\'Therapeutic Privilege\' & \'Truth telling\' PDF

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Summary

Notes on medical therapeutic privilege and truth-telling, and its implications on doctor-patient relationships...

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'Therapeutic Privilege' & 'Truth telling' 08 October 2018 16:28  Truth telling in healthcare is the practice and attitude of being open and forthright

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with patients. It is about encouraging openness and genuineness in the relationship between healthcare professionals and patients Truth telling requires the belief that honesty is better than deception o It requires an intent to be as accurate and honest as possible with patients

Ethics of truth telling  Truthfulness comports well with democratic policy and practices  Without accurate information, patients are less able to make informed decisions about their care o Autonomy must be encouraged, enabled and respected  Options for care and treatment have greatly increased due to improvement in scientific medicine o Non-disclosure will do harm in limiting pt's availability  Pts. Must be told truth because of the respect owing to them as persons o Pts have the right to know what is wrong with them  Telling truth encourages pt compliance- otherwise, worry anxiety and fear       

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Deception by physicians is implicitly recommended as a way of preventing the possible harms of truth telling Ill patients are presumed to have difficulty handling the unvarnished truth Some cultures and families believe that telling the pt the whole truth may cause avoidable worry in pts This 'protective deception' has some credence especially at times where medicine could offer little tangible help to pts A deontological perspective will always view lying as wrong Certain malignancies and health problems that aren't amenable to treatment have posed challenges to clinicians on ways to disclose in a compassionate way Truth can result in 'labelling' patients which can lead to negative consequences such as excessive worry about the future or failure to fulfil role expectations such as work attendance and family obligations Can lead to higher anxiety levels Labelling can also result in shunning, discrimination, and exile. Doctors need to play an apostolic role: be able to guide the pt through their illness, and educate not necessarily on the truth of their condition but on what is a reasonable attitude to take when ill

Deontology  The right to self-determination and respect for autonomy is a fundamental principle  This will demand truthfulness Contractarianism  By entering into a relationship, we enter into a contract based on presumptions of fidelity or promise of keeping. This is the basis of relationship of trust Consequentialism  If deception leads to a better outcome, it is acceptable

Virtue Ethics

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Some argue that lying is never acceptable Deception causes diminished credibility- where docs are seen as unreliable. Public trust on doctors very quickly gets eroded Lying o

Has vague definitions- subjective

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Non-beneficent deception o Moral term o Deception perpetrated for reasons other than the patient's best interest o Morally unacceptable

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Beneficent deception o Knowingly allowing someone to not know something or remain in ignorance of facts- done in the best interest of pts o If there is good and benevolent motive

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Therapeutic privilege o Legal term o Implies the act of exercising a judgement to withhold information that you believe will cause a serious deterioration in the pts condition o Withholding information- not telling pts things o An example of beneficent deception o Act of exercising a judgment to withhold information that you believe will cause serious deterioration o Does not include 'upsetting the pt'

Moral justifications  Duty of honesty conflicts with duties of compassion and caring about the welfare and happiness of others o Respect for autonomy- right to self-determination necessitates truth and honesty o Beneficence- promoting autonomy and virtue of honesty o Non-maleficence- duty to avoid causing unnecessary hurt o Justice- respect for pts right to know what's going on with their health for them to have the opportunity to give valid consent to future treatment. Pts right to information about their health  In scenario 2, o Ppl with dementia have reduced capacity to exercise their autonomy o Assess mental capacity o Opportunities to enhance autonomy can be restricted in certain cases o In which case beneficence might become a matter of promoting happiness and well-being  Spectrum of truth telling o Whole truth telling o Looking for alternative meaning

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Distracting Going along with - seeks neither to confirm nor deny their reality Lying

Legal position    

Law's involvement resides primarily in rulings on informed consent rather on matters of consent# If information is not given to pt, they cannot make informed consent Invalidated consent due to insufficient information Procedure without valid consent is battery

How much information to validate consent? 

The reasonable doctor standard (old standard- Bolam standard) o Docs should share as much info as much as doctors think their pts require o Prevailing view for the last 60 years

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The reasonable patient standard o Came about after the Montgomery case (shoulder dystocia) o Pt must be warned and informed o Pts must know and be able to decide for themselves- doc shouldn’t decide how much information should be disclosed

Duty of candour  A positive legal obligation  A criminal offence not to inform pts about serious harm, consequences and injuries o Serious harm: permanent lessening of the bodily, sensory motor or intellectual function o Moderate harm: moderate increase in treatment not necessarity be perm Professionalism  Should not withhold info unless you believe that giving it would cause serious harm.. That the pt might refuse treatments  Balance obligations of honesty with the virtue of compassion  Ask whether legal considerations are applicable  Balance it with the 4Ps...