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"Should health care professionals ever withhold the prognosis
from dying patients (12 years old to adult)"
Opening Arguments
Pro Side:
We feel that physicians do have the right to withhold prognosis in certain
cases because experts have proven that in many cases disclosing too much
information is more harmful and dangerous to the patient than simply addressing
immediate problems and concerns.
a.) According to a document that we acquired from the Department of
Medicine at Genessee Hospital in Rochester, New York….
Physicians have 6 basic roles when disclosing bad news to a patient:
1.) Minimizing aloneness and isolation for both patient and physician
2.) Achieving a common perception of the problem
3.) Giving information tailored to the immediate needs of the
patient
4.) Addressing immediate medical needs, including the risk of suicide
5.) Responding to immediate discomforts
6.) Delivering the bad news to the patient.
-
We also included in this portion of the debate information from Dr. Elisabeth
Kubler-Ross, M.D. one of the foremost authorities in the field of death
and dying for over 20 years. Dr. Ross' first book On Death and Dying
is today considered one of the major texts on the subject and is used widely
in medical school curricula. The following is an excerpt of the interview
that I found:
"Interviewer: Is there ever any justification for not being honest
with someone who is dying, about the fact that they are dying?"
"Ross: You have to be honest, but you don't have to be totally honest.
You have to answer their questions, but don't volunteer information for
which they have not asked, because that means that they are not ready for
it yet. Without miracles, there are many, many ways of helping somebody
without a cure. So you have to be very careful how you word it. And never,
ever take hope away from a dying patient. Without hope nobody can live.
You are not God. You don't know what is in store for them, what else can
help them, or how meaningful, maybe the last six months of a person's life
are."
-
Our second point is from the physicians point of view in that they have
sworn in the Hippocratic oath to keep the health of their patient's as
their first consideration. A couple of relevant term to define here are
autonomy and non-maleficence. Autonomy is the individual's right to make
decisions on their own behalf; whereas non-maleficence is the physicians
duty to do no harm. In some cases such as the ones we are discussing here,
there is conflict between these two predominant principles of medicine.
In certain situations, the principle of non-maleficence may be seen as
predominant (why this is able to be decided by the physician is part of
our third major point). The physician must access each individual patient
and decide if autonomy weighs more heavily or if the principle of non-maleficence
weighs more heavily. Keep in mind that the Hippocratic Oath that all physicians
take says that even if there is a chance to do harm unto a patient then
it should be avoided (this includes psychological trauma from prognosis
disclosure in my opinion).
-
Physicians have the right to withhold prognosis because society has ascribed
the role to them of deciding competency and deciding the role/importance
of autonomy. Autonomy we have already defined, but now we will define competency
as well. Competency is defined as "the capacity to weigh, to reason, and
to make reasonable decisions about the risks and benefits of treatment."
There were some examples here that I thought were relevant to understand
the point I was making here….. 1.) What if the person is unable to understand
the prognosis if told? What good would it serve? What if it only scares
them more and takes away all hope from their final days? Whether we feel
that withholding prognosis is always fair or not … we certainly should
not say that it should NEVER be done. We have attempted to outline cases
in which prognosis SHOULD be withheld.
B. Con Side:
-
The first main point that we want to make is that failure in prognosis
disclosure is in how the patient is told, rather than if or how
much they are told. Doctors are trained to cure rather than to care for
their patients, there needs to be a multidisciplinary approach with health
care professionals such as community nurses, psychotherapists, social workers,
and psychologists. We feel that mutual trust and respect is very important
when the doctor dealing with a patient suffering from a terminal illness.
Naturally, we know that the patients will be shocked and distressed upon
hearing the true diagnosis about their condition, but at least they know
the truth and can come to terms with it. We should also consider the consequences
of not telling a patient of their illness. If a patient is not informed
of the full diagnosis then they are not informed of the appropriate therapy
and not informed of the side effects. Hiding the diagnosis which is meant
to protect the patient from the painful truth is ultimately depriving the
patient of their autonomy.
-
The second main point we wish to make is that adolescents are able to handle
the truth because they have advanced cognitive thinking abilities. Consider
the following real-life scenario, "A teen has a painful, fatal disease
and is ready to die, her parents aren't ready to let her go … what would
you do?" In this real-life case the courts deemed that the teen was competent
and capable of making her own decisions, so they allowed her to die as
she wished.
