NationStates Jolt Archive

Consult a magic 8 ball.

I've been spending my ever so exciting Saturday evening and night (thank you cancelled dinner date!) reading a book about initial cancer information interviews, and have found the following ethical dilemma interesting.

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis. This patient has not had any thoughts or suspicions about his/her illness being cancer, and will thus only start thinking in that direction and worrying about it if you tell him/her about your suspicion and what the goal of the work-up is.

Do you tell your patient and risk him/her worrying "for nothing" if a malignancy is not found, or do you withhold that information and risk the patient possibly ending up with a cancer diagnosis that for him/her has come out of the blue? How do you ethically defend your position?

Even though I have taken a stance myself, I am curious as to other people's reasoning about this and to see what will prove to be "popular".

I personally would think that informing the patient of your concern, so that they could be prepared for the situation, and risk it being non-malignant in nature; than to not notify them, and have them find out later after the cancer has grown in size and danger... The sooner it is diagnosed, the better chance the patient has of recovering...

Yes, you should say something. I had a doctor pull some crap like that with me last week - run tests for something other than what I was asking about. I was a bit upset, to say the least.

What's the ethical dilemma?

You're just withholding information that they should know about..

I'd rather hear:

"There are a number of possibilities and some are more serious than others. We're going to try to rule out some of the more serious ones first such as cancer. It isn't likely, but thes sooner we know for certain, the better."

than:

"It's probably nothing serious."

A week later...

"It's cancer."

I would tell them my suspicions, but qualify it by saying that nothing is definite yet. In things like these, "exciting" is bad.

Tell him or her your suspicion. If it is cancer, they'll be somewhat prepared, and if it isn't, they'll be relieved to learn that they'll live after all. Not to mention if you tell them it isn't serious and then inform them that they have cancer, you'll be giving them additional anxiety over your competence.

Wouldn't withholding your concerns get you into serious trouble with the Medical Board if your patient did indeed have a malignant growth?

Surely one reason ppl go to quacks is for their expertise. They need to be able to trust their doctor's instincts and training.

An analogy I can think of would taking my car in for a service. I rely on and trust the mechanic's far greater knowledge and experience to tell me if they think there might be something wrong with my car that needs further checking.
Stitch in time and all that.

I would tell them about my suspicion and I would also tell them that I hope that I can rule it out, but if it's not then at least we know what we're dealing with and we can begin treatment immediately.

What's the ethical dilemma?

The ethical dilemma lies in the choice between what "harm" to the patient one wishes to risk occurring.

You're just withholding information that they should know about..

What "they should know about" is in many instances not clear-cut - I am of the opinion that it is not in this scenario.

Given how serious and disruptive cancer is, I'd say it's better to give them the foreknowledge so that they can prepare for the inevitable financial and personal burden that will accompany cancer treatment. Springing it on them when they may not be prepared is almost certainly going to be far, far worse than the psychological stress of knowing ahead of time. Imagine what could happen if they were already struggling financially or emotionally, and then had another colossal burden heaped on to their already fragile state; at least with foreknowledge, they can begin planning to ensure that if it is a positive diagnosis they will be at least somewhat ready to deal with it.

Of course, my opinion is motivated by the fact that I've seen the impact of cancer on my relatives (all of whom were fortunate enough to be successfully treated), and I know that if there were any chance of me having cancer, I'd definitely want to know as soon as possible.

I think the doctor should inform the patient of their suspicions, even if they turn out to be unfounded. In fact, I think the doctor has an obligation to do so. I would much prefer to find out early on, even if I worry about nothing & it turns out to be a false alarm, than to be hit with it as a fait accompli, so to speak, further down the track.

I'd rather hear:

"There are a number of possibilities and some are more serious than others. We're going to try to rule out some of the more serious ones first such as cancer. It isn't likely, but thes sooner we know for certain, the better."

Assume that you cannot say whether it is likely or not.

"It's probably nothing serious."

I need to clarify: you do not attempt assuage the patient in such a fashion. If you choose not to share, you simply don't share. You do the work-up and the patient, as many patients do, does not him/herself demand to know what it's for.

Tell him. He'll be prepared for the possibility that it is cancer, and he'll be relieved if it turns out to be something else.

What "they should know about" is in many instances not clear-cut - I am of the opinion that it is not in this scenario.

