- Email: [email protected]
Multidisciplinary ethical problem presenting as toothache
Current Paediatrics (2002) 12, 519^521
c 2002 Elsevier Science Ltd doi:10.1006/cupe.2002.0336, available online at http://www.idealibrary.com on
Multidisciplinary ethical problem presenting as toothache Mark Brennan* and Richard Oliverw *Lecturer in Medical and Dental Education, UWCM,Visiting Senior Lecturer in Medical Ethics, Royal College of Surgeons in Ireland, Honorary Research Fellow,Centre for Ethics in Medicine,University of Bristol,UK and wSenior Lecturer/Honorary Consultant in Orthodontics, Dental School, University of Wales College of Medicine, Cardi¡ CF14 4XY, UK
KEYWORDS dentistry; haemophilia; hepatitis; Gillick consent; con¢dentiality; multidisciplinary approach; withholding of information
Summary The ethical issues associated with the multidisciplinary management of a 15-year-old boy with a medical history of haemophilia and hepatitis, who attended a dental teaching hospital in urgent need of dental treatment with a parent who disclosed his medicalhistoryin con¢dence, and who requested thatthe dentalpractitioner should not disclose this information to the patient, are presented and discussed.
c 2002 Elsevier Science Ltd
PRACTICE POINTS K
K
K
A person’s age is not always the main determinant of competence to consent Respect for the patient’s autonomy and right to information should increase as the patient grows in maturity Employing the ‘need to know’ principle is crucial to maintaining patient con¢dentiality
he required Factor VIII administration prior to surgical treatment. His parent also divulged that he was su¡ering from Hepatitis C, but insisted that this information should not be passed on to the patient. The dental treatment plan included extraction of teeth of poor prognosis which, due to the anxiety of the patient, may not be achievable under local anaesthesia.
THE ISSUES INTRODUCTION Clinicians are frequently challenged by situations that have complex ethical dilemmas. Ethical dilemmas often lack simple black and white solutions; identifying both the dilemma and its solution requires that clinicians develop the ability to discern shades of grey. This case covers both generic and speci¢c issues surrounding disclosure of information and consent in a multidisciplinary context.
CASE HISTORY AH was referred to a dental teaching hospital by his general dental practitioner when aged 15 years because of pain from a tooth in the lower right quadrant. Intra-oral and radiographic examination revealed several teeth of poor prognosis and a crowded maxillary dental arch. The medical history given by the accompanying parent revealed that he su¡ered from Haemophilia A, for which Correspondence to: RO. Department of Dental Health and Development Dental School, University of Wales College of Medicine, Health Park, Cardi¡ CF14 4XY, UK.Tel.: +44 29 20742 447. E-mail: [email protected]
In addition to the medical and dental management problems, we believe that there are a number of key ethical issues arising from this case:
Disclosure of information 1. Should the parent withhold the information about hepatitis from the patient? 2. Can the parent insist that we do not disclose this information to the patient? 3. Should the information be disclosed to other health professionals? 4. Who should disclose the information to the patient? 5. Whose information is it anyway?
Consent 6. Can we disclose the information to the patient without the parent’s consent? 7. Can we disclose the information to other health professionals without the patient’s or parent’s consent? 8. Is the patient able to consent to the appropriate treatment without the parent?
520
DISCUSSION Should the parent withhold the information about hepatitis from the patient? Withholding such information is not in the patient’s best interests. At age 15 years, he will shortly be able to sign his own consent, he was judged to be Gillick competent, and ignorance of his medical condition is dangerous both to himself and to others to whom he may unwittingly pass on the infection. This may include not only healthcare professionals, but also sexual partners. There are a variety of reasons why the parent might be intent on withholding the information from their child, not least because of over-protectiveness, or denial of the condition on their part. ‘Don’t tell my son/daughterFhe/she couldn’t handle it’ often translates as ‘I (the parent) can’t handle it.’ It may also relate to a lack of understanding of either the diagnosis, implications for health and safety of others or the prognosis for the patient and the condition post-treatment.
