Pure Pedantry

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?

Comments

  1. #1 Joseph
    March 31, 2009

    Your main concern seems to be over whether it would be an invasion of privacy to diagnose strangers. But surely you wouldn’t be interrogating them? You would simply suggest they consult their GP, right? If they want to continue the discussion with you, then they will. If they don’t, well, you’re not forcing it on them. Or are you worried about the minor embarrassment they might feel, that unpleasant self-conscious feeling? If so, I still don’t see how this outweighs the fact that your efforts would occasionally be beneficial.

  2. #2 G.E. Wilker
    March 31, 2009

    I Am Not A Physician, Or An Ethics Expert, but I’d suggest that the decision whether to speak up should at least in part weigh the probability that the problem will otherwise go undiagnosed until it progresses to a point where treatment will be difficult. As you pointed out, there’s little use in approaching someone about a possible disease that can’t be treated. If it’s something fairly obvious, the odds are good the person either knows and isn’t recieving treatment for some other reason, or will notice on their own soon enough to get timely help.

    If, however, you notice something unobvious – something only a neurologist would be likely to spot, and not the patient or their regular doctor – that suggests a treatable disease for which early treatment is important, speak up! You might be doing the person a great favor.

  3. #3 CB
    April 1, 2009

    If I were walking around with something treatable I would greatly appreciate it if passing doctors spoke up instead of just walking on by to avoid hassling me. I think the key would be just to be polite about it.

  4. #4 bsci
    April 1, 2009

    I think the other hard case is whether you might know something a GP might not. For an example, in the 1970’s & 80’s Tourette’s Syndrome was not as well known. A child might bounce around to dozens of diagnoses, but as soon as a neurologist or someone with knowledge of Tourette’s sees the child the diagnoses could sometimes be made from across a street.

    The same argument could go for autism instead of mental retardation in the 1980’s and earlier.

    If you have specialized knowledge and think someone is misdiagnosed or not diagnosed, speaking up could completely change someone’s life.

  5. #5 C
    April 1, 2009

    http://news.bbc.co.uk/1/hi/england/nottinghamshire/7922429.stm

    http://www.handresearch.com/news/handshake-diagnosed-brain-tumour.htm

    Here’s two links (both stories originally reported on the BBC) where patients believed that the doctor that stopped to express concerns saved their lives.

  6. #6 speedwell
    April 1, 2009

    I am not a doctor, either, but I wish you doctors would speak up if you feel comfortable… You could begin with, for example, “I am a [GP, surgeon, specialist in X, etc.] and I noticed you seem to have symptoms of untreated [condition]. Have you talked about the possibility with your doctor?”. You would do a lot to balance all the unqualified fools who, instead of saying, “Bless you, are you OK, here’s a tissue”, instead say, “You know, you should drink more water, eat [fad diet of the week], and take these obscure supplements”.

    Most of you doctors are very good with people, and you know how to speak with immense tact. Please be aware that there are some things that everyone can tell they suffer from. Most fat people know they’re fat, for instance, and most pregnant women are already being treated by someone. One drawback of speaking up is that if you actually treat the condition, you look like you’re drumming up business. That’s not a terrible thing, since you are a certified expert and your diagnosis is your proof you know what you’re talking about, but you don’t want to be seen as an “ambulance chaser.”

  7. #7 JASZ
    April 1, 2009

    MYOB! says the lawyer to the doctors

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  9. #9 Comrade PhysioProf
    April 3, 2009

    Interesting question. I believe that people have the right to be left the fuck alone in the absence of some emergency situation. If some random asshole walked up to me in a public place and started a conversation leading to some kind of diagnosis I would tell the motherfucker in no uncertain terms to get the fuck away from me.

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  12. #12 jemantar
    August 4, 2009

    I had this dilemma just the other day and was reflecting on it. I googled to look for any journal articles about it which is when I came across this. Evry1 I ask says that they wouldn’t say anything – People have a right not to know about something.
    My experience is that I was just getting off the train when I noticed a dishevelled man in flip-flops who I thought may have been homeless. On closer inspection I noticed he had a large blackened toenail that showed the classic signs of melanoma – streaking of the nail as it grows over the lesion,and starting to ulcerated the nail. I thought of saying something but I just didn’t know whether I should….I am also a med student so not exactly an authority. I ended up just walking away. I have since decided I should have said something but some colleagues argue that since it was ulcerating, which is a bad prognostic factor that suggests lower invasion and metastases, treatment would likely be palliative and I wasn’t going to save his life anyway so he would be better off not knowing and enjoying that oblivion. But I am still sorry that I did not say anything.
    I am sorry, whoever you are.

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