to giving the mother the purse I would explain why the purse had to be searched (for medical reasons) and warn her that it contains items that she might find unsettling (in an attempt to reduce any shock related to the purse contents).

 

After giving my response I asked the interviewer what he actually did in this situation (given that he said that this happened to him).

 

His response: he threw the sex paraphernalia in the trash before giving the purse to the mother.

 

He did concede, however, that there were a few ways to approach this scenario and that mine was technically correct too. That is, neither he nor I would have been found negligent by a court of law for either tossing out the sex toys, or exposing the mother to them.

 

Cheers,

Kirsteen

[Guest mydream88]

Kirsteen,

I ran this scenario by my boss (a radiologist) and she would do exactly as you did.

 

sounds like you handled it very well.

 

mydream88

[Guest FrenchyMed]

Oh my God!

 

I can't believe this guy threw the toys away! Ethically, I find this sooo wrong! Unless he had found some illegal drugs or a firearm in there, he had no right (in my mind) to take the matter in his own hands!

 

This was not his decision to make. As someone else earlier mentioned, if she has these in her purse, she probably has a full collection at home, which the mom is bound to find.

 

I would tend to think that the MD would only be concerned with these things if the patient had actually made it through. Then he could have spoken to the her about his concerns. Make sure she is well informed about consent, protection and birth control.

 

In this case, he imposed his personal values and morals. Aren't doctors supposed to remain impartial???

 

Just my 2 cents.

[Guest iceapatel]

I was thinking... would it be right to consult another doctor about what to do? if this happened to me in real life, and I was a newbie doc, I might just ask one of my colleagues what they thought should be done.

 

Is this wrong? Does it violate the doctor-patient confidentiality by telling other people (even if that other person is a reputable physician) confidential info about the sexual activities of the patient?

 

another parallel situation...

 

say there were other people around (nurses, technicians, etc.)when you were going through her purse looking for a J.W. card, etc... and they saw the sex paraphernalia... would you have to tell them to keep quiet and not tell the parents? sure, you as the doctor would most likely be the one primarily doing the talking, but would you want to make sure that any "witnesses" keep hush-hush?

 

on a related note...

 

is it true that every hospital has some sort of ethics guru (an individual or a committee) that can be consulted when faced with a ethical dilemma? are these people readily available to ask, if you're in a pickle?

 

I suppose those who have actually received ethical training during med school would have more confidence to make a decision.

 

- Anish

[Guest Kirsteen]

Hi there,

 

I was thinking... would it be right to consult another doctor about what to do? if this happened to me in real life, and I was a newbie doc, I might just ask one of my colleagues what they thought should be done.

 

Great idea! ...and this was my first response. I noted that I would probably not be alone in the ER and that I would turn to the wisdom of colleagues who may have some insights or advice before facing the girl's mother. The interviewer responded that I had 20 seconds to make the decision--that the mother was coming down the hall to see me and that I could turn to no-one.

 

Cheers,

Kirsteen

[Guest Kirsteen]

Hey there mydream88,

 

I ran this scenario by my boss (a radiologist) and she would do exactly as you did.

 

Good to know that I was in some good company, then. It didn't feel like it at the time. Thanks for checking that out and letting me know.

 

Cheers,

Kirsteen

[Guest chemgirl]

I really like this post because it brought up something I never would have thought of, the legal issue... what if this girl was being coerced/raped in some way and the sex toys were evidence? Throwing them out would be a grievous error in that case. I don't remember who thought of that, but man, I wish I could come up with things like that under pressure!

[Guest mydream88]

Hi guys,

I am sure that this is self-evident but I think that we should be careful to say 'avoid being paternalistic' without using the word 'paternalistic'. Maybe it would be best for example to say: how could I, as the physician, be in a position to determine what a mother can and cannot know about her daughter. I was thinking this because, one wouldn't want to insult the interviewers. In Kirsteen's case for example, the doctor interviewing her DID throw out the belongings in the purse.

