This document discusses two dilemmas in David's situation: whether he is mentally competent to make his own medical decisions, and whether information should be withheld from him at his wife's request. It notes that David's mental state at various points is unclear. The physician should have an in-depth discussion with David's wife about her reasons for wanting to withhold a cancer diagnosis from David, given his stated suicide threat. Ultimately, the physician canceled the biopsy, so there will be no results to disclose or withhold.

1. Dilemma 1Terea McCarthy Side A

2. David

3. There are two dilemmas in play in this situation.Is David mentally compromised to the extent that he can not make decisions for himself? The second is should medical information be withheld from him, regardless of his capacity, at the request of his wife?

4. In order to address these questions David, his wife and his physician all need to be involved.

5. David when brought to the ER, he was mentally compromised as evidenced by disorientation and being incoherent. We do not know what caused this. If we assume it is because he is known to have alcohol dependence, are we not profiling him?His disoriented and incoherent state may indeed be caused by something other than alcohol.

6. We have no indication as to the time when physician discussed the biopsy with David. Was it scheduled first and then David approached with the information/consent?Did David sign an informed consent?We also do not know to what extent David’s mental status has improved. Improvement does not always signify competence.

7. “The doctrine of informed consent dates back to English Common Law. As early as 1767 doctors were charged with torts of battery if they had not gained consent from the patient before surgery or procedures.” (e.g., Slater V. Baker and Stapleton).http://www.enotes.com/everyday-law-encyclopedia/informedconsent 6/16/2010

8. David has stated that if he learns he has cancer, he will kill himself.One can only surmise if this is an actual suicidal threat or not.“Consents are to be voluntary, competent and informed.” “The fact that someone has a mental illness of diminished mental capacity does not mean the individual is incompetent.” http://legaldictionary.thefreedictionary.com/patient’s +rights 6/15/2010

9. The AMA clearly delineates informed consent as a communication process. This process is to include: The patient’s diagnosis, if known; The nature and purpose of a proposed treatment or procedure; The risks and benefits of a proposed treatment or procedure;

10. Alternatives: The risks and benefits of alternative treatment or procedures; and The risks and benefits of not receiving or undergoing a treatment or procedure.http://www.ama-assn.org/ama/pub/physician-resources/legal-topic/patient-physician-relationships 6/15/2010

11. Has David given informed consent for the biopsy? Was he in a mentally acceptable status to do so for himself?If he gave informed consent for the biopsy, does he want to know the results?Is it his right to request that the information be discussed with someone other than himself or withheld?

12. “Physicians should encourage patients to specify their preferences regarding communication of their medical information, preferably before it is available. Moreover, 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.”http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics6/15/2010

13. David’s wife requests that he not be informed if the diagnosis is malignant.The physician should discuss with her the reasons for her request. An in depth discussion may lend to other issues at stake in this situation. She may have cause to believe that David would go through with his threat to kill himself. We also do not know if her request is time limited. Maybe she does not want him told until he is in a more improved mental status. There could be many reasons for this request. She may want to wait for other family members to arrive for an increased support system.

14. “The courts recognize situations where a physician’s nondisclosure will be excused. Under the therapeutic privilege, the physician may withhold information if disclosure would be upsetting or otherwise would interfere with treatment or adversely affect the condition or recovery of the patient.”http://www.piercelaw.edu/risk/vol2/winter/mertz.htm 6/16/2010

15. Disclosure does not have to occur all at once. The physician should determine the amount of information that the patient can assimilate at a time and tailor his communication accordingly.

16. David may indeed kill himself if he is informed of a malignant diagnosis. This does not mean he is ignorant, incompetent or does not understand.Everyone bases their opinions on personal life experiences. His views may be based on watching a loved one with cancer suffer, endure prolonged treatments, pain and lose all quality of life.

17. David’s wife is acting in his best interest when she requests that certain information remain undisclosed at this time. His wife knows him better than anyone else. She will be able to tell when David will be more able to receive additional information.

18. In summary the physician should discuss with David’s wife her reasons and time frame for wanting to withhold certain information.He should also find out what David’s requests are related to disclosure of information.The physician should disclose the information to David’s wife based on the fact that David at times suffers from mental compromise.

19. Who knows what his mental status would have been when time for disclosure occurred.However, the physician has cancelled the biopsy so at this point there will not be a result to disclose or withhold.