To tell or not to tell: A case of informed consent

In medicine, there is a perennial conflict between the physician’s overarching goal of preserving the personal well-being of his or her patients, and the patient’s right to make independent decisions. Just a few decades ago, it was standard policy that physicians did not obtain the informed consent of their patients. This paternalistic policy stemmed largely from the belief that physicians, with their years of training and expertise, knew what was “best” for the patient. In the 1990s, these views began to change when people began to realize that sometimes the physician may not know which option is best for a patient. Moreover, even if he or she is confident in the outcome, the patient may not necessarily choose this option. In some cases, patients may refuse certain procedures out of principle (e.g., Jehovah’s Witnesses refusing blood transfusions); in other cases, patients may decide that they don’t want to live anymore and refuse life-sustaining treatments. In his article “What Makes Someone’s Life Go Best?” Derek Parfit suggests that the best decisions (i.e., medical decisions) must allow the person to fulfill goals and values to the extent that the person is capable at the time and that this decision must outweigh the benefits of other alternatives. In terms of patient well-being, I think happiness can be defined as the fulfillment that individuals experience from achieving their life goals and values, and personal good as the degree to which they succeed in this endeavor. To better illustrate these ideas, I will introduce the case of Mr. Williams in an article written by author John D. Arras.

Mr. Williams was a 40-year-old black man who had recently been married and had two young stepdaughters. On his first visit, Mr. Williams had been diagnosed with mild hypertension. Dr. Sylvia Kramer, his primary care physician, prescribed regular exercise and healthy diet in order to avoid burdening her patient with costly anti-hypertensive drugs. However, despite his best effort, Mr. Williams’ blood pressure remained consistently elevated during subsequent check-ups. The concern was that if his blood pressure wasn’t lowered, Mr. Williams could be at risk for more serious health problems such as a stroke. To avoid this, Dr. Kramer had to decide if she should prescribe hydrochlorothiazide, a relatively cheap, diuretic drug with one minor risk—about 3 to 5 percent of males who take the pill are likely to experience sexual impotence. A fellow colleague and senior physician in her program advised her not to tell Mr. Williams about the potential risks, not only because the side effects are highly unlikely and reversible, but because she may cause him to be so worried about the drug that he refuses to take it at all. Dr. Kramer is concerned that if she follows the senior physician’s advice, Mr. Williams, a shy man, may not bring up the topic of his sexual impotence to his female physician, which in the long run might affect the happiness of his marriage.

I found Mr. Williams’ case interesting because it illustrates a realistic example of the conflict between the physician’s goal of preserving the well-being of his or her patients and preventing the occurrence of further complications, and the patient’s right to be informed of consequential side effects. In this case, I believe Dr. Kramer should sit down with Mr. Williams and discuss the possibility of using the hydrochlorothiazide as a second line of defense against his hypertension, in light of past failures with dieting and exercise. Dr. Kramer should explain why she thinks it would be best for Mr. Williams to address his hypertension sooner rather than later and fully explain the likelihood and types of side effects the drug may cause, as well as the reversibility of these effects. I fully support efforts to persuade patients—however, the decision to take the drug should ultimately be up to Mr. Williams. I do not support the paternalistic decision of not informing Mr. Williams about the risks for two reasons: First, not telling Mr. Williams the potential risks may seriously affect his personal relationship and mental well-being, and second, I believe that forgoing consent is a great disrespect to the patient’s decision-making abilities and violates a person’s rightful control of his body.

Mr. Williams’ case demonstrates the intrinsic values of both personal good and personal choice, and exemplifies the complexities of medical decision-making. As long as the patient is competent, patient rights to informed consent must be respected as much as possible, because ultimately, it is his or her body. No matter how confident a physician feels about a particular procedure, the patient must be fully informed of any potential risks and give his or her consent. Though others may come to different conclusions, I believe that having a defined view on topics in medical ethics is essential to becoming a good physician, because these principles will almost inevitably be challenged throughout later years of medical practice.

Georgia McLendon, Trinity ’14, is a Duke pre-med. This column is the ninth installment in a semester-long series of weekly columns written on the pre-med experience at Duke, as well as the diverse ways students can pursue and engage with the field of medicine.