The comments on yesterday's ethics post are terrific. Please keep them coming. I'm working on responding to each one in context.
One, though, I'm promoting to it's own post, because the author asks particularly interesting questions that require more space for examination:
I don’t really see an ethical problem here.
I love that phrase, and what follows, so let's discuss.
First, contemporary doctors in most countries are forced to practice “defensive medicine”, i.e. they are trying to protect themselves against possible lawsuits. The most important thing is to have impeccable documentation.
I've argued previously that a medical ethics course should be a pre-requisite for medical school admission. The ethics of our profession are not easy to follow, and before committing to being constrained by them for a lifetime, a student has the right to know what they're getting into. The commenter's first point shows exactly why she doesn't see an ethical problem: she is focused primarily on the physician's well-being. While the physician's well-being is important, it is not primary. Ignoring the unfounded assumption that most doctors practice "defensive medicine", she is correct about good documentation being vital. But it is not the "most important thing." The most important thing is providing good care, and usually, proper documentation furthers this goal. But not always.
After explaining to the patient that a doctor cannot lie in the chart and after informing her/him of their other possible options, they are free to choose what to do.
This is certainly true. Transparency is important, but it's also important not to back a patient into an insoluble dilemma. The patient wants my help and I am ethically bound to provide it, within certain parameters. I certainly cannot lie in the chart (barring extreme circumstances such as guarding dissidents in a totalitarian regime or something), but this is not a dichotomous problem.
Second, I can’t really sympathize with such patients because what they are trying to do is shift the responsibility for their own medical problems and their consequences solely onto their doctors (not only for STDs, but even for the running nose of their children). This is not how the doctor-patient teamwork should function.
The patient has a problem. Who "caused" the problem is largely irrelevant in providing proper care (aside from explaining to the patient the nature of disease and prevention, which she probably already understands). I don't see her trying to "shift responsibility" as such, but she is reaching out for help. She feels trapped, and from her perspective, my "lie" will help mitigate the harm of her actions. I may believe her assumption to be wrong, and I will tell her that. But it's not about blame.
Third, if a patient doesn’t want to to disclose a piece of sensitive information, he/she is not obliged to but once it’s on the table, there is little they can do about it.
An actual, dynamic doctor-patient relationship does not close doors. Yes, she cannot make me "forget" the information, but neither should I tell her she no longer has any control over what happens. This may cause harm to someone I'm trying to help.
The comment is one I expect to hear from many of my colleagues. It is much more biased toward paternalism than patient respect and autonomy, a set of values that has shifted but that many clinicians still need to catch up with.
It is important to remember that the first goal is to provide care that helps the patient, minimizes harm to the patient, and does so respecting her autonomy, privacy, and dignity. How the physician feels is much less important.