Blog | Tuesday, June 5, 2012

Ethics rounds

A 35 year old woman comes to see you for a sore throat. It began about a week ago with fever, chills, and a tickle in the throat. The throat became rapidly worse, making swallowing painful. She feels that her "glands" are swollen. She mentions that her spouse thought there was also a rash. She has a headache.

Her past medical history is negligible, having had no history of diseases other than childhood ear infections and strep throat. She has had two normal vaginal deliveries and four pregnancies that were not brought to term. She smokes one pack per day of cigarettes and an occasional marijuana cigarette. She does not drink alcohol.

She does not have a cough, shortness of breath, chest pain, or any other symptoms than those listed.

On physical exam, her temperature is 38.5 degrees Celcius (about 101 degrees Fahrenheit). She is in no significant distress. Her voice is muffled. She has enlarged tonsils with some white patches. She has tender, swollen lymph nodes in her neck. She has a fine, bumpy rash on her trunk.

You do a rapid strep test in your office and it is negative (sensitivity about 80 to 90%). You consider doing additional testing.

Among the relatively common conditions you are considering are: plain old upper respiratory infection, strep throat, mononucleosis, other bacterial infections of the throat, thrush, gonorrhea, herpes, and HIV.

Since beginning to see you the patient has signed a yearly "General Consent to Treatment", which states, in part:

By signing below, I, (or my authorized representative on my behalf) authorize ____________________ and their staff to conduct any diagnostic examinations, tests and procedures and to provide any medications, treatment or therapy necessary to effectively assess and maintain my health, and to assess, diagnose and treat my illness or injuries. I understand that it is the responsibility of my individual treating health care providers to explain to me the reasons for any particular diagnostic examination, test or procedure, the available treatment options and the common risks and anticipated burdens and benefits associated with these options as well as alternative courses of treatment.

Right to Refuse Treatment: In giving my general consent to treatment, I understand that I retain the right to refuse any particular examination, test, procedure, treatment, therapy or medication recommended or deemed medically necessary by my individual treating health care providers. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and/or treatment.

What are you obligated to tell the patient before performing the tests for the diseases you are considering?

Respecting a patient's autonomy (one of our current ethical imperatives) means providing informed consent, that is, telling the patient anything they reasonably need to know to make decisions about their care. If this is taken ad absurdum, we would be asking permission to specifically examine each toe (which we do not). Some procedures though require more specific informed consent. Any surgery requires the surgeon to tell the patient what they can expect, good and bad, from the procedure. A breast or genital exam requires specific consent (ethically). What about blood tests?

Some blood tests are more "ethically loaded" than others. A prostate specific antigen (PSA) test requires a discussion rather than a check mark on a lab sheet. When we order a PSA, we set off a series of potential events (biopsies, radiation, chemotherapy). We don't know precisely what a screening PSA test tells us, so we have to talk about it first. Some patients choose to get one, some do not.

Other more common blood tests do not typically come with a specific discussion of consent. We often order blood counts or electrolytes as part of the course of diagnosing and treating patients. It's not that these cannot reveal serious diseases--they can. Why don't we normally get specific consent?

Some of the tests we are contemplating doing for our patient are the more ethically loaded type, specifically HIV. In the early days of the pandemic, a positive HIV test could mean the loss of your home, job or life. Since then, the social stigma and danger has decreased a bit, but it's still "different."

A diagnosis completely changes one's life, medical, social, and in other ways. Most physicians and physician groups see HIV testing as somehow different, even though we wish it weren't. Because of the consequences of testing, we generally will discuss the test in some detail before ordering it. This discussion will usually include your pre-test probability of HIV given in lay-terms, and the consequences of negative and positive results.

Even though HIV is now recommended as part of standard yearly health screening, we treat it differently.

Should we?

Peter A. Lipson, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. After graduating from Rush Medical College in Chicago, he completed his internal medicine residency at Northwestern Memorial Hospital. This post first appeared at his blog, White Coat Underground. The blog, which has been around in various forms since 2007, offers "musings on the intersection of science, medicine, and culture." His writing focuses on the difference between science-based medicine and "everything else," but also speaks to the day-to-day practice of medicine, fatherhood, and whatever else migrates from his head to his keyboard.