Cross-cultural miscommunication has undermined this immigrant's trust in his physician. How do you respond to his demand that alternative therapies be discussed?
A 60-year-old immigrant from Germany is diagnosed with widely metastatic colon cancer. His sigmoid tumor is nearly obstructing, and he undergoes a laparoscopic hand-assisted sigmoid colectomy, from which he recovers successfully. His staging CT scans demonstrate multiple bilobar liver metastases, bilateral small pulmonary nodules, and upper retroperitoneal lymphadenopathy. The initial consultation focuses on a discussion of the extent of the patient’s disease, its incurability, and an approach to therapy that includes the use of multiple, sequential chemotherapy regimens aimed at improving his length and quality of life. The patient calls 2 weeks later and tells me that I “disrespected” him by only focusing on chemotherapy and not mentioning alternative treatments, including those offered at some of the well-known alternative treatment centers around the US. What ethical obligations should guide me in deciding whether I should continue to treat the patient? Do I have an ethical obligation to discuss alternative treatments with the patient?
Two separate ethical questions are raised by this case. The first concerns the ethics of the doctor-patient relationship, and the second concerns obligations to discuss unproven therapies in the context of an informed consent discussion.
The patient’s claim that he felt “disrespected” because alternative strategies were not discussed suggests that the relationship may be irreparably damaged on account of the patient’s perception (which both came as a shock to the treating physician and was upsetting to him). Such incidents-irrespective of how the physician perceives their validity-can be extremely harmful to the creation and sustaining of a therapeutic relationship; they are particularly damaging at the beginning of such a relationship. However, with few exceptions (eg, a patient who verbally or physically threatens staff), a physician cannot sever the relationship-even though patients can fire their doctors. My worry in this case is that re-establishing trust with this patient is likely to be difficult given his perceptions of the first interaction with his physician. I also suspect that there is either a hidden cultural or linguistic issue (ie, what did the patient mean by “disrespected”, and did the physician understand his meaning as he understood it?) In any case, I feel that, ethically, severing the relationship is not an option for the treating physician, even though it would be within the patient’s rights to end it. I have debated whether it might be helpful for the physician to have an open discussion about the patient’s feelings of disrespect in an effort to repair the damage; ultimately, however, I don’t feel that such a discussion is likely to lead to a different perception, and it might come across as defensive, so my recommendation is that he not pursue such a conversation.
As for the question of whether discussing alternative therapies is something a physician is ethically obligated to do, I think the short answer is no. Those of us trained in, and who believe in, Western, scientifically-driven, allopathic medicine should not have to include discussions of unproven therapies as part of a comprehensive informed consent discussion. Offering an opinion about such treatments, when asked directly, certainly seems reasonable when patients desire to know the physician’s opinion.
The patient decided not to return to the physician to seek care and died within 6 months of this interaction.
Disclaimer: The advice offered in this ethical consultation feature is based solely on the information supplied by readers, and is offered without benefit of a detailed patient history or physical or laboratory findings. The information is offered as a discussion of ethical issues and is not intended to be medical or legal advice and, therefore, should not be considered complete or used in place of a formal ethics consultation or in place of seeking advice from your ethics committee, legal counsel, or other available resources. One should never disregard or change medical advice or delay in providing it because of something that is printed here. The opinions expressed here are only those of the author and do not reflect the viewpoint of Cancer Network.