I'd say it depends in large part on how invasive the testing is.

from a practical standpoint, i believe doctors are mostly trained to disclose as much information as possible, perhaps not so much for ethical reasons, but for legal reasons.

poor doctor-patient communication are the cause of most medical lawsuits. in this case, withholding information is clearly a breakdown in communication.

let's break it down into contingencies: the outcome is either cancer or no cancer. if the outcome is no cancer, in the end the patient has no cause to worry. the forthright doctor loses slightly by worrying his patient temporarily, but in the long run, no harm done.

however, if the outcome is cancer, the patient would have to worry about the disease. in practically all cases, it is much better to have disease awareness and time to plan early on, rather than later. the withholding doctor loses greatly because he 1) stole the patient's time that could be used to mentally, financially, and otherwise prepare for the upcoming illness; and 2) he will traumatize the patient by breaking the news out of the blue, as opposed to the forthright doctor who broke the news gradually.

so the forthright doctor is opting for a small cost (temporary worry) to protect against a catastrophic cost (lost time, sudden disclosure), whereas the withholding doctor is risking a catastrophic cost for a temporary gain (or breaking even, if you will).

both doctors are gambling with the patient's emotions. in the case of the forthright doctor, he is adequately buffering against extreme outcomes, whereas the withholding doctor is taking a bigger risk. ethically, the conservative approach (the forthright doctor) wins.

But he/she will have been caused anguish over a falsity. How do you argue for valuing "relief" over "avoidance of anguish"?

Yes, but what if he does have cancer and is caused anguish over you not telling him sooner? Apparently in this scenario it's damn if you do, damn if you don't.

Tell him. He'll be prepared for the possibility that it is cancer, and he'll be relieved if it turns out to be something else.

But he/she will have been caused anguish over a falsity. How do you argue for valuing "relief" over "avoidance of anguish"?

But he/she will have been caused anguish over a falsity. How do you argue for valuing "relief" over "avoidance of anguish"?

The proper phrase is he/she may be caused anguished over a possible falsity... There is obvious cultural differences as well,in the US if he does have cancer, and you do not inform the patient, you've opened yourself to a possible malpractice suite if the patient, or the family later finds out you had the concern and did not inform/act on it. I would say the health of the patient, and getting to the problem far outweigh "avoidance of anguish".

The ethical dilemma lies in the choice between what "harm" to the patient one wishes to risk occurring.



What "they should know about" is in many instances not clear-cut - I am of the opinion that it is not in this scenario.

Meh, I'd just be like "Standard procedure.. at your age.. couldn't hurt.."

Make it sound like a non-issue, until it's something to worry about.

though I suppose the cost and nature of the diagnosis vs the probability of malignancy would need to be considered.

Say the diagnosis procedure is very costly and invasive while the chances of malignant growth is extremely low and you know the patient cannot afford the diagnosis cost, so is likely not to get it (or at least be put on a waiting list at the public hospital for months). Is the added stress of thinking they might have cancer for weeks or months and being able to do nothing about it worth the extremely minimal chance that there might actually be something there?

And then there's the cost-benefit of using all those resources and monies in doing diagnosis on a patient with an extremely low chance of having a malignancy versus spending it on a patient who the doctor feels is much more likely to have a cancerous growth.

I'd say it depends in large part on how invasive the testing is.

Naturally outside of a thought experiment it would be pretty difficult to, say, perform a colorectal biopsy without informing the patient the reasons thereto, than it would be to get a CT or MRI, but let's assume that such practicalities that "force" you one way do not exist.

But he/she will have been caused anguish over a falsity. How do you argue for valuing "relief" over "avoidance of anguish"?

citing a possibility does not constitute a falsity.

citing a possibility does not constitute a falsity.

It does after the fact - he/she will have worried over something not true (thus false). Nota bene: not a lie.

It does after the fact - he/she will have worried over something not true (thus false). Nota bene: not a lie.

at the time of the statement (ie the time of incomplete knowledge of future outcomes), listing all possibilities is the closest thing to the truth. to withhold information at the time is the closest thing to a lie. to apply, post hoc, the value of falsity to the act of complete disclosure, is ethical backtracking.

I'd rather hear:

"There are a number of possibilities and some are more serious than others. We're going to try to rule out some of the more serious ones first such as cancer. It isn't likely, but thes sooner we know for certain, the better."

than:

"It's probably nothing serious."

A week later...