One example of a well-known organization that is closely associated with
dying teens and children is the Make-A-Wish Foundation. This organization
makes it a point not to tell the children, although the majority of the
children already know all facets of their disease. A lot of the children
reportedly tell people at the foundation about their condition, in sincere
and honest terms. And according to the Make-A-Wish foundation, children
that are not told are able to read their parents actions and emotions and
realize what is going on.
In one study that I read about leukemia patients, children who were
not told had strong feelings of being abandoned or isolated. One girl said,
" Daddy doesn't care about me. I know he comes to visit me practically
every day, bit once he comes he always seems so far away. It's like he
can't wait to leave again." According to experts, this fear of abandonment
stems from the fact that the parents are distancing themselves from their
children.
In Maria Nagg's 3 stages of Death Comprehension, Stage 3 (9-10 years
old) view death as personal, universal, final, and inevitable. I believe
that this is the same way that most adults see death as well. When children
learn ,ore and more about their particular illness, they become more sophisticated.
For example, children learn the names of various treatments, drugs, changes
in body, etc.
Another aspect of adolescent competence and right to choose and have
their prognosis revealed to them comes from our interpretation of the American
Medical Association's Principles of Medical Ethics. The first point I want
to consider here is that "The physician shall be dedicated to providing
competent medical service with compassion and respect for human dignity."
The second point listed here is that "A physician shall deal honestly with
patients and colleagues, and strive to expose those physicians deficient
in character or competence or who engage in fraud or deception." I think
that this all relates to my original statement that adolescents understand
because they have advanced cognitive thinking capabilities.
Patients have a right to know the truth. They may want to take care
of such things as wills, or future guardians for their children, or they
may have last words to say to loved ones or friends; thus this is our third
reason why we feel it is wrong to not disclose the full prognosis to a
dying patient.
Rebuttal of Points Made By Both Sides:
Pro Side Rebuttal:
The main point that we attempted to make in the rebuttal was that we were
not arguing for a withholding of prognosis on a wide scale term, but rather
to point out that there were circumstances than made the nondisclosure
relevant and practical. We also attempted to point out that we were not
trying to provide a blanket or "all-inclusive" answer to a problem, we
just wanted the audience to realize that there were special cases that
were the exception to the rule and we wanted people to see the issue form
that viewpoint. Also we argued against an example that they gave of a 17
year old boy who had always known of his terminal condition and felt better
because that he had known and was able to deal with it. Our argument was
that this was great for that particular individual , however what about
those young adults or children that can't handle it? Once they know everything
there is no way of taking back that knowledge … it is something that they
will always know and be thinking about on some level every day until they
pass away.
Con Side Rebuttal
The main point that we wanted to argue against was that we were not advocating
for removing hope from the patient. We feel that hope is very important
as does the other side in the well-being of a patient, we in no way meant
to come across as being desensitized towards the patients feeling. In addition
we want to emphasize that the patient who is terminally ill should be told
gradually, not abruptly or broadly.
Questions Posed By the Class During the Debate
This section of the debate was rather long and extensive and it was not
really possible for us to be able to write down all of the questions and
responses that were asked and given. However, questions and criticisms
that were posed to us will be addressed in a later section.
Concluding Remarks
Pro Side Closing Remarks
Our main point in closing was that knowledge is seen as a powerful and
dangerous thing. From our text book it was mentioned that when a patient
claims that he or she is seeking the plain truth, often times this means
that the truth is the last thing that the patient really wants. Another
philosophical concept that we wanted to leave the class with was that the
expression "to have the right to the truth is unmeaning, rather a man has
a right to his own truthfulness, a subjective truth in his own person."
Next, we gave a personal example from someone in our sides family who
responded the way that many scientific and psychological experts predict.
The person upon being told of their complete diagnosis was not really able
to handle it so well and this person's health begin to decline as if their
will to live was no longer as great as it was before they found out. We
also gave examples of what various people in the medical field felt about
our debate topic and how these real life situations really seem to work
in the real patient situation. We presented information from physicians,
chaplains at local hospitals, ER Nurses, ICU Nurses, CCU Nurses, Life-support
Nurses, and hospital security officials. Most agreed that sometimes not
telling the patient every single detail about their condition is in the
long run what is best for them. These real life experts gave personal testimony
of what can happen when a patient can not handle the disclosure of their
full prognosis.
