Bioethics Case 2- Lying to a Patient

Welcome to the second episode of the UC Davis Bioethics Podcast series. This is Sam Yamshan, your host. What follows is a real case seen on the teaching service at the UC Davis Hospital. This case is presented by Alicia Hanson, a third-year medical student with expert commentary from Dr. Nathan Fairman, one of our Bioethics faculty at UCD. I hope you find this series valuable and then informs your patient care in the future. This case is about a 20-year-old man with a history of IV heroin use who presented to the ER with chest pain. He was admitted in workup revealed he had MRSA endocarditis with multiple septic embalides to the lungs. Our team began treatment with IV vancomycin, and because the anticipated length of antibiotics was six weeks, a pick line was placed for prolonged access. After one week in the hospital, he was medically stable and we arranged for transfer to an extended care center. During his time in the hospital, I spent a lot of time getting to know this patient. He shared with me some of his experiences as a war veteran and his struggles with substance abuse upon returning from combat service. He repeatedly expressed as a desire to remain sober, which he had attempted several times in the last few years. He had a detailed plan for quitting this time, which included moving back with his family in another state and attending rehab. The night before, his discharge to the extended care center, he seemed really excited, and he told our team that his friends were coming to visit him in the hospital. They planned to eat together in a cafe downstairs. Upon hearing this, however, my resident said that the patient was not allowed to leave the floor, that this was hospital policy. Our patient was clearly dejected and explained it was something he had looked forward to because he wasn't sure if he'd see these people again. When we suggested he invite them upstairs, he said he was too embarrassed to have him see him in his bed. My resident repeated that he had to stay upstairs. However, she told me that it was actually not hospital policy, but that she was concerned that he would use his pick line to inject drugs if he were let off the floor. To me, the ethical dilemma in this case is that between autonomy and beneficence. The resident lied to the patient about the hospital rules, but she did so because she believed it was in the best interest of the patient, that he might jeopardize his health by abusing his IV access. However, to believe that the doctor knows better than the patient would best for him, is a paternalistic attitude that impinges on the patient's right to make his own choices. I think we avoided directly discussing our reasoning with the patient because he had specifically expressed to us his plan to maintain his sobriety, and so we would have been insulted that we did not trust him, and as a result, lost trust in us. He was someone who was hypersensitive to being treated differently because of his addiction. On the one hand, I understand the practicality of the resident's decision. The worst case scenario she is envisioning is dire, that the patient could die. On the other hand, it doesn't sit well with me to lie to a patient, even if the intentions are good. Hi, this is Dr. Fairman. I'm going to comment on two aspects of the case, which stood out to me. The first comment is really just a reminder of the value in carefully identifying the ethical issues in a case so that they can be separately analyzed. And the second comment has to do with some challenging issues that often arise in cases like this one, involving the care of patients with substance use disorders. So, first, I think this case gives us an example of why it can be important to carefully identify the ethical issues in a challenging scenario. That probably sounds obvious on its surface, but a careful analysis can sometimes help to reveal separate ethical issues or separate challenging facets of a case that ought to be considered on their own. In this scenario, you should note that the resident made two separate decisions, and I bet they happened almost simultaneously. The first decision was that the patient couldn't be trusted to take dinner in the cafeteria with his friends. The second decision was to lie to the patient in order to justify the first decision. Now, if you take a moment to think about it, there's really no reason that the second choice had to follow from the first. Even if preventing the patient's meeting with the friends was the right thing to do, and I'm setting that question aside here, even if it was the right thing to do, lying to the patient about it seems hard to defend no matter what. But because the two choices were made simultaneously, they kind of got mushed up together. Yes, mushed up together is a technical bioethics term. When you think about them separately, though, it seems obvious that the second decision, the lying, was inappropriate. Well, the first decision, I think, is more complicated. We can see that the two choices were mushed up together in the student's analysis, too. And the suggestion she makes that the resident's lie was perhaps justified by beneficence, and I'll quote from the student here. She says the resident lied, but she did so because she believed it was in the best interest of the patient. In fact, I think that concerns about beneficence, or maybe it was non-maleficence, were probably used to justify the decision not to allow the patient to leave the floor. But the lie gets mixed up in this. And so it seems that the beneficence gives some cover for the lying as well. In other words, beneficence might be an appropriate justification for the decision not to let the patient off the floor. But whether or not it also justifies the lie is a separate question entirely. So separating the two decisions is helpful for us retrospectively in analyzing the case. But I think it also would have been helpful prospectively for the resident in deciding how to negotiate the situation. So in a backwards kind of way, maybe we can see this situation as an example of one way that an analytic framework can be helpful in reaching a decision when faced with an ethical quandary. Carefully thinking about this situation, perhaps in a structured sort of way, might have helped the resident to uncouple the decision about whether to detain the patient from the decision about whether to be truthful with the patient. And again, all of that is separate from any judgments we might make about the two decisions. But just so I don't leave you guessing, suffice to say that I think it would have been better to acknowledge the concerns about safety and the lack of trust and to address those concerns more directly with the patient. Okay, enough of that. So the second comment I want to make about this case very briefly is that it brings to light some of the issues that can arise in caring for patients with substance use problems. And I mention them here because I think you should be aware of them and also because they raise interesting questions about the nature of autonomy that you might want to think about. Health problems that appear to have rude and personal responsibility often engender strong negative feelings in providers, including frustration, mistrust, and cynicism. There can be a sense that patients are not holding up their end of the deal in the doctor patient encounter, which is to say that they're not making good use of our expertise, of our care, of our concern for them or our time, etc. I'd go so far as to say that those feelings, frustration, mistrust, cynicism, and others, those feelings are natural in this kind of dynamic, although natural is probably not the right word. My point is just that you should be vigilant to this and acknowledge it if it arises in you with your patients because otherwise it may become a source of bias that interferes excessively in your care. Sort of related to this, it's helpful to bear in mind that one of the core features of a substance use disorder is the concept of loss of control. You'll find that language in most definitions of substance use disorders. The idea is that pathological substance use is the kind of use that is beyond the control of the individual to stop, hence some interventions that you might never consider in other patients, for example random drug testing as part of an opioid contract, or preventing unsupervised social visits in a patient with a pick line in a history of IV drug use, may be justified by appealing to both beneficence and the duty to respect autonomy. If the patient has lost the ability to control their substance use, then how are we to understand their autonomy when they use substances? Are they acting autonomously or are they acting under the control of the disorder? In that kind of situation, the best way to respect autonomy might involve taking steps to ensure the patient's safety. That's kind of a complicated concept, but I raise it only to let you know that I think it's not entirely clear how clinicians ought to respect autonomy in situations where the disease itself is believed to exert control over the patient. Something for you to think about, and I'll leave it at that, thanks. In summary, there are two main learning points from this case. First, is the importance of using an analytic framework for reflecting on our ethical decisions, which allows us to separate different points at which our process may have diverged. The second key point is that the clinical definition of pathologic substance abuse includes loss of control. This can make understanding patient autonomy complicated in the setting of substance abuse. If you have any feedback or additional thoughts about this case or case commentary, please feel free to email me, Sam Yamshan at www.SamYamshan.com. at S.J. Yamshan at ucdavis.edu, that's S.J.Y.A.M.S.H.O.N. at ucdavis.edu. Looking forward to seeing you next episode. Thanks for listening.