Ethical Case Discussion with the last year medical students
of introductory clinical medicine course, 2000



Case 6)
This time, I would like to present the case in which the medical student feel ethical dilemma in the clinical clerkship.

One 5th year medical student (In Japan, usually the medical students study in the ward in 5th and 6 the year) took care of the 64 year old female who is suffering from jaundice owing to the end stage gallbladder cancer.
The doctor in charge said to the student "The patient's family strongly asked the doctor not to tell the truth. So the patient was told that the diagnosis was difficult gallstone. If the patient asked the diagnosis, you should not answer it."
Under the instruction from the teacher, the student goes to the patient room every day. The patient liked to talk with the student because the student's age is just as same as the patient's grandchildren who lives abroad.
After these good relationship between the student and the patient, the patient said to the student, "My true diagnosis is cancer, and incurable isn't it?"
The medical student surprised and answered "I am a medical student and I don't know the diagnosis in the detail. Please ask the doctor in charge."
But after that conversation, the patient did not want to talk with the student and denied to accept the physical examination by the student.

(Question)
What the student should do in this case?
What the instructor/teacher in this clinical clerkship or the doctor in charge should teach for this student?



Mike Fetters (University of Michigan, Department of Family Medicine)
               
I do not think that all patients in Japan or anywhere necessarily must be told the cancer diagnosis.
However, when the patient asks for the truth, I believe that great consideration must be given to the patient's preference.
Due to the power dynamics between the attending and the student, the student should probably first speak to the attending and tell the attending that the patient has specifically asked to be told the truth.
I think the student should explain that he/she is aware of the family's wishes, but also he/she is aware of the patient's clear preference.  This may be new information to the attending , and the attending should then explain what he thinks should happen given the patients EXPLICIT request for information.
If the attending still insists on following the family's preference, the student should speak with the family to make it clear that the patient suspects that it is gall bladder cancer, and further that the patient wants to know if it is or not.
It would be worth exploring with the family in a family conference why they think the patient should not be told.  Most people think the patient will lose hope.  However, many times the patient fears abandonment, and lack of attention from the family.
If the student convinces the attending and family about disclosing cancer to the patient, this will alllow him/her to become close to the patient again.  Also, the student can continue to attempt to see the patient.  The patient may well have come to realize that he/she has cancer.  Therefore, the patient's moods are likely to change, and may well include anger.  You are probably aware of the stages of death and dying by Kubler Ross.  If the student stops going to see the patient, the student too will be abandoning the patient, and this is most likely the patient's most important fear.
If the attending and the family still forbids this, the student, again because of the power difference between the student and his attending and the family, may not be able to go further.  In this case, I would ask the student what he/she thinks she be done.  As a teaching moment, it may be more important to help the student formulate an approach for how  he/she will practice medicine and influence others.
The data from Japan suggests more physicians are telling patients they have cancer.  This is a transition.  The transition cannot be expected to change all at once.
Hope this is helpful.  Let me know what you think.



Yooseock Cheong M.D.
Department of Family Medicine
Dankook University, College of Medicine, Korea

There are lots of similar cases in Korea.
Korean people have more strong familial bond than western people. Family involves many important decision instead of patient(especially elderly patient). I think that beneficience or nonmaleficience rule is more important than patient's autonomy in oriental countries traditionally including Korea and Japan. We are more paternalistic than Western society.  That's one of the major reason that family and the attending don't want to inform the patient.
I'm a physician in Korea also, but I cannot agree to this kind of tradition personally. It's negligence of patient's autonomy.  As the physician's obligations are to the patient, not to the family, it is reasonable to try to speak to the patient, without family as the intermediary, in order to ascertain the patient's preferences.  In this case, the student couldn't do anything mort than he had done("I am a medical student and I don't know the diagnosis in the detail. Please ask the doctor in charge." ).   The attending physician, however, should inform the patient for preparing dignified death. If the attending keeps the secret to the patient, he/she cannot give any educational message.  The change comes slowly with increasing patients' right to know about their real situation in Korea.



Maurice Bernstein, M.D.
Assistant Clinical Professor of Medicine
University of Southern California School of Medicine

I think the student said the right words.  It should be the responsibility of the Attending physician to decide whether to communicate.  In some cultures, the family or the communal group such as Navajo indians declare that the patient should not be told a diagnosis.
However, whenever a competent patient requests a diagnosis, that patient should be informed despite the declaration of others to the contrary.
If the patient does not ask then a physician may follow the family's decision, if it appears to be in the patient's best interest.  This is though a difficult situation in most states in the U.S. since by not telling a diagnosis,  full informed consent by the patient for treatment cannot be established.
Fortunately, in California USA, a new law was passed and signed last July where a competent patient can, at any time, designate a surrogate to immediately learn the diagnosis and make decisions for the patient without the patient needing to know or decide.  Unlike previous legal directives, the surrogate does not have to wait until the patient becomes incompetent to act.  This law will certainly remove the ethical and legal dilemma which this case raises.

Comment from Masashi Shirahama
I also agree with your opinion. But in Japan, these situation still persists, so the students or residents have this kind of conflict.
And I think the informed consnt only to the patient is still heavy to the patient. Some people do the Family consent.
Please read the following paper.
*************************************************************
A.Akabayashi, M D Fetters and T S Elwyn: Family consent, Communication,
and advance directives for cancer disclosure; a Japanese case and
discussion. Journal of Medical Ethics, 25:296-301, 1999.
*************************************************************
>   Fortunately, in California USA, a new law was
> passed and signed last July where a competent patient can, at any time,
> designate a surrogate to immediately learn the diagnosis and make
> decisions for the patient without the patient needing to know or
> decide.  Unlike previous legal directives, the surrogate does not have
> to wait until the patient becomes incompetent to act.  This law will
> certainly remove the ethical and legal dilemma which this case raises.
Is this "surrogate" means the family who knows the pateint's desire? Are your patients usually have their surrogate legally?

Re-comment from Maurice Berstein
<<Is this "surrogate" means the family who knows the pateint's desire?Are your patients usually have their surrogate legally?>>

A surrogate is usually anyone, but often is a family member, who has the understanding of the patient's desires and goals and can communicate them to the physician when the patient is unable to do so.  However, a legal surrogate is a person who in the U.S. has been selected previously by the patient and incorportated into the Durable Power of Attorney for Health Care and is able to legally speak for the patient.  That means that whatever the legal surrogate decides for an incompetent patient is as though the patient himself has expressed a decision.  In California, we now can have a perfectly competent patient say verbally (in words) "I want Mr. A. as my surrogate and he is to learn about my diagnosis and he is to make all the decisions for me now".  Mr. A then becomes the legal surrogate and immediately can make decisions.  There is no need now for Mr. A. to wait until the patient becomes incompetent.Most of my patients still have not selected a legal surrogate.



If you kindly send your comments on this case, please send it to the
following mail address.

mailto:HQC00330@nifty.ne.jp

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Masashi Shirahama M.D.
Director, Mitsuse National health Insurance Clinic
Clinical Professor, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan
mailto:HQC00330@nifty.ne.jp