Can the parent insist that we do not disclose this information to the patient? We see a con£ict of duties between maintaining the trust and co-operation of the parent, and passing on essential information to the patient. A private discussion with the parent may help to resolve the issue, but if that fails then the clinician’s primary duty must be to the patient. As a rule, there is very rarely a good justi¢cation in law for withholding con¢dential information pertaining to a patient, even one who is still a minor. Indeed, it could easily be argued that a health professional is negligent (and liable to be sued) if they withhold such information, even if it is at the parent’s request. Health professionals sometimes ¢nd themselves in a position where they are invited to collude in unethical behaviour by others who would also claim to care for the patient (parents, partners, children of the patient, etc.); where such behaviour seeks to exclude the patient from decision making or information sharing, it is almost always wrong and unethical. Health professionals need to remember that they have autonomy tooFparticularly the autonomy to say ‘No’, and that autonomy should be respected by others.
Should the information be disclosed to other health professionals? In theory, medical information should remain con¢dential between the patient and the practitioner; in practice, this bond of con¢dentiality often extends to other members of the health professions, but should be restricted to those with a clearly identi¢able ‘need to know’. Each
CURRENT PAEDIATRICS
health professional who has contact with the patient should take a medical history, and all patients should be treated as if they are a risk by employment of routine cross-infection control methods. However, referral between health professionals, and in particular between the dentist and a Professional Complementary to Dentistry (PCD) such as a dental hygienist (who may be undertaking an invasive procedure) within the same practice, where a written referral is not customary, may result in a breakdown of the necessary crossinfection control measures. Furthermore, whilst healthcare professionals usually appreciate the risk of failure to disclose, patients may choose not to disclose information to those whom they consider do not need to know, especially if there is a social stigma attached to the condition.This is an additional reason for patients to be fully informed about their condition, and advised as to which healthcare professionals need to be told of their condition.
Who should disclose the information to the patient? Under ideal circumstances, the parent and patient should be together, and the information disclosed by someone with appropriate training for the task, has counselling skills, and can answer questions that will arise. Under the current circumstances, it would probably be inappropriate for the dentist to disclose the information, but might well be appropriate for the dentist to contact the patient’s medical general practitioner or hospital consultant (for example, in the haemophilia unit) in order that such a person may take on the responsibility. Prima facie, it seems surprising (and rather worrying) that neither of these doctors has already discussed the condition with both the patient and his parents.
Can we disclose the information to the patient without the parent’s consent? By not revealing the condition to the patient, we may be interfering with their autonomy. Whilst it would be better to disclose the information to the patient with the parent’s consent, there is no legal impediment to a health professional proceeding to inform the patient without such consent.
Can we disclose the information to other health professionals without the patient’s or parent’s consent? There is a clear duty of con¢dentiality between health professionals and their patients, however, we also have a duty of care to others, especially our colleagues. Within
MULTIDISCIPLINARY ETHICAL PROBLEM PRESENTING AS TOOTHACHE
dentistry, the dental surgeon has responsibility for his or her dental team, and hence referral to a hygienist must be accompanied by a relevant medical history. If the patient speci¢cally requests that we do not disclose con¢dential information that will have an impact on the actions of other healthcare professionals, our choice is either agreement (in which case the dentist may be liable to action by their employees, and would certainly have an impact on professional working relationships within the practice), discussion in an attempt to change their mind, breach of con¢dentiality, or onward referral. In such cases, it would be wise for the health professional to consult their defence organization. An alternative strategy that will avoid such con£ict is for the dentist to undertake the treatment themself. However, there are wider issues in relation to a di¡erent clinician attending to the patient on an emergency basis. This possibility highlights the need for important clinical information to be recorded in the notesFprivate agreements between clinician and patient frequently do not re£ect the best interests of either party. In all cases, it is important that careful, contemporaneous records of investigations, treatment, conversations and referral to other healthcare workers are maintained. In the case of a complaint against a clinician, defence organizations will require to see the notes from the outset; failure to produce the notes leaves the clinician in a very vulnerable position. The maxim ‘no notes equals no defence’ may be worth remembering.
