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Rapid Responses: Rapid Responses published:
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Rights and Duties
- Robert E Marcus (4 May 2007)
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Legal Obligation to Inform Patients about "Unavailable" Treatments
- Kayvan Shokrollahi (7 May 2007)
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Treating a patient when not cost effective: a moral dilemma highlighted by neuroscience!
- Sebastien TASSY, Bruno WICKER, Perre Le COZ, Guillaume GORINCOUR (9 May 2007)
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Robert E Marcus, Consultant Haematologist Addenbrookes Hospital Cambridge CB2 2QQ
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Dr Godlee's editorial implies that the rights of the individual and the duties of the state are one and the same and it is the responsibility of Physicians and those employed by the health care system to reconcile the two.This is a pernicious notion , since it implies a return to the worst elements of medical paternalism and is a denial of democratic accountability. The two concepts are entirely separable and should not be confused.It is the duty of the state or its agencies, with the active and informed consent of the people, to defray the costs of medical care to its citizens, according to an explicitly agreed framework. It the right of the citizen to know what treatment is right for his or her condition , informed by a physician whose primary responsibility is to impart such information Levels of funding or reimbursement by an external agency and appropriateness of therapy are, thus, entirely separate notions. To imply that a health care establishment should make unquestioned decisions about the care available to patients without informing them is denial of their basic human rights and is a concept of the relationship between citizen and state that I thought a thing of the past that had disappeared with the Berlin Wall. Robert Marcus Competing interests: None declared |
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Kayvan Shokrollahi, SPR Plastic Surgery Welsh Centre for Burns and Plastic Surgery, Swansea, SA4 0ZW
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In relation to should or should not, it is perfectly clear that doctors have a legal obligation to inform patients about other treatment options even if these are not available on the NHS. This decision is often within the context of patients consenting to a specific treatment that has been recommended and IS available. In order to consent to any treatment, patients must know not only what is involved with the treament and the risks and complications but also the alternatives as well as the risks of not having treatment. In UK law, a critical point which can sway the balance in deciding whether consent is adequate or not (i.e. negligent) depends upon whether the patient would still have undergone the treatment in question had they been informed of the specific details which have been alleged to have been ommited as in Chatterton v Gerson [1]: "The plaintiff must prove not only the breach of duty to inform but had that duty not been broken [she] would have chosen not to have the operation". If the ommision of information with regards to a patient's treatment options can be shown to have swayed their decision in accepting the treatment they are given, then the chances of a jury finding this consent invalid and negligent are high. The guidance of the General Medical Council on consent should also be noted: patients should understand the "options for treatment including the option not to treat" [2]. A futher important point is that witholding this information removes patient autonomy and choice. Perhaps the patient would seek alternative treatment privately or through the generosity of some donor or health care provider either here or abroad. Furthermore, they may wish to challenge the lack of availability of this treament in the courts and only through knowledge of the alternatives would undertake such a challenge. Who are we to make assumptions about patients in this way? [1] Chatterton v Gerson. [1981], I All ER 25, Bristow J at p 1012 [2] General Medical Council. Seeking patients' consent: the ethical considerations. November 1998. Http://www.gmc-uk.org/standards/consent.htm Competing interests: The author's legal thesis was on the issue of consent for medical treatment |
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Sebastien TASSY, MD (1) Espace Ethique Méditerranéen, EA 3783, Hôpital de la Timone, 13005 Marseille, France, Bruno WICKER, Perre Le COZ, Guillaume GORINCOUR
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Do doctors owe a primary duty to the community or the patients when financial resources are scarce. This dilemma, underlined by Godlee (1), is very difficult to solve for ethicists. However neuroscientists provide us with knowledge to understand what happens in our minds when such a dilemma raises. Moral philosophers and moral psychologists showed that people judge “morally” acceptable and widely shared an action causing individual’s harm when its purpose is to benefit the community, if harm is indirect or “impersonal”(2). NICE’s experts or any medico economics expert do it by providing with guidelines regarding treatment restrictions, even if such a guideline will cause harm. Nevertheless, an action leading exactly to the same consequences (in terms of harms and benefits) is perceived as unacceptable in a”personal” moral dilemma, in which the moral violation in question occurs in an “upclose- and-personal” manner. It is the very situation faced by physicians when they have to refuse a treatment for a patient they are directly taking care of, because they are trying to preserve the healthcare system. In a very famous experiment, Greene(3) found that judgements in response to “personal” moral dilemmas, compared with “impersonal” ones, involved greater activity in brain areas that are associated with emotion and social cognition. This emotional pressure comes from the fact that others’ situations and emotions highly influence our own emotions and intervene in our decision process [3]. A doctor's untrammelled advocacy for the individual patient may not be only a thing of the past. It is also an emotional innate reaction. This view illustrate the possibility offered by neuroscience to highlight bioethics questioning. Progresses in cognitive neurosciences have brought some scientific elements that help to understand what moral rules are related to and how we cope with moral decisions(5). 1. Godlee F. For patient or population? BMJ 2007;334, doi:10.1136/bmj.39203.526481.47 2. Greene J. From neural 'is' to moral 'ought': what are the moral implications of neuroscientific moral psychology?. Nat Rev Neurosc 2003;4:846-9 3. Greene JD, Sommerville RB, Nystrom LE et al. An fMRI investigation of emotional engagement in moral judgment. Science 2001;293: 2105-2108. 4. Keysers C, Wicker B, Gazzola V, et al. Both of us disgusted in My insula: the common neural basis of seeing and feeling disgust. Neuron 2003;40:655-64. 5. Tassy S, Le Coz P, Wicker B. Current knowledge in moral cognition can improve medical ethics. Journal of medical Ethics, In press Competing interests: None declared |
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