Truth-telling in Medicine And: The Justification of Paternalism

Critical Analyses n Difficult question!! n Veatch: As a rule is strongly in favor of almost unlimited patient autonomy-- BUT this reading was taken from a case book where Veatch was trying to lay out both sides of the issue and not take a stand himself

Critical analyses cont. n Gawande: Several “mixed signals” –Title of paper –“Lazaroff” example –Mammogram example –“Mr. Howe” example n Which is the “real” Gawande?

Critical Analyses: take home message n Need to read the article at least once without a highlighter (don’t ignore specific words and phrases but rather put them in overall context) n Be sure to ask how each paragraph fits into overall scheme of author’s argument

TRVTH

Traditional approaches to truth n NO general duty to disclose n Truth as medicine; bad news can be harmful or fatal n Subsumed under general duty of beneficence or “do no harm” (nonmaleficence)

How culturally bound is current US view? n Only a tiny slice of the entire history of medicine is dominated by an autonomy ethic of truth-telling n Majority of other world cultures still seem reluctant to embrace this ethic n BUT at least some traditional cultures are moving in a “Western” direction (e.g. Japan)

“Truth-dumping” n Violation of beneficence-- usually perceived by patient as cruel and uncaring n Violation of autonomy? –Does cruel disclosure make patient a better (freer) decision-maker? –Does patient get a voice in how truth is told?

Reasonable Mix of Beneficence and Respect for Autonomy? Robert Buckman, How to Break Bad News (Baltimore, Johns Hopkins U. Press, 1992)

Truth Protocol (Buckman) n Pick a good time and setting and assemble right people n Find out how much the patient already knows n Find out how much the patient wants to know

Protocol (cont.) n Share the information the patient seeks –in sensitive manner –in appropriate “chunks” n Respond to patient’s feelings n Planning and follow-through

Lessons from Buckman n Effective truth-telling is heavy on listening and light on talking n Most patients want to know more and can handle it; a few don’t want to n Giving patient greater role in setting agenda is respectful of autonomy and is also compassionate and caring

Seldom the Question n “Should we tell the patient the truth, or conceal it from her?”

Usually the Questions n “When to tell?” n “How much to tell?” n “What exact words to use?” n “Whom should be there with the patient?” n “What comes next?”

When Can Paternalism Be Justified? Atul Gawande, “Whose Body Is It Anyway?” New Yorker, Oct. 4, 1999

“Weak” Paternalism n Patient lacks important dimensions of capacity to make autonomous decisions –Child –Dementia –Mentally ill n Generally easier to justify

“Strong” Paternalism n Patient appears to have full capacities for autonomous decision-making n Provider nevertheless feels that decision is mistaken and will cause great harm n Usually seen as much harder to justify-- threat to respect for autonomy

Gawande’s defense of strong paternalism n Dependent upon arguments in: Carl E. Schneider, The Practice of Autonomy (Oxford U. Press, 1998)

Schneider’s Approach n Read ethics literature n Read legal cases n Read books written by people about their own experiences with illness (pathographies) n Interviewed patients in a chronic renal unit

Schneider’s Conclusions n Some people wish to exercise autonomy as per the “ideal case” in ethics literature today n Many do not wish to and would wish to defer or delegate part or all of major health decisions to others including physician

Schneider (cont.) n The people who wish not to choose often have very rational reasons for this preference –Weakness and fatigue –Lack of knowledge or understanding –Awareness of problems in own thinking process –Avoidance of guilt

What Does “Respect for Autonomy” Require? n Forcing each patient into “ideal autonomy” mold regardless of preferences? n Allowing each patient to select the degree to which she wants to be informed and to participate?

Gawande’s “Mr. Howe” n Traditional argument often offered as justification for strong paternalism-- “Thank you” test n Is this an adequate ethical justification? n Is Gawande a “good physician” or an arrogant, paternalistic physician (or both)?