A debate in the BMJ has discussed whether patients should or should not be told about beneficial treatments that are available but inaccessible, usually because of the cost, highlighting the need to balance issues of ethics, pragmatism and humanity.
The 'yes, tell them' case was built on an example of a man losing his vision in both eyes from macular degeneration who was seeking the opinion of an ophthalmologist about a new treatment that could be prescribed but had not yet been approved by clinical guidelines or funding authorities. There were many unknowns, such as whether the patient or perhaps the family would or could pay for the drug.
"If the ophthalmologist does not tell him that such a treatment exists, the patient will not even be able to consider his options," the case stated. "Depriving the patient of such knowledge is not only depriving him of choice but is a dereliction of professional duty. It is the doctor who must be the patient's advocate, and it is a betrayal of trust if the doctor does not act in the patient's best interests."
Doctors had some responsibility for the effective management of health care resources, and for those employed within health systems there was sometimes a genuine conflict of interest between their duties as employees and their responsibilities to patients. However, these concerns had little bearing on the rights or wrongs of informing patients about their diseases and potential treatments. It was the right of the citizen to know and the obligation of the doctor to impart this knowledge.
Similarly, it was quite reasonable for health care funders to pay for some treatments but not others. "But it is the grossest hypocrisy to pretend to provide universal health care when it cannot, and worse if the only way of maintaining the fiction is to deprive citizens of the knowledge of treatments that would benefit them," it said.
The 'no, don't tell them' case was essentially one of pragmatism. It discussed a frail and financially disadvantaged 79 year old with renal failure who would benefit from erythropoietin for which there was no budget. There was a need to respect autonomy, but real autonomy also required the capacity for choice and this man had none. There was also a risk of doing harm rather than good, as he ruminated on the treatment that was unavailable to him. "So I keep silent," the doctor stated.
Reference
Marcus, R. Firth, J. 2007, 'Should you tell patients about beneficial treatments that they cannot have?' BMJ vol. 334, pp. 826-827.
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