Is the patient able to consent to the appropriate treatment without the parent? If the patient is perceived to be Gillick competent, then he or she is able to give consent without the parent. In this case, however, if the patient is not in possession of the information about hepatitis, healthcare professionals cannot discuss all aspects of the management of their
521
problem with them, and hence they cannot be said to give fully informed consent.
CONCLUSIONS This case study highlights several issues of ethical case management given in this issue of Current Paediatrics. Sometimes, health professionals assume that the purpose of con¢dentiality is to restrict patient information to those within the healthcare team; this is not so. In general, health professionals involved in the care of children and young people need to remember that: a person’s age is not always the main determinant of competence to consent; respect for the patient’s autonomy and right to information should increase as the patient grows in maturity; and employing the ‘need to know’ principle is crucial to maintaining patient con¢dentiality. However, the one person who almost always has both a right and need to know the information is the patient, and yet this case illustrates quite clearly the ethical dilemma when he or she is the only person who does not know. If health professionals truly believe that patient autonomy is worth respecting, even when it relates to young patients, it is incumbent upon them to ensure that those patients are empowered and enabled to exercise theirs.
FURTHER READING 1. Brazier M. Medicine Patients & The Law. London: Penguin, 1992. 2. The Dental Defence Union. Good Dental Practice. London: The DDU, 1998. 3. The UK Department of Health. Reference Guide to Consent for Information or Treatment. Available via the Department of Health websiteFwww.doh.gov.uk/consent 4. The General Medical Council. Duties of a Doctor. London: The GMC, 1998. 5. Waterston T, Curtis E. The rights of a child. Curr Paed 2001; 11: 28–32.
c 2002 Elsevier Science Ltd doi:10.1006/cupe.2002.0336, available online at http://www.idealibrary.com on
Multidisciplinary ethical problem presenting as toothache Mark Brennan* and Richard Oliverw *Lecturer in Medical and Dental Education, UWCM,Visiting Senior Lecturer in Medical Ethics, Royal College of Surgeons in Ireland, Honorary Research Fellow,Centre for Ethics in Medicine,University of Bristol,UK and wSenior Lecturer/Honorary Consultant in Orthodontics, Dental School, University of Wales College of Medicine, Cardi¡ CF14 4XY, UK
KEYWORDS dentistry; haemophilia; hepatitis; Gillick consent; con¢dentiality; multidisciplinary approach; withholding of information
Summary The ethical issues associated with the multidisciplinary management of a 15-year-old boy with a medical history of haemophilia and hepatitis, who attended a dental teaching hospital in urgent need of dental treatment with a parent who disclosed his medicalhistoryin con¢dence, and who requested thatthe dentalpractitioner should not disclose this information to the patient, are presented and discussed.
c 2002 Elsevier Science Ltd
PRACTICE POINTS K
K
K
A person’s age is not always the main determinant of competence to consent Respect for the patient’s autonomy and right to information should increase as the patient grows in maturity Employing the ‘need to know’ principle is crucial to maintaining patient con¢dentiality
he required Factor VIII administration prior to surgical treatment. His parent also divulged that he was su¡ering from Hepatitis C, but insisted that this information should not be passed on to the patient. The dental treatment plan included extraction of teeth of poor prognosis which, due to the anxiety of the patient, may not be achievable under local anaesthesia.
THE ISSUES INTRODUCTION Clinicians are frequently challenged by situations that have complex ethical dilemmas. Ethical dilemmas often lack simple black and white solutions; identifying both the dilemma and its solution requires that clinicians develop the ability to discern shades of grey. This case covers both generic and speci¢c issues surrounding disclosure of information and consent in a multidisciplinary context.