"It's cancer."

i agree.

its important to warn the patient that something bad might be up. otherwise it comes out of left field and they will feel that you lied to them when you didnt mention that it was a strong possibility.

from a practical standpoint, i believe doctors are mostly trained to disclose as much information as possible, perhaps not so much for ethical reasons, but for legal reasons.

poor doctor-patient communication are the cause of most medical lawsuits. in this case, withholding information is clearly a breakdown in communication.

let's break it down into contingencies: the outcome is either cancer or no cancer. if the outcome is no cancer, in the end the patient has no cause to worry. the forthright doctor loses slightly by worrying his patient temporarily, but in the long run, no harm done.

however, if the outcome is cancer, the patient would have to worry about the disease. in practically all cases, it is much better to have disease awareness and time to plan early on, rather than later. the withholding doctor loses greatly because he 1) stole the patient's time that could be used to mentally, financially, and otherwise prepare for the upcoming illness; and 2) he will traumatize the patient by breaking the news out of the blue, as opposed to the forthright doctor who broke the news gradually.

so the forthright doctor is opting for a small cost (temporary worry) to protect against a catastrophic cost (lost time, sudden disclosure), whereas the withholding doctor is risking a catastrophic cost for a temporary gain (or breaking even, if you will).

both doctors are gambling with the patient's emotions. in the case of the forthright doctor, he is adequately buffering against extreme outcomes, whereas the withholding doctor is taking a bigger risk. ethically, the conservative approach (the forthright doctor) wins.
best post here thus far.

My mother, who has a family history of breast cancer (her mother and grandmother died from it, and two of her sisters have had lumps removed) found a lump on her breast. She went to see her doctor who examined it and told her there was nothing to worry about and no need to get a tissue analysis.
Guess the quack wanted to 'save' my poor mum from having to worry unnecessarily about possible cancer only to find out later it was nothing.

But guess what?

It was a malignant growth. But the time it was diagnosed correctly (and only because my mother had gone in several times over several months telling the doctor she wanted a tissue test before finally being put on the waiting list as 'low priority') it was too late to save her breast. To really add to it, she was told the cancer had spread to her other breast, but was in remission. She was also informed that if and when the cancer starts up again, there's probably not a lot they can do about it.
Thus the doctor's decision to 'save' my mother from 'unnecessary' worry in getting an early test has resulted in mum now living with the fact that she will almost definitely one day die from breast cancer.

at the time of the statement (ie the time of incomplete information), listing all possibilities is the closest thing to the truth. to withhold information at the time is the closest thing to a lie. to apply, post hoc, the value of falsity to the act of complete disclosure, is ethical backtracking.

Or in worse case, if you one thinks that there is a possibility, and yet withold, and it turns out that they did... then it's a falsity... So really, there's no way out of this concern of falsehood... You could end up being false in either decision... Though I'd rather tell them, and make sure they are informed enough to make the right decisions, and turn out to be wrong, than not tell them, have them find out later if its run along further, and be wrong...

I don't think this is really an ethics matter, its just bedside manner. The doctor has to let the patient know there is a chance of cancer, and tell them realistically how likely or unlikely it is. If they have it, then its not a complete shock. If they don't, then they're relieved.

The proper phrase is he/she may be caused anguished over a possible falsity... There is obvious cultural differences as well,in the US if he does have cancer, and you do not inform the patient, you've opened yourself to a possible malpractice suite if the patient, or the family later finds out you had the concern and did not inform/act on it. I would say the health of the patient, and getting to the problem far outweigh "avoidance of anguish".

The question isn't about "investigating or not investigating" - you are going to investigate. The question is how much of your motives for your investigation do you share with someone who doesn't come with "worry in the baggage".

The other thing you mention is "if they found out you had a concern" - one always has a "concern" when one decides for any sort of test/examination. For instance when I take a blood test in conjunction with a patient whose main complaint is "shortness of breath", I have several "concerns" (we call them "differentials"): Anemia - what type - due to malignancy? Embolus ? Infection? Cardiac failure? Arrhythmia? Inflammatory disease? Rheumatic disease? Metabolic syndrome? Acid/base derangement? Anxiety/panic disorder? And so on... Obviously one doesn't share all those, so I find it a bit simplistic and also quite unworkable to share "everything".

The question isn't about "investigating or not investigating" - you are going to investigate. The question is how much of your motives for your investigation do you share with someone who doesn't come with "worry in the baggage".

