2000 Ethical Case Discussion Case 1) The Successful Businessman, Unsuccessful Patient

Here is another case for student discussion forwarded by Dr. Masashi Shirahama of Saga Medical
School, Japan:

Case 1) 55-year-old male. He is working as a man-of-ability marketing-department chief of a
construction company. He was a very busy person, so he did not go to the clinic for rechecking,
although diabetes was pointed out by the company medical checkup about 2 years ago.
He drinks alcohol every day as part of his negotiations with customers.
Recently, he felt thirsty and tired and went to the hospital for further examination. The glucose
level was 350 (very high level) and insulin secretion was very low. So the doctor said to the
patient, "You should be admitted to the hospital immediately and begin insulin therapy".
But the patient refused hospital admission, because he is very busy and plays an important
role as a chief and he cannot be absent from his work.

If you were this patient's doctor in charge, what do you do to this patient?


Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life Sciences,
Michigan State University, East Lansing, MI USA.

The Successful Businessman, Unsuccessful Patient (Japanese case)
 Monday, January 24, 2000 12:04 PM

This case describes a fairly typical psychological reaction to illness. A certain number of heart
attack victims like this man, who could have survived with prompt medical attention, end up
dying because they stay at their offices, treating themselves for "heartburn," until they drop dead
several hours later. So denial of the seriousness of the illness is bound up with the practical
problems of how to run a business when the responsible person is away from the office.

There are therefore two ways to think about this case, roughly corresponding to an ethical and a
psychological approach.

The ethical approach starts from the acceptance of the principle of patient autonomy and asks
whether this patient shows signs of impaired capacity to make medical choices. Presumably he
would be found competent to choose by any formal psychiatric examination (simply making a
mistaken choice does not equate with being unable to make choices) and so a quick-and-dirty
ethical judgment would be that he should be allowed to assume the risks of untreated diabetes
once he has been informed about those risks. This ethical approach may sound "minimalist" (in
Daniel Callahan's terms) and neglectful of one's deeper duty of care to the patient; but actually
it sets up the psychological approach in a helpful way. This patient, I would suggest, feels a
strong need to be in control, and so by promising that you will respect his autonomy in any
event, he may feel enough in control to then listen to the rest of what you say to him.

The "rest" in a case like this may be trying to find a way to use the patient's management skills
to address the medical problem at hand. The wisest physician would think of a way to compare
the problem with diabetes management to a kind of problem the patient may face in his own
business. This is legitimate since obviously with untreated diabetes this patient will soon be
physically unable to work at all, and so at some level he must know that his refusal to get care is
irrational. By presenting the problem of diabetes management to the patient, as one would seek
a consultation on a business matter, the physician approaches him respectfully as an ally. The
patient may then decide to cooperate rather than fight the physician. The skills he is most proud
of-- his business management skills-- are now being appealed to in the service of his own

In the US we tend to treat most diabetes these days in the outpatient setting which greatly
simplifies the care of this sort of patient. He can continue to work and still bring his diabetes
under control.

Back to the English Home Page

If you kindly give me your comment on this case, please send me your E-mail to the following E-mail adress.
And if you have interest in these case discussion, I hope to send you the new cases.
Please tell me your E-mail adress.

Masashi Shirahama M.D.
Director, MItsuse National health Insurance Clinic
Lecturer, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan

TEL0952-56-2001, FAX0952-56-2912
Home Page:http://square.umin.ac.jp/masashi