CASE HISTORY AH was referred to a dental teaching hospital by his general dental practitioner when aged 15 years because of pain from a tooth in the lower right quadrant. Intra-oral and radiographic examination revealed several teeth of poor prognosis and a crowded maxillary dental arch. The medical history given by the accompanying parent revealed that he su¡ered from Haemophilia A, for which Correspondence to: RO. Department of Dental Health and Development Dental School, University of Wales College of Medicine, Health Park, Cardi¡ CF14 4XY, UK.Tel.: +44 29 20742 447. E-mail: [email protected]
In addition to the medical and dental management problems, we believe that there are a number of key ethical issues arising from this case:
Disclosure of information 1. Should the parent withhold the information about hepatitis from the patient? 2. Can the parent insist that we do not disclose this information to the patient? 3. Should the information be disclosed to other health professionals? 4. Who should disclose the information to the patient? 5. Whose information is it anyway?
Consent 6. Can we disclose the information to the patient without the parent’s consent? 7. Can we disclose the information to other health professionals without the patient’s or parent’s consent? 8. Is the patient able to consent to the appropriate treatment without the parent?
520
DISCUSSION Should the parent withhold the information about hepatitis from the patient? Withholding such information is not in the patient’s best interests. At age 15 years, he will shortly be able to sign his own consent, he was judged to be Gillick competent, and ignorance of his medical condition is dangerous both to himself and to others to whom he may unwittingly pass on the infection. This may include not only healthcare professionals, but also sexual partners. There are a variety of reasons why the parent might be intent on withholding the information from their child, not least because of over-protectiveness, or denial of the condition on their part. ‘Don’t tell my son/daughterFhe/she couldn’t handle it’ often translates as ‘I (the parent) can’t handle it.’ It may also relate to a lack of understanding of either the diagnosis, implications for health and safety of others or the prognosis for the patient and the condition post-treatment.
Can the parent insist that we do not disclose this information to the patient? We see a con£ict of duties between maintaining the trust and co-operation of the parent, and passing on essential information to the patient. A private discussion with the parent may help to resolve the issue, but if that fails then the clinician’s primary duty must be to the patient. As a rule, there is very rarely a good justi¢cation in law for withholding con¢dential information pertaining to a patient, even one who is still a minor. Indeed, it could easily be argued that a health professional is negligent (and liable to be sued) if they withhold such information, even if it is at the parent’s request. Health professionals sometimes ¢nd themselves in a position where they are invited to collude in unethical behaviour by others who would also claim to care for the patient (parents, partners, children of the patient, etc.); where such behaviour seeks to exclude the patient from decision making or information sharing, it is almost always wrong and unethical. Health professionals need to remember that they have autonomy tooFparticularly the autonomy to say ‘No’, and that autonomy should be respected by others.
Should the information be disclosed to other health professionals? In theory, medical information should remain con¢dential between the patient and the practitioner; in practice, this bond of con¢dentiality often extends to other members of the health professions, but should be restricted to those with a clearly identi¢able ‘need to know’. Each
CURRENT PAEDIATRICS
health professional who has contact with the patient should take a medical history, and all patients should be treated as if they are a risk by employment of routine cross-infection control methods. However, referral between health professionals, and in particular between the dentist and a Professional Complementary to Dentistry (PCD) such as a dental hygienist (who may be undertaking an invasive procedure) within the same practice, where a written referral is not customary, may result in a breakdown of the necessary crossinfection control measures. Furthermore, whilst healthcare professionals usually appreciate the risk of failure to disclose, patients may choose not to disclose information to those whom they consider do not need to know, especially if there is a social stigma attached to the condition.This is an additional reason for patients to be fully informed about their condition, and advised as to which healthcare professionals need to be told of their condition.