The other thing you mention is "if they found out you had a concern" - one always has a "concern" when one decides for any sort of test/examination. For instance when I take a blood test in conjunction with a patient whose main complaint is "shortness of breath", I have several "concerns" (we call them "differentials"): Anemia - what type - due to malignancy? Embolus ? Infection? Cardiac failure? Inflammatory disease? Rheumatic disease? Metabolic syndrome? And so on... Obviously one doesn't share all those, so I find it a bit simplistic and also quite unworkable to share "everything".

Yes, but you also want them to be informed of the decision... If you merely tell them you want to do a workup on them, and not state your concerns as to why, they may not consider the importance of the workup, and not take it... It's obvious that you consider a malignancy a possibility in this scenario... so they should be informed of this... In a case where you have an entire array of concerns, you should probably be telling them that such-n-such procedure is needed to track down the problem...

at the time of the statement (ie the time of incomplete knowledge of future outcomes), listing all possibilities is the closest thing to the truth. to withhold information at the time is the closest thing to a lie.

As I mentioned earlier, listing all possibilities is unworkable and simply not done - I very much disagree that it is "close to a lie" not to share everything, especially in cases where the differentials are numerous and of varying aetiology.

to apply, post hoc, the value of falsity to the act of complete disclosure, is ethical backtracking.

Or an actual ethical school of thought somewhat akin to utilitarianism/consequentialism.

Yes, but you also want them to be informed of the decision... If you merely tell them you want to do a workup on them, and not state your concerns as to why, they may not consider the importance of the workup, and not take it... It's obvious that you consider a malignancy a possibility in this scenario... so they should be informed of this... In a case where you have an entire array of concerns, you should probably be telling them that such-n-such procedure is needed to track down the problem...

I was just using that as an example to demonstrate how I find the "one should always share" type of deontological argument not as simple an answer as seemingly presented. Also, in the thought experiment the patient will submit to your work-up, because if he/she doesn't because he/she isn't worried then the answer is simple - worry him/her! Such a thing obviously vacates the dilemma.

In March of last year I develped a problem with balance and various mental processes, short term memory and so forth. My doctors took a family history and informed me early on that there was a fair chance the problem was multiple sclerosis. It took 3 weeks to get me in for the MRI to rule it out and for that time I was living in consant worry that I would have a dibilatating condition for the rest of my shortened life.

Even so I would rather have known exactly what was going on rather than being kept in the dark so I guess my answer to your question Fass is that you should always be upfront with your patients.

For instance when I take a blood test in conjunction with a patient whose main complaint is "shortness of breath", I have several "concerns" (we call them "differentials"): Anemia - what type - due to malignancy? Embolus ? Infection? Cardiac failure? Arrhythmia? Inflammatory disease? Rheumatic disease? Metabolic syndrome? Acid/base derangement? Anxiety/panic disorder? And so on... Obviously one doesn't share all those, so I find it a bit simplistic and also quite unworkable to share "everything".

practical point. however, no medical professional ever lists the complete differentials to the patient, a la medical student being pimped by the attending. but i suspect you've seen much fewer nutritional osteomalacia cases than tumor-induced osteomalacia. plus, rickets and cancer don't carry the same weight, either morally or medically. you are going to disclose your suspicion of cancer because it is one of the morally and medically serious differentials.

I would tell them of my concerns. Lying by omission is still lying.

As I mentioned earlier, listing all possibilities is unworkable and simply not done - I very much disagree that it is "close to a lie" not to share everything, especially in cases where the differentials are numerous and of varying aetiology.



Or an actual ethical school of thought somewhat akin to utilitarianism/consequentialism.

i can see your concern. i've addressed the practicality of disclosing "everything" in my post just prior to this.

utilitarianism/consequentialism is quite elegant, and i do admire many of its qualities, but it is the ultimate in post hoc analysis, and does nothing to aid decision making in real time. when you say the ends justify the means, you need to *know* the ends, in order to justify the means.

as i alluded in a much earlier post, the dilemma occurs at the time of suspicion, not when you receive the final lab report. therefore, you have to make the best of your incomplete knowledge. and as i mentioned before, in any case you are gambling with the patient's emotions, simply because you do not know the outcome. right? because gambling is decision-making based on incomplete information. forgive me if i repost some things i wrote before:


so the forthright doctor is opting for a small cost (temporary worry) to protect against a catastrophic cost (lost time, sudden disclosure), whereas the withholding doctor is risking a catastrophic cost for a temporary gain (or breaking even, if you will).

both doctors are gambling with the patient's emotions. in the case of the forthright doctor, he is adequately buffering against extreme outcomes, whereas the withholding doctor is taking a bigger risk. ethically, the conservative approach (the forthright doctor) wins.

