Would you tell the truth or lie?

Truth telling and confidentiality problems arise daily in the medical field. As a physician, it is his/her duty to tell the patient the truth if the patient wants to know, but in some cases is it morally right to tell the truth? Let’s look at an example for more clarification. A family of four, a father, a mother, and two children, got into a fatal car accident. The mother and two children were declared dead at the scene and the father was taken to the hospital with very serious injuries that require surgery. As he was being rushed to the operating room, he asks the doctor how his wife and children are doing. The doctor says that "they are being cared for". Was it morally right for the doctor to lie? What would you say if you were the doctor? 

Cases like these can get very controversial because our society thinks that it is morally wrong to lie. But is it okay to lie in some instances? I thought of this example as if I was in the situation myself, first as if I was in the father’s shoes, and second as if I was in the doctor’s shoes. If I was in the father’s shoes, I would want to know how my family is doing. By asking the doctor, I would think I am ready to hear the truth and nothing but the truth. But as the doctor, I would want to save this father’s live. By telling the father the truth, it could cause the father to feel responsible and guilt for the deaths right before the surgery. The father could lose hope and just tell the doctor that he doesn't want to get treated and wants to die with his family. Personally I wouldn't think it’s fair for the live that could be saved. Yes, the father will have to go through emotional and physical pain, but it can be overcome. Also telling the father after the surgery could put the doctor’s reputation at risk.  Sadly, cases like this happen every day.

Confidentiality

Confidentiality is “an obligation or pledge of medical professionals to keep secret the personal health information of patients unless they consent to disclosure.”  One of the conflicts we discussed concerning confidentiality was whether the obligation to respect confidentiality is absolute, meaning it applies the same way in all cases, or Prima Facie, meaning we allow for exceptions when other duties apply.  I thought this was a difficult topic to have a definitive answer on, since if I was to pick one way or the other there will always be at least one really good exception that will follow to make me unsure of my decision.  Although I do believe that doctors should definitely hold firm to their code of confidentiality, I also think that there are some special cases in which the doctor may have a better grasp on the situation, and therefore has a right to use his best judgment to do what is most advantageous for the patient.  However, when a patient goes to a doctor or other medical professional for help, they are aware that this code of confidentiality exists between them, but the doctor also has an obligation to do what is best for the patient.  Therefore when this patient approaches the doctor seeking his professional help, they are also allowing the doctor to take a paternalistic authority in their lives and furthermore releasing a tiny bit of their own autonomy to him. 

                The point that I am trying to convey is that I do not think that we as spectators can rightfully decide whether confidentiality should be accepted as absolute or prima facie; but it is something that only a doctor or medical professional in such a situation can decide for what would be the most advantageous thing to do based on the concern of that specific patient.  Which could potentially therefore result in a different decision in each and every situation, depending on the doctor, the patient, or the situation.  The only downfall that may be associated with this idea is that doctors are only human, in so far as they too are just as flawed as every other human on earth; they make simple human errors, they make irrational decisions based on the influence of their emotions, and they let other people’s opinions sway their own.  Therefore, I guess this means that I think that the obligation to respect confidentiality is Prima Facie.  

To Tell the Truth, or Not to Tell the Truth. That is the Question...

Telling the truth should not be considered a moral dilemma. According to Kantian ethics one should always tell the truth because it is morally right. But what if telling the truth would cause great harm (psychologically, emotionally, or physically) to the opposing party involved. For example, let's say that there is a family that is caring for their elderly grandmother who has recently developed Alzheimer's. Eventually, the grandmother forgets who each member of the family is, but still believes that her deceased husband is still alive and has asked to see him. Should you lie to her or say that the husband is away on business? One would think it would be a more humane solution to simply tell the woman that her husband is not there at the moment, as opposed to putting her through the heartbreak of telling her again that her husband is deceased. What's the harm? She won't remember anyway. But if one has to make exceptions to the moral rule of always telling the truth no matter what, this is not a viable option. So we are led to the rules of utilitarianism. It would cause less emotional and psychological harm to the grandmother and the family if they played along with the fact that the grandfather is still alive, but he is not there at the moment. It would cause more harm to break the heart of the ill grandmother and to (most likely) repeatedly tell her that her husband is gone. But is it okay to lie to patients for their own sake? Should they be forced to handle the truth and deal with reality because it is a part of life? Or is it more humane to let them live in ignorant bliss until their time has come?

HIV and patient confidentiality

In class yesterday, we discussed a specific case where a HIV positive patient told her doctor that she was having unprotected sex and was not going to tell the partner. Some believed that patient confidentiality was more important, while others argued for the partner being told. I wanted to further elaborate on why physicians who have HIV positive patients with known sexual partners must tell the partner. If the physician does not tell the partner then he/she has the potential of infecting many others. The Hippocratic Oath says “first do no harm.” By not telling him/her that their sexual partner is HIV positive the physician is in fact doing harm. HIV is an epidemic with some of its origins involving HIV positive people having unprotected sex with some one else. If the sexual partners of these patients are not told about the risk then this pandemic will continue to grow exponentially because people will have unprotected sex never suspecting that they may be killing their partner. The best way to end this outbreak is by telling the unknowing sexual partners that the one they are sleeping with has HIV.

When Telling the Truth to Patients Is a Hard Thing to Do

In class this week the topic on truth-telling and deception was visited. Some cases that we focused on are represented in categories such as dying patients and interventions. We all know that truth-telling in clinical cases are a very difficult topic. An example of an intervention clinical case that our textbook gave is below.

