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All in the family
Conduct and compassion Books Software Doctoring the risk society
Robert Harding Picture Library
Jabs & Jibes
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Joal Hill e-mail: [email protected]
1482
Conduct and compassion
All in the family he questions in the panel, and similar requests, present no obvious ethical concerns in the context of daily medical practice, unless we add that each is voiced by a physician’s relation. Even so, it may not be obvious why such routine matters pose problems. But closer consideration reveals many levels at which treatment of family members may compromise professional judgment and threaten familial bonds. Since it is obvious how this could occur when treating one’s own children or spouse, assume that these requests came from a cousin, aunt, or sibling. With regard to the first appeal to renew a prescription, it is likely that a physician could offer several reasons for refusing if asked the same question by a stranger. Pharmaceutical prescriptions should be written in the context of an overall plan of care, including knowledge of the patient’s medical history, considerations of other medications the patient may be taking, physical examination, and lifestyle issues that may make one medication or dosing schedule preferable to another. A close family bond confers none of this information, nor can it be obtained over the phone. The medication requested may be unfamiliar to the physician, or relate to a medical condition outside her knowledge and experience. Moreover, if the drug in question is a controlled substance there may be serious legal repercussions for writing this prescription. The physician might also ask how she would react to her own patients
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obtaining prescriptions from family members for convenience, and the extent to which such practices make it more difficult to follow compliance and response to treatment. The second example in the panel highlights how it may seem preferable to turn to a relation who is a physician if a family member is unwilling to see an unfamiliar doctor. However, the family bond that
wish to transfer his care in the future, if only for personal convenience, yet hesitate for fear of causing a rift in the family. More importantly, it should be noted that confidences disclosed in the course of a patient’s care may run counter to habits of family communication or trust. This child’s care may require divulging personal information that touches on sensitive family issues,
“My plane leaves in 6 hours and I forgot to renew my prescription. Can you write one for me?” ■ “Mom has not had a physical in years, and you are the only person she trusts. Can I bring her in?” ■ “I think the baby has a fever. Could you see him this afternoon?” ■
confers extra confidence when things go well may be all the more fragile should serious illness, medical error, or an iatrogenic event occur. Of course, it is not necessarily the case that such a turn of events would cause family members to experience a change of heart toward their relation. Even so, it is worth noting that physicians who have seen bad outcomes in the treatment of relations sometimes report a deep sense of guilt and regret that stems from a self-imposed belief that they owe more to a member of the family, even when they are convinced intellectually that they provided good care. The third scenario in the panel could play out to be unremarkable should the infant require only routine care. But, as in the second case, future events and reactions cannot be known in advance. Furthermore, there is more to consider than possible medical complications. For example, the parents of this infant may
which might cause the physician to be less than thorough in taking a history, or the parents less than truthful in responding. Either could compromise medical care. Additionally, while adults may be able to distinguish between professional actions and family ties, for small children it is not so easy. To the extent that this child feels fear or pain in the course of his care, he may avoid contact with “the doctor” at family gatherings, and be deprived of a loving relationship he could otherwise enjoy. Treatment of family members when no other medical care is available is certainly permissible, if not obligatory. Event treatment for short periods or for simple health issues may not be problematic. However, to the extent that such events give rise to deeper dependence, the possible ramifications for everyone concerned should be carefully considered.
THE LANCET • Vol 361 • April 26, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.
Robert Harding Picture Library
Jabs & Jibes
Rights were not granted to include this image in electronic media. Please refer to the printed journal.
Joal Hill e-mail: [email protected]
1482
Conduct and compassion
All in the family he questions in the panel, and similar requests, present no obvious ethical concerns in the context of daily medical practice, unless we add that each is voiced by a physician’s relation. Even so, it may not be obvious why such routine matters pose problems. But closer consideration reveals many levels at which treatment of family members may compromise professional judgment and threaten familial bonds. Since it is obvious how this could occur when treating one’s own children or spouse, assume that these requests came from a cousin, aunt, or sibling. With regard to the first appeal to renew a prescription, it is likely that a physician could offer several reasons for refusing if asked the same question by a stranger. Pharmaceutical prescriptions should be written in the context of an overall plan of care, including knowledge of the patient’s medical history, considerations of other medications the patient may be taking, physical examination, and lifestyle issues that may make one medication or dosing schedule preferable to another. A close family bond confers none of this information, nor can it be obtained over the phone. The medication requested may be unfamiliar to the physician, or relate to a medical condition outside her knowledge and experience. Moreover, if the drug in question is a controlled substance there may be serious legal repercussions for writing this prescription. The physician might also ask how she would react to her own patients
T
obtaining prescriptions from family members for convenience, and the extent to which such practices make it more difficult to follow compliance and response to treatment. The second example in the panel highlights how it may seem preferable to turn to a relation who is a physician if a family member is unwilling to see an unfamiliar doctor. However, the family bond that
wish to transfer his care in the future, if only for personal convenience, yet hesitate for fear of causing a rift in the family. More importantly, it should be noted that confidences disclosed in the course of a patient’s care may run counter to habits of family communication or trust. This child’s care may require divulging personal information that touches on sensitive family issues,
“My plane leaves in 6 hours and I forgot to renew my prescription. Can you write one for me?” ■ “Mom has not had a physical in years, and you are the only person she trusts. Can I bring her in?” ■ “I think the baby has a fever. Could you see him this afternoon?” ■
confers extra confidence when things go well may be all the more fragile should serious illness, medical error, or an iatrogenic event occur. Of course, it is not necessarily the case that such a turn of events would cause family members to experience a change of heart toward their relation. Even so, it is worth noting that physicians who have seen bad outcomes in the treatment of relations sometimes report a deep sense of guilt and regret that stems from a self-imposed belief that they owe more to a member of the family, even when they are convinced intellectually that they provided good care. The third scenario in the panel could play out to be unremarkable should the infant require only routine care. But, as in the second case, future events and reactions cannot be known in advance. Furthermore, there is more to consider than possible medical complications. For example, the parents of this infant may
which might cause the physician to be less than thorough in taking a history, or the parents less than truthful in responding. Either could compromise medical care. Additionally, while adults may be able to distinguish between professional actions and family ties, for small children it is not so easy. To the extent that this child feels fear or pain in the course of his care, he may avoid contact with “the doctor” at family gatherings, and be deprived of a loving relationship he could otherwise enjoy. Treatment of family members when no other medical care is available is certainly permissible, if not obligatory. Event treatment for short periods or for simple health issues may not be problematic. However, to the extent that such events give rise to deeper dependence, the possible ramifications for everyone concerned should be carefully considered.
THE LANCET • Vol 361 • April 26, 2003 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet Publishing Group.