AMA rejects therapeutic privilege, advises giving patients full story
AMA rejects therapeutic privilege, advises giving patients full story
Physicians shouldn't decide what information patients can bear learning
Perhaps for as long as there have been physicians, there has been the notion that sometimes what a patient knows could hurt him. "Therapeutic privilege," the decision by a physician to withhold information from a patient for his or her own good, is a concept of the past, the American Medical Association (AMA) has determined.
"I don't know how long [therapeutic privilege] has been around — maybe since Hippocrates," says John D. Banja, PhD, assistant director for health sciences and clinical ethics at the Emory University Center for Ethics in Atlanta. "I find this change [away from the practice] refreshing and realistic and totally congruent to the consumer sovereignty and autonomy that has been going on in the U.S. for the last 20 or 30 years."
At the AMA's annual meeting in June, the AMA Council on Ethical and Judicial Affairs (CEJA) introduced a change in ethics policy, saying, "Withholding pertinent medical information from patients under the belief that disclosure is medically contraindicated, a practice known as 'therapeutic privilege,' creates a conflict between the physician's obligations to promote patients' welfare and respect for their autonomy by communicating truthfully."
Physician should not decide what patient should know
In changing its ethical policy, the AMA council said, point blank: To withhold medical information from patients without their consent, even if the physician is concerned that the patient can't withstand hearing bad news, "is ethically unacceptable."
That's not to say that there aren't cases in which it is ethical to withhold information, but only when the patient has made it clear to the physician that that is his or her wish. Physicians "should honor patient requests not to be informed of certain medical information or to convey the information to a designated proxy, provided these requests appear to genuinely represent the patient's own wishes," the council wrote.
Banja says that's an important point.
"What we need to teach physicians to do is, very early on in their relationship with patients — especially in physicians who deal with high-risk patients, such as oncologists and surgeons — to teach them to say in their first interview, before any interventions have been made, something like, 'Mrs. Jones, I am wondering how you'd like me to deliver information to you, especially if the news is not going to be good. Would you like to know about it, or would you want me to tell your spouse or your child and let them decide whether or how you are told?'
"And then the physician should stop talking and let the patient talk," he suggests.
Banja, who has written extensively on the effect that the demand for perfection has on physicians (Medical Errors and Medical Narcissism, Jones and Bartlett Publishers, 2005), says he often finds it is the physician, not the patient, who can't deal with bad news.
"We need to teach physicians how to control their own feelings, especially the feelings of inadequacy and helplessness, when they encounter these difficult situations," says Banja. "That's the fundamental reason they do badly in these conversations; these conversations contradict their psychological need to feel adequate, to feel knowledgeable, to feel helpful, to feel in control, and to feel they can do something to make the situation better."
When a physician can't live up to that standard, Banja explains, the encounter becomes painful to confront, so the physician might transfer his or her own feelings onto the patient, and make the decision that the patient won't be able to handle hearing the bad news.
Cultural considerations must be considered
The new AMA opinion prompted some questions about whether it conflicts with strides in cultural awareness among physicians, specifically that some cultures tend to protect patients from bad news in the belief that it could make them sicker.
Banja says the two aren't necessarily mutually exclusive.
"Asking 'how would you like your news?' is very interesting, culturally," he explains. "Some cultures think it is disrespectful, and even harmful, for a physician to actually say 'you have a very, very serious disease' to a patient. They believe that if a doctor says it, that makes it real.
"If physicians would just ask the patient how they would like the news delivered, they could get around that. If a patient is from Asia, China, the Mediterranean, a place we know the culture wants to shield the patient, and the patient says, 'I want to know,' then that's the way it ought to go."
Banja says that in the vast majority of cases, patients don't want to be shielded from the truth. Even bad news, when delivered frankly, candidly, and with compassion, is greeted with relief in that it puts speculations to rest.
"Without a full story, patients and their families will ask what happened or what will happen, and whose fault it is," he points out. "They want to develop a plan and manage what's going on, and they can't manage it if they have a vague, ambiguous idea of what's going on."
Teach doctors what to say, and when to say it
While the new AMA policy urges full disclosure, it concedes that not all bad news need be delivered in one blow.
"Physicians should assess the amount of information a patient is capable of receiving at a given time, delaying the remainder to a later, more suitable time, and should tailor disclosure to meet patients' needs and expectations in light of their preferences," the AMA opinion states.
Disclosure should be delayed only if early communication is contraindicated, the opinion continues, "according to a definite plan, so that disclosure is not permanently delayed."
Consultation with patients' families, colleagues, or an ethics committee may help in assessing the balance of benefits and harms associated with delayed disclosure, the opinion states.
Banja says while medical schools and residency programs are doing a fairly good job at educating doctors about the importance of delivering full information to their patients, physicians who have been practicing with a more paternalistic approach for two or three decades could probably use help in knowing what to say and how.
Discarding therapeutic privilege marks a "paradigm change," Banja says, from doctors controlling the conversation to allowing patients and families to be in charge.
"They have a hard time being frank and candid with patients sometimes," he says.
Knowing what to say is one part of the equation, Banja says; the other part is knowing when to listen.
"Stopping talking is one of the most difficult things to do, especially when you are anxious and things are tense," he explains. "When you say 'cancer' or 'death,' you have to stop talking and let the patient engage his or her reception of that word. If they stare blankly, you have to say, 'I wonder what you're feeling right now.'
"You have to take your cues from the patient, and a lot of doctors don't know how to do that. They come in with their script, and they impose that on the patient rather than taking conversational cues from patient."
Sources/Resources
For more information:
- John D. Banja, PhD, assistant director for health sciences and clinical ethics, Emory University Center for Ethics, Atlanta, GA. E-mail: [email protected].
- American Medical Association, text of resolutions and report on withholding information from patients (therapeutic privilege). Available at www.ama-assn.org/ama/pub/category/15931.html.
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