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis...
Obviously the tests must occur. Assuming I have a genuine reason to either suspect or need to rule out the possibility of a terminal illness, it would be negligent to fail to act.

In terms of how to approach the patient, if we're just acting as a precaution then we can say as much without causing harm, since we may be acting on non-symptomatic concerns such as genetic disposition, working conditions, previous record etc., none of which would give any supposition that the patient actually -has- cancer; merely that it is physically possible for them -to get- cancer.

If we're acting on the basis of competent observation of condition, however, assuming there is some uncertainty involved, it is always best to note the other possible diagnoses first, only mentioning the cancer as "one option that you're hoping the tests will rule out" if it is more likely than not. If you think another is the most likely option, then say so, and note that you'd like to run a few tests to make sure that's what it is.

On no account, though, should you mention the term "cancer" until you're convinced - the common name has a tendency to evoke fear. The phrase "abnormal growth" would probably be much better used if you must refer to it; you can respond to the inevitable query of "Cancerous?" with "Hopefully not"

As I mentioned earlier, listing all possibilities is unworkable and simply not done - I very much disagree that it is "close to a lie" not to share everything, especially in cases where the differentials are numerous and of varying aetiology.
Then you list the most common possibilities in order of probability. If cancer is near the top, then you are ethically obliged to say it.

practical point. however, no medical professional ever lists the complete differentials to the patient, a la medical student being pimped by the attending. but i suspect you've seen much fewer nutritional osteomalacia cases than tumor-induced osteomalacia.

Actually, the Nordic countries being this far north and having a comparatively large incidence of celiac sprue makes osteomalacia due to malnutrition not that uncommon, in my limited experience (then again, the region where I live has an even higher prevalence of celiac sprue than the rest of the country, so...).

plus, rickets and cancer don't carry the same weight, either morally or medically. you are going to disclose your suspicion of cancer because one of the morally and medically serious differentials.

Cancer is, if one wishes to pick nits, often a differential and isn't always easily dismissed nor strongly assumed. What does one do when it's "just" part of the question and it might as well be three other things none more likely than the other?

Wait, I feel that I in my diabolical advocacy am drifting away from the OP, where it is indeed clear that one has what can be seen as a quite motivated suspicion, so the last paragraph is not all that pertinent... but, blame that on my poor advocacy skills! The devil is not an easy client to have when one doesn't have the motivation to defend him in the middle of the night and one yearns for bed. ;)

On no account, though, should you mention the term "cancer" until you're convinced - the common name has a tendency to evoke fear. The phrase "abnormal growth" would probably be much better used if you must refer to it; you can respond to the inevitable query of "Cancerous?" with "Hopefully not"

I choose this to reply to from your post because it is the part I cannot agree with. I do not think that it serves anyone anything to be obtuse or confusing or unclear about things. My opinion is that if one is going down the road of sharing suspicions of malignancy, then one should share them and not just dip one foot in the puddle. All these "growths, tumours, anomalies, densities, changes" or what have you are cop-outs that sow for nothing but a harvest of misunderstanding.

Actually, the Nordic countries being this far north and having a comparatively large incidence of celiac sprue makes osteomalacia due to malnutrition not that uncommon, in my limited experience (then again, the region where I live has an even higher prevalence of celiac sprue than the rest of the country, so...).

Wait, I feel that I in my diabolical advocacy am drifting away from the OP, where it is indeed clear that one has what can be seen as a quite motivated suspicion, so the last paragraph is not all that pertinent... but, blame that on my poor advocacy skills! The devil is not an easy client to have when one doesn't have the motivation to defend him in the middle of the night and one yearns for bed. ;)

that geographical distribution of celiac sprue in your neck of the woods is a fact that i will keep in mind! i will not contest your claim that you've seen more nutritional osteomalacia cases.

just curious though, are you polling our opinions, as a proxy for your patients' views on the matter? or were you simply probing how denizens of nationstates think about these things?

