PATIENTS RIGHT TRUTH TELLING INFORMED CONSENT CONFIDENTIALITYVictoria Edna G. Monzon, MD, FPCP, FPCC, FCGCChairman, Department of BioethicsUST Faculty of Medicine and Surgery

PATIENTS RIGHTSPatient has the right to receive information from physicians and to discuss the benefits, risks and costs of appropriate treatment alternatives.Patients should receive guidance from their physicians as to the optimal course of action. Patients are also entitles to obtain copies or summaries of their medical records.

4. They have the right to have their questions answered, and to receive independent professional opinions.5. The patient has the right to make decisions regarding the health care that is recommended by his physician. He may accept or refuse any recommended medical treatment.6. The patient has the right to courtesy, respect, dignity, responsiveness and timely attention to his or her needs.

Doctors too have rights from their patientsThey have the right to support and cooperation, truth, respect, good reputation, gratitude and professional fee.

Corollary obligations are to maintain confidentiality, to avoid harming patient, to proceed in accordance with the wishes of the patient once the appropriate information has been presented so that an informed voluntary decision can be made.

PATIENTS REFUSAL OF MEDICAL ADVICESuch refusal is often related to a failure of communication or trust or both, in the physician-patient relation.Some patients may not want a specific intervention for personal or religious reasons.Some may be uncertain or confused because of contradictory information from several health providers.

PHYSICIANS REFUSAL TO TREATThere is no obligation on the part of the physician to provide a specific intervention or treatment it is runs counter to his or her good judgment.A physician may respond and be guided by medical standards, second opinion or policy statement based on socio-economic guidelines.

If disagreement with patient cannot be resolved or a proposed treatment is morally unacceptable to the physician, transfer of the patient to the care of another competent physician is appropriate.

INFORMED CONSENTIt is voluntary acceptance of physicians recommendations for treatment or research investigations by competent patients or surrogates who have been furnished with truthful information regarding the risks, benefits and alternatives of the proposed interventions.

ELEMENTS OF INFORMED CONSENTCompetenceAdequate informationUnderstanding or comprehensionVoluntariness

INFORMED CONSENTSurrogate represents the patients interests and previously expressed wishes in the context of the medical issues, they are usually designated before critical illness.Types of SurrogateDurable power of attorneyPatients family or the courtMoral surrogate who best knows the patient and has the patients interest at heart.Surrogate decision maker represents patients best interest or may use substituted judgment.

CONFIDENTIALITYThe physicians obligation to preserve the principle of medical confidentiality is based on a concern for protecting the physician-patient relationship and a desire to respect patients right to privacy.

CONFIDENTIALITYA. FoundationsHistorical BackgroundHipprocratic OathWhat I may see or hear in the course of the treatment, or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.

HISTORICAL BACKGROUNDThomas Percivals medical ethics in 1803 says Secrecy and delicacy, when required by peculiar circumstances should be strictly observed. And the familiar and confidential intercourse, to which the faculty are admitted in their professional visits should be used with discretion and with the most scrupulous regard to fidelity and honor.

PATIENTS BILL OF RIGHTS AHA, 1973Patient has the right to expect that all communications and records pertaining to his care should be treated as confidential.

International Code of Medical EthicsWMAA doctor owes to his patient absolute secrecy on all which has been confided to him or which he knows because of the confidence entrusted to him.

CONFIDENTIALITYA physicians duty to observe the principle of confidentiality is a very important moral obligation, but not an absolute obligation or ones only obligation.

POSSIBLE GOUNDS FOR VIOLATING THE PRINCIPLEThe principle may come into conflict with the rights of the patient himself.That it may come in conflict with the right of an innocent third party.Serious conflict between the principle and the right or interest of society in general.When he is called to testify in court.

CONFIDENTIALITYIn Case of HIV patient who refuses to inform third parties who may not be infected yet but will surely have future contact with the individual what can possibly be done.1. Attempt to persuade the infected patient to cease endangering the third party or to notify the third party of the risk.2. If persuasion fails notify an authority who can intervene.3. If the authority takes no action or is not available, tell the patient what you are going to notify the third party of the risk.

TO WHOM SHOULD MECIAL INFORMATION BE DISCLOSED?To the competent patientIf the patient is unable to comprehend the information, to whoever is in charge and makes decision for the patient (parent of a child)To those who may be afflicted by patients health (children, subordinates, innocent 3rd party, employers, employees).