In this case a young Hispanic woman is in a coma and in the process of coming out of the coma. The only responses she makes are from commands. Since this woman is not in a situation in which she can make decisions for herself, her mother and father deal with all of her healthcare decisions.  Her boyfriend is also accepted in the family, so when it is later discovered by physicians that this woman is five weeks pregnant the physicians ponder on how to handle this condition.  Because if she does not recover from this coma the physicians will then have to inform the patient’s decision makers, who will then be in a position in deciding whether to continue the pregnancy even if it is a harm to the young woman’s recovery.  Therefore, the physician exposing this information will cause problems in the family. For example, why should the young woman mother get to decide what to do about the pregnancy? Shouldn’t the father/boyfriend decide since it is his child?

According to David Thomasma, author of this clinical case, “revelation of the truth must be carefully managed.” Furthermore, the pregnancy should be revealed only when it is critical to the patient health\survival. This clinical case is an example of how the truth is somewhat hidden from not the patient, but from the patient surrogate decision makers. This case to me is a bit arduous, because the patient autonomy is not at all violated because she incompetent to decide for herself. But does this make it morally right for the physician to withhold information from the family because the physician feels that it is not important for the family to know at the current time? In this case like all other clinical cases, I have the perspective that questions what gives the physician the right to decide what information he chooses to share with the family. Specifically in this case, the father should of course know that his girlfriend is pregnant with his child. Withholding this truth is not going to change the state that the woman is in. So therefore, I feel that the physician should not hide this information.

The NFL and Morality

     Recently, the National Football League has come under intense scrutiny for the mishandling of personal/legal matters of certain players.  Most notably the domestic assault case of Ray Rice and his then fiancée Janay Palmer.  Months ago, we all became familiar with the tape of Rice dragging an unconscious Palmer out of a hotel elevator after they had been involved in an intense argument.  Though we realized Rice had put his hands on Palmer, it wasn't until TMZ released a new video weeks ago showing what actually took place inside the elevator.  We see an angry Rice punching Palmer unconscious and attempting to drag her outside of the elevator, at times kicking her feet and her motionless body.   It wasn't until this video that we became truly angry.  We questioned the NFL's Commissioner Roger Goodell's handling of the case and the details he actually knew.  Rice claims that he told Goodell the truth about punching Palmer, and we have also heard a voicemail recording of a female in the NFL's front office saying that they have received the tape showing what happened inside the elevator.

     Not long after TMZ released the video of Rice punching Palmer unconscious, Adrian Peterson, arguably one of the best players in the league, had been charged with child abuse.  Ironically and sadly enough, one of Peterson's other sons was tragically killed by the hands of the mother's boyfriend.  Reports also surfaced that Peterson was recently investigated for the abuse of yet another son.  The Minnesota Vikings, the teams for which Peterson plays, has taken the necessary steps of deactivating him from the team--although with pay.

     Two other incidents involving domestic violence have caused players to be deactivated from there teams--Carolina Panthers' Greg Hardy (although this happened awhile ago, but in light of the Rice controversy, the Panthers have changed their tune) and Arizona Cardinals' Jonathon Dwyer (this incident being the most recent).

My question is: how do you think the NFL should handle such cases?  The NFL has a Personal Conduct Clause that each player must abide by, but how harsh should the punishments be?  These cases are all also legal matters--should the outcome of these legal decisions affect how the NFL and each individual team punishes their player?  Should Goodell himself be held responsible for the mishandling of the Greg Hardy and Ray Rice cases?  And lastly, what does it say about our culture that even though we knew what happened inside the elevator, we didn't truly care until we saw a video of a strong NFL player knocking his fiancée unconscious?

DNR and CPR: Strong Paternalism

Some years ago I was working on a project in a hospital.  While working with the charts, every now and then I would see these letters “DNR” printed boldly in black on the first page.  At that time I did not know what this abbreviation meant and did not ask.  Seeing this abbreviation again in Chapter 3 reading brought that back to me. 

DO NOT RESUSCITATE. This is a directive from medical staff saying basically do not try to give CPR if the patient’s heart or breathing stops.  The book states that this is considered “medically appropriate and morally permissible” under some conditions (seriously or terminally ill).  Also, a patient can personally set these orders in place via verbal notice or living will. 

     The point I am addressing is what seems to be the AMA's (American Medical Association) strong paternalistic stance concerning DNR protocols.  “The physician has an ethical obligation to honor the resuscitation preference expressed by the patient. Physicians should not permit their personal value judgments about quality of life to obstruct the implementation of a patient’s preferences regarding the use of CPR.”

     I thought it interesting that the AMA was addressing this issue in very strong language.   The organization seems to be directing physicians to give patient consent priority over any of the personal, moral or medical objections doctors may have.  This only addresses the organization’s side of the issue.  Though I am not trying to be cynical, I do believe this statement has more legal rather than moral implications. 

     Below are two recent legal cases about DNR orders.  The first is when a hospital (UK) initiated them without the patient’s consent.  This has two ethical issues involved.  The paternalist move concerning the DNR status and the moral issue of not involving the patient's family in the decision making.  The other is quite different.  While the hospital initiated the DNR again, it was done over the protest of the infant's mother.  There are other legal issues that make this very complex.   the other is patient’s fighting to have DNR status lifted.

http://www.theguardian.com/society/2014/jun/17/hospital-patient-rights-do-not-resuscitate-addenbrookes

http://www.pressherald.com/2014/09/05/parental-rights-injured-infant-at-heart-of-court-case/ 

The first ruling reiterates the priority of patients’ rights and informed consents in DNR cases.  The second is an unresolved but is looking a parent’s right to override a hospital’s DNR decision.