ETHICAL ISSUES
IN
MEDICAL PRACTICE 
SEMINAR 1
THE PHYSICIAN  AND THE
FIDUCIARY RELATIONSHIP
FALL, 2000
LAWRENCE P. ULRICH, PH.D.
Lawrence.Ulrich@notes.udayton.edu
http://homepages.udayton.edu/~ulrich/


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I. OBJECTIVES
A. Students will be able to identify the key ethical components of the physician-patient relationship.
B. Students will be able to describe the parameters of informed consent including two distinct models of informed consent.
C. Students will be able to identify three virtues which physicians must practice in order to promote the well-being of their patients.
II. ESSENTIAL CONCEPTS III. CONCEPTUAL OUTLINES IN SLIDE FORMAT [CLICK ON THE TOPIC TO VIEW THE SLIDES]
 
CLINICAL ENCOUNTER
CONFIDENTIALITY
GOALS OF MEDICINE
FIDUCIARY RELATIONSHIP
INFORMED CONSENT
PROFESSIONAL
VIRTUE
VIRTUES OF PHYSICIANS

IV. REQUIRED READINGS: BIBLIOGRAPHY AND SOME DISCUSSION QUESTIONS
 


Junkerman C, Schiedermayer D. Practical Ethics for Students, Interns, and Residents [Chapter 3: "Informed Consent;" Chapter 5: "Confidentiality;" Chapter 19: "The Physician's Professional Responsibilities"] (5 pages).

"Osteopathic Oath" (1 page).
"The Hippocratic Oath" (1 page).
Discussion Questions on the Oaths:
1. How far must a physician go to "preserve the life of patients?"
2. What kind of practices will bring shame and discredit on the profession?
3. What are the principles of osteopathic medicine which were enunciated by Andrew Taylor Still?
4. What precepts of the Hippocratic Oath have remained unchanged through the centuries?
5. What precepts of the Hippocratic Oath have changed through the centuries? Are these changes for the better?

Lidz CJ, Appelbaum P, Meisel A. "Two Models of Informed Consent." Arch Intern Med 1988;148:1385-1389 (4 pages). [ERESERVE]
Discussion Questions:
1. What is the event model of informed consent?
2. What are the shortcomings of the event model?
3. In general what is the process model of informed consent?
4. What are the strengths of the process model?
5. What strategies are necessary to implement the process model?
6. How can effective communication reduce the time commitment required by the process model of informed consent?

Ulrich LP. "The Physician-Patient Relationship." Breckenridge Bioethics, 1996 (4 pages).
Discussion Questions:
1. What is the ethical principle which has traditionally been the driving force behind the fiduciary relationship?
2. What does the term "fiduciary" mean?
3. What is the role of trust in the fiduciary relationship?
4. In what sense is the fiduciary relationship a relationship of mutual empowerment?
5. What is parentalism and when is it appropriate and when is it inappropriate in the fiduciary relationship?
6. How does the notion of patient autonomy currently figure in the understanding of the fiduciary relationship?

SOME ADDITIONAL RECOMMENDED READINGS:
 
AMA, Council on Ethical and Judicial Affairs. Current Opinions or Code of Medical Ethics.
American College of Physicians. Ethics Manual, 4th edition. Annals of Internal Medicine 1998;128:576-594.
Ulrich LP. "Informed Consent."Breckenridge Bioethics, 1996. 
Ulrich LP. "The Role of the Virtues in Conducting the Moral Life." Breckenridge Bioethics, 1996.[The Virtues of the Physician at the end of the essay.]

V. CLINICAL CASES

Students should be able to identify the basic concepts and distinctions of the unit which are present in the cases, reach a resolution, and develop a plan of action for the case.
 

Case 1 (Mrs. M.).
Mrs. M., a 35-year-old secretary, is found after her routine pap smear to have a carcinoma of the cervix. The cancer is in an early stage, confined to the cervix, with minor invasion (microinvasion) of the tissue of the cervix (stage 1A). The tumor is still easily treatable by means of a simple hysterectomy. Even though the physician informs Mrs. M. that there is a 90 percent chance of a complete cure, she is very distraught and apprehensive. When the physician raises the issue of scheduling a time for surgery, Mrs. M. is evasive and says she wants to think things over. The physician makes another appointment to speak with her a week later. Mrs. M. still is very reluctant to discuss the matter of surgery but agrees that "most likely, it is something I will have to face." She then asks what risks would be involved in a hysterectomy. The physician is concerned that if he describes all of the risks in full detail (e.g., injury to the bladder, to the ureter, injury to the bowel and/or intestinal obstruction, and urinary incontinence, not to mention possible death due to anesthesia), the patient will postpone the surgery even further. He wonders whether he should instead inform the patient's husband of the usual risks and indicate to the patient more globally that things will likely go well and that people are able to return home from the hospital after only a few days.
For a list of issues raised in Case 1 (Mrs. M.) CLICK HERE or HERE.
Reflection Questions on Case 1 (Mrs. M.).
1. What virtues does the physician need to practice in this case?
2. Is a parentalistic intervention by the physician appropriate in this case?
3. How does the issue of Mrs. M.'s dignity arise in this case?
4. Does self-determination as a special value underlying informed consent need special attention in this case?
5. How could the process model of informed consent help in this case?
6. What strategies would you implement to bring this case to a resolution which maximizes the well-being of the patient?
7. How might an ethics consultation be helpful in resolving the disputes in this case?