 

mydream88:)

 

p.s. PLEASE ignore this post if it is redundant to you

[Guest chemgirl]

Mydream88, I hope I didn't insult you when I used that word because that wasn't my intention. I would have never said that in the interview, but I just wanted to bring up a point for everyone to think about, so I figured it was okay to call it like I saw it. And, in the confines of this forum, I think it is okay to say that I DO find the actions of Kirsteen's interviewer somewhat irresponsible, although of course he/she had the best intentions in mind. I'm also wondering about what they said to you (Kirsteen) afterwards, that either scenario was legal. I question the legalities of what he/she did. Even if they didn't want the parent to see the toys, perhaps they should have held onto them in case there was criminal activity going on victimising this 14 year old girl and they were needed as evidence. Ah well... hindsight is 20/20 I guess, I wonder if they felt they would have handled the scenario differently now?

[Guest mydream88]

chemgirl, no offense was taken, i promise . In reviewing your response I realized that paternalism was an inappropriate approach to handling this (or any) ethical clinical dilemma. I proceeded to 'practice' my answer using the term 'paternalism' then promptly realized that one shouldn't come out and say it outright, but merely imply it, so i decided to share my tip with the group .

 

I really appreciated the constructive criticism. It is much better for this type of critiquing to go on here, at our home base, then at an interview.

 

seriously, it is so great that we all have a place to debate about these questions because they could/and do turn up at interviews

 

mydream88:)

[Guest physiology]

When the radiologist mentioned that your option was "technically correct as well" was he implying that his answer was also correct?

 

In my opinion, I don't think he should have thrown anything away. Legally, girls at age 14 are allowed to have sex and it's their own decision. Who is he to impose values or judge this girl, or conceal (pertinent) information from the mother?

 

Did you challenge him on that? I thought that interviewers loved to be told "No, I disagree" because then it shows that you have strength, resolve, and a firm conviction in what you believe, especially with ethical issues, because they often have no right or wrong answer.

 

But the fact that you mentioned that there were unsettling items in the purse to soften the blow, was excellent.

 

You have a wonderful "bed-side" manner

[Guest glo]

Ok, I'm going to weigh in here and take the opposite view of everyone...

 

I am about to shatter that mother's world. Her child is dead and there is nothing I can do to change that. As a parent, she will likely feel guilty that she didn't keep her daughter safe. To then add the sexual paraphenilia and the lifestyle that this hints at, would just multiply those feelings of guilt. How could she not know what was going on etc. It is possible that the daughter was holding them for a friend or something, but she is not around to clarify. I would withhold the items from her.

 

My job as a doctor is not to reveal the child's lifestyle, and granted, nor is it to hide it. But in that 20 seconds I had to decide, my only thoughts would be on how to help her cope with such a loss, and not how to explain what was in the purse.

 

Ok...so don't be too mean

[Guest Kirsteen]

Hey there,

 

I wonder if they felt they would have handled the scenario differently now?

 

The interviewer did concede that it was possible that the mother may have given her daughter the sex items and that she may have questioned the doctor as to where they were, possibly thinking that he had taken them and was some sort of "pervert".

 

I truly was interested in what the doctor would have done, hence asking him what he did. Given that this was an ethical scenario there are no definitively right or wrong responses; instead there are just those that are more right or more wrong. Therefore, I didn't challenge his response, but said that I could see his point. His mention of the courts were with respect to how our actions would perceivably be judged were we to face court action for negligence. Given that both of us were trying to act in the best interests of the patient and their family, and we were not acting with wanton and reckless disregard for the patient nor her family, we would most probably not be found negligent.

 

I find these ethical interview situations interesting, because this is not the first time when I was caught off guard in this way. During my UBC interview a couple of years ago I was asked the now, not-uncommonly-heard, medical error scenario. That is, a surgeon accidentally leaves a clamp inside the abdominal cavity of the patient, only to discover it on a radiological image when the patient returned with a post-surgical abdominal complaint. How would you proceed? Do you tell the patient the truth or not that an error was made?

 

During that interview, the interviewer couched this question in a way that demonstrated that he had faced this scenario. Again, once I had given him my response, I was interested and so I inquired as to how the situation actually played out. It's really interesting to hear their side of things, especially in an interview setting. (You guys must have gotten this question by now, yes? In case not, what would you do? )

 

Cheers,

Kirsteen