I was just using that as an example to demonstrate how I find the "one should always share" type of deontological argument not as simple an answer as seemingly presented. Also, in the thought experiment the patient will submit to your work-up, because if he/she doesn't because he/she isn't worried then the answer is simple - worry him/her! Such a thing obviously vacates the dilemma.

True there... I do consider an obvious difference between having a few possible concerns, or several concerns... If you were to think there could be one of 18 problems, I wouldn't expect you to outline them; I would if you thought it could be 2-3 possible problems.... Though if there were some grave possibility on one of them, I would expect the concern to be voiced.

that geographical distribution of celiac sprue in your neck of the woods is a fact that i will keep in mind! i will not contest your claim that you've seen more nutritional osteomalacia cases.

Damn my lack of energy to look for exact figures, but I think the prevalence somewhere around 1/100 for Sweden.

just curious though, are you polling our opinions, as a proxy for your patients' views on the matter?

Oh, perish the thought, no! That would be... insane.

or were you simply probing how denizens of nationstates think about these things?

Basically, and I also wanted to "debate" a bit. As I said, not that exciting a Saturday night, this one for me...

Would be bad to poll for consideration of patients... People's views on this matter tend to spread from "ignorance is bliss" to "I would want to be informed".... And I have a feeling most people would rather remain ignorant of things and let someone else worry, than be informed of the matter..... I personally would rather be informed... I would find it distasteful if someone were to "pull punches" in this case.

I choose this to reply to from your post because it is the part I cannot agree with. I do not think that it serves anyone anything to be obtuse or confusing or unclear about things. My opinion is that if one is going down the road of sharing suspicions of malignancy, then one should share them and not just dip one foot in the puddle. All these "growths, tumours, anomalies, densities, changes" or what have you are cop-outs that sow for nothing but a harvest of misunderstanding.

Agreed. If you're going to raise the possibility at all, then you have to be clear about it. Not try & confuse/mislead the patient with euphemisms & obfuscations.

I'd rather hear:

"There are a number of possibilities and some are more serious than others. We're going to try to rule out some of the more serious ones first such as cancer. It isn't likely, but thes sooner we know for certain, the better."

than:

"It's probably nothing serious."

A week later...

"It's cancer."

What LG said

I would interview him about history and cancer and stuff. If he mentions people affected but it; then you could probably ask and get a test.

If he doesn't; I would explain why I would like to test and let them make the judgment call.

No matter what happens the person would be nervous. Who wouldn't?

I choose this to reply to from your post because it is the part I cannot agree with. I do not think that it serves anyone anything to be obtuse or confusing or unclear about things. My opinion is that if one is going down the road of sharing suspicions of malignancy, then one should share them and not just dip one foot in the puddle. All these "growths, tumours, anomalies, densities, changes" or what have you are cop-outs that sow for nothing but a harvest of misunderstanding.
I find it strange that you use the term "cop-out". The thing is, uncertainty lies at the very heart of this problem, and there is no sense hiding that. I do not know for sure whether what my patient has is actually something infamous or gravely serious; that is why I want to perform further testing. As a result, it is important that the language I use conveys a sense of abstraction in line with the uncertainty behind the diagnosis itself. I do not want to seem overly confident in or committed to an outcome of what is only a possibility.

It may well be that some people find this disconcerting. This is understandable. However, to use a parallel, it would be far less worrying to find out that an army has a 1/10 chance of attacking your castle than it would be to find out that an army of heavily armed robot aliens from the future has a 1/10 chance of attacking your castle. At least in speculating about the abstract army, the sense of dread is only as much as your imagination can conjure up, whereas that particular army is perhaps one of the worst possible things you could imagine that fall under the heading of military forces.

Should the tests you do solidify the supposition of the gravity of the problem, then you can start speaking with more authority and fill in the details. Not only will you be more confident in the correctness of the diagnosis, but you will also be in a better position to notify the patient about treatment and medication (akin to bringing news of the alien army's weaknesses back from reconnaissance).

If you're going to raise the possibility at all, then you have to be clear about it. Not try & confuse/mislead the patient with euphemisms & obfuscations.
I don't get where the "confuse/mislead" bit comes from. Describing my suppositions without using the colloquial name of the condition is not misleading or confusing; if anything, it is a prevention of the confusion or false conclusions that the word "cancer" might bring about. As long as you meet the colloquial term head on with an "its always a possibility" or some such response if the patient asks you directly; you can't lie about it, but you can always try to avoid the approach that might cause unnecessary panic.

just say somthing like " we are going to try and rule out canser."