TRUTH TELLING

A decision to reveal a grave prognosis which maybe ethical in itself maybe unethical if the physician tells the patient bluntly and then withdraws, without offering any emotional support to help the patient resolve his feelings.

The question should not be Should we tell?, but rather, How do we share this with the patient?

TRUTH TELLINGPATIENTS HAVE THE RIGHT TO THE TRUTH ABOUT THEIR HEALTH BECAUSE THEY HAVE THE PRIMARY RESPONSIBILITY FOR THEIR HEALTH.

FALSEHOOD - False statementLIE - False statement made to someone who has the right to a true answer.

Truth TellingISSUES:Has the patient a right to know the truth?Has the doctor an obligation to tell it?What is truth? Deception?What if the patient does not want the truth or does not ask for the truth?Can the physician initially disclose information to the family without the patients consent?

Truth TellingPATIENTS RIGHT TO THE TRUTH VS. NONMALEFICENCE

DECEPTIONMisrepresenting the facts as physician sees themWithholding them

Why is deception immoral?Because they keep from the patient what is rightfully his (truth about himself) - acts of theftBecause they deny to another what is his due as a free and responsible person - acts on injusticeHe who once lies is never believed, even when he is telling the truth.German Proverb

What if the patient does not ask for the truth?When the patient has no desire to know the truth and the doctor has good reason to believe that the patient does not want to know it, the doctor should respect his wishes through it may be part of his role to help his patient to want the truth and to be able to accept it.

What if...When the patient is too ignorant to ask for the information acquired by the doctor, it is clearly the doctors moral obligation to supply it, together with the explanation of its meaning and importance.

TRUTHThe Right to know the truth does not apply to all truths.As far as truth telling, what is at stake is honesty.A part of the truth which the doctor owes the patient is: that the doctor cannot be absolutely correct.We are obliged to tell the truth as we see it according to our best knowledge.

Can physician initially disclose truth to the family without patients consent?The best policy is to ask the patient both at the outset and as the illness progresses about the extent to which he or she wants to share information and to involve others in the disclosure of decision-making process

Truth TellingShould truth be told?What truth?How much?By whom?When?How?

To tell or not to tell?Before 1970s - physicians preference of protecting patients from the news of impending death from cancerUS physicians: 55% - 79% was most likely to tell patientsCanadian: moderately likely to tell(49% to 67%)British: least likely (45% to 44%)

Justifications of physicians:Disclosure can set off a destructive interplay of psychological and physical processes that result in worsening of patients condition.In case of painful treatment or risky procedure, physicians warn that the power of suggestion can exuberate pain and side effects unnecessarily to decline to participate in randomized treatment.

Justifications...Medical works prior to the 1970s tended to assume that revealing a fatal diagnosis would cause patients to experience painful emotions, commit suicide, refuse needed care or give up hope and die more swiftly.

Objection to above justifications:Some studies showed that patients coping skills are enhanced; cooperation with treatment is increased and levels of anxiety are reduced when they are provided with adequate information about their illness.

Kelly et. al. found that 89% of their respondents wanted to know their diagnosis of cancer. Subsequent studies in Australia, Scotland and Canada report the same high proportions of patients with cancer who would like to hear from their physicians about the nature of their malignancies or other illness.

Issues to be resolved:Is the right to be informed absolute or can it be overriden?If yes, can the patients spouse under certain conditions assume the right to prevent his being informed of the true state of his health?

Does professional and personal honesty demand that the physician always speak the truth?May a patient be deprived of the right to prepare for his death if his death is known to be imminent?

SURVEY ON THE DYINGBy Alora, Lumitao, MonzonDo you want to be told the truth?YES - 88%If so, who should tell?1. Attending physician - 82%2. Closest relative3. Closest friend4. Religious or chaplain5. Others

Circumstances and cultural interpretations influence what patients and families desire to know and how they want to be told.

Kubler Ross strongly opposed disclosing detailed predictions of life expectancy

Truthful disclosure is a key element in a good professional -patient relationship

Sharing bad news involves timing and a commitment to continuing empathy, compassion, reassurance and conversation.

Health professionals who withheld truth from patients reflected several concerns:Denial of their own and the patients fear of dying.Unconscious wishes to foster dependency in their patients.The concern that discussing death constituted admitting failure.Manipulation of hope to encourage more extensive treatment choices.

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