Who should disclose the information to the patient? Under ideal circumstances, the parent and patient should be together, and the information disclosed by someone with appropriate training for the task, has counselling skills, and can answer questions that will arise. Under the current circumstances, it would probably be inappropriate for the dentist to disclose the information, but might well be appropriate for the dentist to contact the patient’s medical general practitioner or hospital consultant (for example, in the haemophilia unit) in order that such a person may take on the responsibility. Prima facie, it seems surprising (and rather worrying) that neither of these doctors has already discussed the condition with both the patient and his parents.
Can we disclose the information to the patient without the parent’s consent? By not revealing the condition to the patient, we may be interfering with their autonomy. Whilst it would be better to disclose the information to the patient with the parent’s consent, there is no legal impediment to a health professional proceeding to inform the patient without such consent.
Can we disclose the information to other health professionals without the patient’s or parent’s consent? There is a clear duty of con¢dentiality between health professionals and their patients, however, we also have a duty of care to others, especially our colleagues. Within
MULTIDISCIPLINARY ETHICAL PROBLEM PRESENTING AS TOOTHACHE
dentistry, the dental surgeon has responsibility for his or her dental team, and hence referral to a hygienist must be accompanied by a relevant medical history. If the patient speci¢cally requests that we do not disclose con¢dential information that will have an impact on the actions of other healthcare professionals, our choice is either agreement (in which case the dentist may be liable to action by their employees, and would certainly have an impact on professional working relationships within the practice), discussion in an attempt to change their mind, breach of con¢dentiality, or onward referral. In such cases, it would be wise for the health professional to consult their defence organization. An alternative strategy that will avoid such con£ict is for the dentist to undertake the treatment themself. However, there are wider issues in relation to a di¡erent clinician attending to the patient on an emergency basis. This possibility highlights the need for important clinical information to be recorded in the notesFprivate agreements between clinician and patient frequently do not re£ect the best interests of either party. In all cases, it is important that careful, contemporaneous records of investigations, treatment, conversations and referral to other healthcare workers are maintained. In the case of a complaint against a clinician, defence organizations will require to see the notes from the outset; failure to produce the notes leaves the clinician in a very vulnerable position. The maxim ‘no notes equals no defence’ may be worth remembering.
Is the patient able to consent to the appropriate treatment without the parent? If the patient is perceived to be Gillick competent, then he or she is able to give consent without the parent. In this case, however, if the patient is not in possession of the information about hepatitis, healthcare professionals cannot discuss all aspects of the management of their
521
problem with them, and hence they cannot be said to give fully informed consent.
CONCLUSIONS This case study highlights several issues of ethical case management given in this issue of Current Paediatrics. Sometimes, health professionals assume that the purpose of con¢dentiality is to restrict patient information to those within the healthcare team; this is not so. In general, health professionals involved in the care of children and young people need to remember that: a person’s age is not always the main determinant of competence to consent; respect for the patient’s autonomy and right to information should increase as the patient grows in maturity; and employing the ‘need to know’ principle is crucial to maintaining patient con¢dentiality. However, the one person who almost always has both a right and need to know the information is the patient, and yet this case illustrates quite clearly the ethical dilemma when he or she is the only person who does not know. If health professionals truly believe that patient autonomy is worth respecting, even when it relates to young patients, it is incumbent upon them to ensure that those patients are empowered and enabled to exercise theirs.
FURTHER READING 1. Brazier M. Medicine Patients & The Law. London: Penguin, 1992. 2. The Dental Defence Union. Good Dental Practice. London: The DDU, 1998. 3. The UK Department of Health. Reference Guide to Consent for Information or Treatment. Available via the Department of Health websiteFwww.doh.gov.uk/consent 4. The General Medical Council. Duties of a Doctor. London: The GMC, 1998. 5. Waterston T, Curtis E. The rights of a child. Curr Paed 2001; 11: 28–32.