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis. This patient has not had any thoughts or suspicions about his/her illness being cancer, and will thus only start thinking in that direction and worrying about it if you tell him/her about your suspicion and what the goal of the work-up is.

Do you tell your patient and risk him/her worrying "for nothing" if a malignancy is not found, or do you withhold that information and risk the patient possibly ending up with a cancer diagnosis that for him/her has come out of the blue? How do you ethically defend your position?

Hmm, looking at the poll results, my stance appears to be rather unpopular, which is why I'll explain it in a bit more detail than I planned to do.

I'm against telling the patient at this stage, because I believe that there lies no value whatsoever in telling for the patient, while carrying lots of downsides.

This is, of course, based on several premises relating to how I understood the situation described in the OP:

a) Whether you tell your patient what the test are for or not doesn't affect the speed with which said tests are carried out and the results brought in.

b) The time period between having the choice to tell the patient and having the test results back is short enough so that a "mindful" behavior of the patient, knowing they have cancer and thus maybe behaving more "healthily", in that time period would not affect the chances of curing the potential cancer.

With these two given, I see no positive effect for the patient that might possibly come from telling them - except, of course, the "on fundamental principle" one that one has a right to know what the doctor is doing with one, and what for. In the case that a patient should ask what exactly is being done for what purposes, I believe that it is the doctor's duty to tell them. If, however, they don't ask, or don't really ask for details, I think telling them that "we are running all tests necessary to rule out all and any diseases/causes that could be probable in your case" is perfectly acceptable and your best choice.

So for me the dilemma is only between such an abstract right to an information most patients appear to not seek, and to (medically) unnecessarily worry the patient, and I think the worry and upset from a possible cancer diagnosis is enormous. Therefore, unless the patients explicitly ask for what kind of tests are being run and/or other circumstances make it medically advisable to inform the patient of his potential cancer status, I wouldn't tell the patient of the cancer suspicion.

I do not agree with SoWiBi.

No matter the likelihood or unlikelihood of a particular diagnosis, it is this patient's body that is under discussion. Ultimate authority to make choices, to seek opinions, and to choose treatments, lies not with the doctor, but with the patient. In fact, an important thing to remember is that the doctor has no authority at all.

The doctrine of informed consent is an absolute. The doctor has no right, nor any ethical position, to ever withhold information about a person's treatment or tests.

Tell him. He'll be prepared for the possibility that it is cancer, and he'll be relieved if it turns out to be something else.

QFT and agreement.

I've been spending my ever so exciting Saturday evening and night (thank you cancelled dinner date!) reading a book about initial cancer information interviews, and have found the following ethical dilemma interesting.

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis. This patient has not had any thoughts or suspicions about his/her illness being cancer, and will thus only start thinking in that direction and worrying about it if you tell him/her about your suspicion and what the goal of the work-up is.

Do you tell your patient and risk him/her worrying "for nothing" if a malignancy is not found, or do you withhold that information and risk the patient possibly ending up with a cancer diagnosis that for him/her has come out of the blue? How do you ethically defend your position?

Even though I have taken a stance myself, I am curious as to other people's reasoning about this and to see what will prove to be "popular".

i have one better:
you have been caught for robbing an armored car, the prosecuter offers you a deal: if you had a partner, you turn him in and get a reduced sentence, you know of a friend that has commited bad things before, but he has a wife and child do you give him to them?

I agree with Dododecapod on this.

The patient owns his/her body and has the absolute right to make all decisions concerning medical treatment of it. In order to make those decisions, the patient must have full information.

If you conduct a test, I will naturally assume you are testing for something. If I ask you what, and you do not tell me, I will not trust you as a doctor and will likely seek another opinion. Depending on my mindset, this could have either very good or very bad consequences.

Granted, full disclosure will have wildly mixed results from patient to patient, but whether the goal is to balance risk assessment against unnecessary stress, or to keep a hypochondriac patient focussed on reality instead of dire imaginings, or to get informed consent for various procedures, or to avoid a malpractice suit, or any number of other variations of interpersonal relations between doctor and patient, the basic wisdom remains: honesty is the best policy.

Unless the person is a very small child or mentally incapacitated, it would be insulting not to tell. And even with a small child or (not severely) mentally retarded person, the explanation can, for the most part be geared to their level.

