Nature Clinical Practice Neurology has a salient article on ethics and medicine. The article asks the question: is it ethical to confront an individual with whom you do not have an official doctor-patient relationship, if you think they have a medical problem? Should you or should you not tell them if you see a medical problem?
Neurology is unique among the medical specialties in that much of the clinical examination can be appreciated visually and taught by use of video recordings.3, 4 Since 2003, we have conducted a ‘neurological localization course’, during which participants are taught correct clinical examination techniques with the help of patients.5 Trainees are often impressed by the wealth of clinical information that can be gleaned by observation alone; for example, how the externally rotated, slightly plantar-flexed attitude of the lower limb of a supine patient can hint at the possibility of an underlying footdrop, or how muscle atrophy, diabetic dermopathy and trophic changes can not only provide clues to an underlying peripheral neuropathy, but can even indicate the level of the stocking paresthesia.
Several weeks after our encounter with the woman with choreiform movements, we were enjoying another post-rounds breakfast-cum-discussion when our attention was drawn to a colleague whose subtle neck and facial movements were accompanied by grunting noises while eating–phenomena indicative of complex motor tics, rather than the more facile explanation that he was really enjoying his morning porridge. When he had left, the medical student attached to our team asked the obvious question: with the evidence staring us in the face, why did no one inform him of the diagnosis and proffer appropriate treatment? Having acknowledged the proverbial ‘elephant in the room’, we launched into an animated discussion about a physician’s duty of care, asking whether the ethical imperative to treat exists only in a medical emergency or after the establishment of a formal doctor-patient relationship.
Few would argue that doctors have a moral and legal obligation to render assistance in the event of a medical emergency.6 A formal doctor-patient relationship likewise provides a doctor with the moral and legal imperative to practice ‘good medicine’. Hence, a neurologist seeing a patient for diabetic polyneuropathy would not hesitate to enquire about symptoms of hyperthyroidism when the patient has a noticeable goiter, despite its apparent irrelevance to the case. Indeed, the same doctor would be thought negligent if he were to ignore or fail to notice a goiter in a patient with myasthenia gravis, in view of the known associations between these two conditions.
Was our group remiss because we did not inform the stranger with choreiform movements or our colleague with tics of their diagnoses, simply to avoid embarrassment?
Read the whole thing.
I can tell you that I run into this issue all the time since I got into medical school. You would be shocked about the amount that you can know about someone’s medical history just by looking at them.
For example, in the last month, I have seen at least two people on the subway with digital clubbing — a symptom usually associated with heart or lung problems. Considering that neither of them had O2 tanks and both were coughing profusely and were short of breath, I doubt that either had been diagnosed with something. As one of the things they could be diagnosed with is lung cancer, I considered the possibility of asking whether they were OK.
Another time, I saw someone with spider angiomas and a mild yellow tinge to their skin — both suggesting liver disease. The guy didn’t stink of alcohol, so it might have been hepatitis.
I can’t even tell you the number of homeless people in our neighborhood wandering around a weird wide gate characteristic of Wernicke-Korsakoff syndrome. Wernicke’s encephalopathy is caused by thiamine deficiency — usually secondary to alcohol abuse. It causes degeneration in part of the cerebellum that helps you maintain balance, so patients have a really wide gate to keep from falling over.
These are just some examples.
In all of these cases, I didn’t say anything. Partly that is because I am not a real doctor yet. But even if I were, I don’t think I would. Partly it is because their problems weren’t acute. If I saw someone on the subway who didn’t look like they would finish the ride without being resuscitated, I would definitely do something. But mostly it is because I consider it a violation of their privacy to do so.
There are many things that can go wrong with your body. There are many people in this world that would like to destroy their bodies blissfully unaware of those consequences. What right do I have to inflict my values on them? (Even if I saw them in a hospital setting, someone who doesn’t want to get healthy isn’t going to. A heroin addict is likely going to get worse in spite of any tongue lashing I give them.)
Further, what if I suspect they have something wrong with them that no one could make better? What about Huntington’s disease or end-stage cancer? It may be that they would want to finish what remains of their lives unburdened by a diagnosis.
They may even know what they have already, and my confrontation would only remind them of a very unpleasant fact — adding to their pain.
I feel like this is an issue that a lot of doctors and medical students struggle with. On the one hand, we have this special knowledge. We try to use that knowledge to make people better. On the other hand, this knowledge gives us a lot of access into people’s private lives. People often don’t want that information revealed, and particularly not paraded in front of them.
So what’s the verdict? Aside from acute cases like performing CPR — where it is obviously appropriate — when do you think it is ethical to offer medical advice to a stranger?