 
Case 2 (Todd Z.).
Todd Z. is a 75-year-old male who has been diagnosed as having lung cancer with brain metastases. His physician of thirty years, Dr. S., is seriously concerned that, if told of his diagnosis, Todd Z. will go into a deep depression and spend the remainder of his life in that state. Dr. S. keeps the information from Todd Z. and orders Todd Z.'s wife and three sons not to tell the patient of the diagnosis. He claims that "deep down" Todd Z. would not want to know about his diagnosis. He tells them that he wants to keep the patient in the hospital for a couple of weeks for brain radiation and promises to make up some excuse for the treatment. After the treatment is concluded, the family can take him home to die. Dr. S. promises that he will visit Todd Z. at his home every week and care for him until he dies because he has been very fond of him and lives nearby. Todd Z. becomes increasingly persistent with his questions about his physical condition. By the third week the family breaks down and tells him about the diagnosis. Todd Z. does go into the predictable depression, but it is not as severe as Dr. S. had feared. Dr. S. is angered by the fact that the family has disobeyed his orders. He releases Todd Z. from the hospital and does not keep his promise to visit him at home. He never visits him during the six-month period from Todd Z.'s departure from the hospital to the day of his death. During that six-month period Dr. S. is very uncooperative. When the family contacts him to discuss the medication program, he is very curt with them, and when they ask him about a particular condition that is developing, he insists that they will have to bring Todd Z. to the office or to the hospital. He even refuses to talk with the patient on the telephone.
For a list of issues raised in Case 2 (Todd Z.) CLICK HERE or HERE.
Reflection Questions on Case 2 (Tood Z.).
1. How does Dr. S. place Todd Z.'s autonomy in jeopardy?
2. Does depression inevitably eliminate the power of self-determination by the patient and justify a parentalistic intervention by the physician?
3. How would you characterize the quality of the fiduciary relationship in this case?
4. What components of informed consent are being ignored in this case?
5. Does Dr. S. act as a proper patient advocate in this case?
6. What has happened to trust and mutual empowerment in this physician-patient relationship?
7. Is Dr. S. exemplifying or violating any essential virtues which physicians ought to practice in the fiduciary relationship?
9. What strategies would you implement to bring this case to a resolution which maximizes the well-being of the patient?
10. How might an ethics consultation be helpful in resolving the disputes in this case?

 
Case 3 (Your Case).
Select a case from your clinical experience in which some of the issues addressed in this module have surfaced. Recount the details of the case and identify the ethical issues which arise from the case.
Reflection Questions on Case 3 (Your Case).
1. What are the ethical issues in the case and in what way are they significant in the case?
2. How can patient dignity and the quality of the physician-patient relationship best be preserved and promoted in this case?
3. What strategies would you implement to bring this case to a resolution which maximizes the well-being and self-determination of the patient and the integrity of the physician?
4. How might an ethics consultation be helpful in resolving the disputes in this case?

VI. LEGAL CASE

Students should be able to identify the basic issues and explain the ethical foundations for the plan of action they would have followed if they had been participants in the case.
 
 

JOHN CANTERBURY

John Canterbury was a 19-year-old male who developed paraplegia after a laminectomy. He was not informed prior to the operation by his physician, Dr. Spence, that the operation involved a risk of paralysis. Mr. Canterbury brought an action against the physician and the hospital. In defending his decision to withhold the information from Mr. Canterbury, Dr. Spence testified that communication of the 1% risk was not good medical practice because it might deter patients from undergoing surgery which they needed because of fear of the risk and because of adverse psychological reactions which might compromise the success of surgery. The Court held that an adult patient of sound mind has the right to determine what should be done to his or her body and that physicians have the obligation to give patients the information that a "reasonable patient" would want to have. Thus, patients have a right to the information which is "material" to the patient's decision. The only exceptions are (1) emergency situations involving incompetent patients who are not in a position to make decisions in any case and (2) instances of "therapeutic privilege" when the information would clearly damage the patient's well-being.

[Canterbury v. Spence. 464 F.2nd 772, 150 U.S.App.D.C. 263 (1972).]

For the complete court decision in this case (Canterbury v. Spence) CLICK HERE.
Reflection Questions on the Legal Case (Canterbury v. Spence).
1. How had Dr. Spence compromised Mr. Canterbury's autonomy?
2. How did Dr. Spence fail to act as Mr. Canterbury's patient advocate?
3. How did Dr. Spence fail to empower Mr. Canterbury?
4. Was Dr. Spence acting parentalistically or beneficently?
5. How could informed consent be obtained without unduly alarming the patient?
6. Was Dr. Spence being true to the integrity of his profession in this case?
7. In what way did Dr. Spence fail to trust Mr. Canterbury?
8. How did the Court reinforce the autonomy rights of the patient?
9. Could an ethics consultation have helped in this case before it went to court?



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