My daughter went to school with a girl whose mother had a malignant brain tumor. The woman's husband would not permit the doctors to tell his wife that she was terminally ill, thinking he was sparing her mental anguish. Needless to say, the woman died without information that could have spared her said anguish (and, I think, she knew on some level what was going on which only made things worse for her), and the daughter, a medical/public health student totally lost respect for her father.

Give them a pet dog. Since they can smell cancer, you could totally find out, whilst giving the patient something to love and cherish forever.

*nods*

I've been spending my ever so exciting Saturday evening and night (thank you cancelled dinner date!) reading a book about initial cancer information interviews, and have found the following ethical dilemma interesting.

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis. This patient has not had any thoughts or suspicions about his/her illness being cancer, and will thus only start thinking in that direction and worrying about it if you tell him/her about your suspicion and what the goal of the work-up is.

Do you tell your patient and risk him/her worrying "for nothing" if a malignancy is not found, or do you withhold that information and risk the patient possibly ending up with a cancer diagnosis that for him/her has come out of the blue? How do you ethically defend your position?

Even though I have taken a stance myself, I am curious as to other people's reasoning about this and to see what will prove to be "popular".There was a "House" episode on this. It turned out the cough actually was terminal cancer.

The patient owns his/her body and has the absolute right to make all decisions concerning medical treatment of it. In order to make those decisions, the patient must have full information.

If you conduct a test, I will naturally assume you are testing for something. If I ask you what, and you do not tell me, I will not trust you as a doctor and will likely seek another opinion. Depending on my mindset, this could have either very good or very bad consequences.


Please note that I excluded the case where a patient explicitly asks you what the tests are for - do you feel the same as you described above if the patient doesn't ask on their own initiative?

Ass Cancer?

I've been spending my ever so exciting Saturday evening and night (thank you cancelled dinner date!) reading a book about initial cancer information interviews, and have found the following ethical dilemma interesting.

Let's say you are a doctor and you have a patient in whom you either suspect or need to rule out a cancer diagnosis. This patient has not had any thoughts or suspicions about his/her illness being cancer, and will thus only start thinking in that direction and worrying about it if you tell him/her about your suspicion and what the goal of the work-up is.

Do you tell your patient and risk him/her worrying "for nothing" if a malignancy is not found, or do you withhold that information and risk the patient possibly ending up with a cancer diagnosis that for him/her has come out of the blue? How do you ethically defend your position?

Even though I have taken a stance myself, I am curious as to other people's reasoning about this and to see what will prove to be "popular".

I've always been taught, and found I agree, that in that kind of situation you lay out the groundwork in an initial consultation when you suspect that as a possible diagnosis. You then ask the patient to bring a family member along with them to the next consultation when you have the results. That way when they inevitable shut down completely when they hear that they have the dreaded big C there is another persron there who is more likely to take in the necessary information.

Yes I would tell him why I'd want to do a certain examination and try to inform him as good as I could if he had certain questions.
I see no reason to lie against a patient, if the diagnosis comes out of the blue it will probably be harder for the patient to cope with it and if it turns out to not be cancer he will be relieved.
If it turns out that you lied to the patient his relation with you might also be damaged. Besides, I would also be worried if my doctor did an examination "for no real reason, especially not cancer".

I would. And I would expect my doctor to do the same if I was in such a position.

Ass Cancer?
"I hate you, and I wish you both had cancer."
"Cancer?"
"Yes. In the head."
"Head cancer?" [/obvious reference]

I don't see an ethical problem. You're a doctor, and you have a reason to suspect cancer, and you want to confirm it or rule it out. You have to tell the patient what the test is, and why you want to have it done.

Certainly, giving bad news is one of the worst parts of your job, but withholding it is simply not an option. The patient needs to know.

You tell the patient, unless they have indicated to you beforehand that they'd rather not know. I believe as a patient I have a responsibility to be forthright with my doctors, answering their questions truthfully and honestly. I expect nothing less than the same from my doctors. If they were to begin withholding information from me, I suspect I would no longer trust them and would likely seek out treatment from one more honest.

I've had doctors tell me they were ruling out cancer in my daughter. It's an awful thing to hear, but necessary. Plus, I'm not an idiot -- when I see 'biopsy' on an insurance claim, I have a fairly good idea what is going on. Besides, diagnosis codes aren't too difficult to decipher if you're really curious.