The final thing we did was to reiterate our three main points and why
we believed that they were important. Our first point was that physicians
have the right to withhold prognosis because health care workers have proven
that disclosing too much information is more harmful than simply addressing
immediate concerns and discomforts. Our second point was that physicians
have sworn in the Hippocratic Oath to "do no harm" unto patients and this
includes psychological trauma. Thus many physicians feel it is their duty
to not disclose too much information for fear of inflicting psychological
harm unto their patients. Our third and final point was that physicians
have the right to withhold prognosis in those cases where competency is
questioned and where the patient seems to be unable to make a well-informed
decision on their own behalf (used to illustrate an extreme case, but to
show there are cases when nondisclosure is appropriate).
Con Side Closing Remarks
The main ideas we wanted to end the debate with was a reemphasis of our
three main points which we felt sufficiently expressed all those ideals
that argued most strongly for our viewpoint. Our first main point was that
the "failure" that occurs in disclosure results not from what or
how much the patient is told but rather the way in which
they are told of their condition. Our second main point was that we felt
adolescents should be told the entire truth about their condition because
they are able to handle it due to their possession of advanced cognitive
thinking ability. Our third main point was that people have the need to
know the truth in order to deal with issues like wills, child care once
they are gone, saying good-bye to loved ones, etc. It was these three points
which we felt argued the most strongly for why the patient always has the
right to be told their prognosis when they are dying.
Questions and Comments That We Received From The Class
The questions and comments that we received as feedback from the class
were really helpful in showing us those aspects that we did well or poorly
as well as showing us things that we should have possibly considered more.
In this section we wish to share a few of the comments that we received
so that everyone has the chance to think about these new ideas and possibly
get even more out of the debate. One comment we received was that the pro
side should have provided more points to support their arguments. We were
(according to the guidelines) limited to presenting only the main three
points that we felt best supported our argument. It was for this reason
why we did not share more, and there were more good reasons we could have
used, it was just that those were the three that we thought were the best.
Another criticism was that we should have used more props (etc. posters,
etc.) in our debate. Our response to this is that the two opposing sides
had to maintain strict guidelines about not discussing the debate before
we presented the debate. Thus it would have been difficult to have known
what to make posters of without breaking this "gag" order imposed upon
us. In addition, we don't feel that in a debate posters and props are as
important as they would be in presentations. We just wanted everyone to
understand that what we were doing was a new format for the class, and
there would be distinctive differences between the regular presentations
and our debate. Another comment was that an audience member felt that we
did not sufficiently address long-term illnesses. We apologize if there
was any misunderstanding, but we thought (it is difficult to remember since
in a debate so much is played by ear) that both sides addressed long term
terminal disease as well as short term terminal illnesses. One thing that
seemed to be the most common advice of things that we should have done
differently was that we should have included more on informed consent.
In retrospect, we agree that this should have played a larger role, but
when we were compiling information for our arguments neither side came
across it. We all wish that this point could have been included since it
was relevant to what we were discussing and we thank those individuals
that pointed this out to us.
The majority of the class seemed to enjoy the debate since it encouraged
so much class participation as well as caused each individual to think
more about their own views on the subject. The consensus was that the debate
was well organized and also presented well. We appreciate all comments
made, whether they were good or bad, and we hope that we have addressed
the majority of your queries here in this portion of our debate outline.
We also wanted to add that the response to our debate on the listserv has
been phenomenal and we hope that everyone keeps asking us more questions
about this topic.
Sources Used In This Debate
Campbell, Steve. Personal Interview. 20 Feb. 1998.
Carmichael, Chaplain. Personal Interview. 20 Feb. 1998.
"Contemporary Health Care and the Ethics of Medicine," May 1997.
Internet. http://www.cmss.org/workgroups.html
"Ethical Principles and the Doctor," Feb. 1998. Internet. http://www.Vftp.monash.edu.au/PUBLICATIONS/LEM/01.ETHICAL.PRINCIPALS
Harvey, Mark (Chaplain). Personal Interview. 19 Feb. 1998.
ICU/CCU/ER Nurses. Personal Interviews. 19 Feb. 1998.
Jose. (VA Police Officer). Personal Interview. 20 Feb. 1998.
Legal Issues In Psychiatry. Author unknown. Section 52.1
Penn, Dennis. Personal Interview. 20 Feb. 1998.
Quill, TE. "Bad News: Delivery, Dialogue, and Dilemmas," Arch
Inernal Med (7FS) Mar. 1991: 463-8.
Ross, Dr. Elisabeth-Kubler. Internet Interview. http://www.Doubleclickd.com/kubler.html
UK Doctors and Nurses. Personal Interview. Feb. 21 1998.