Medical Ethics: Paternalism in Withholding Diagnosis
The scenario described is an example of paternalism (Answer C), where the physician makes a decision on behalf of the patient based on what the physician believes is in the patient's best interest, overriding the patient's right to know their own diagnosis.
Definition and Ethical Framework
Paternalism occurs when a physician acts in what they perceive as the patient's best interest while limiting the patient's autonomy and right to self-determination. 1 In this case, the physician is withholding critical diagnostic information (lung cancer) based on the patient's prior statement about suicide, essentially making a unilateral decision that the patient should not know their diagnosis.
Why This Represents Paternalism
The physician's action demonstrates several hallmarks of paternalistic behavior:
Overriding patient autonomy: Medical ethics establishes duties based on beneficence (acting in the patient's best interest), nonmaleficence (avoiding harm), respect for patient autonomy, and promotion of justice. 1 By withholding the diagnosis, the physician is prioritizing what they perceive as beneficence and nonmaleficence over the patient's fundamental right to autonomy.
Substituting physician judgment for patient choice: The physician has decided that knowing the diagnosis would harm the patient more than not knowing, without giving the patient the opportunity to participate in this decision. 1
Why Other Options Are Incorrect
Fidelity refers to faithfulness and keeping promises in the physician-patient relationship—this scenario actually violates fidelity by not being truthful with the patient. 1
Utilitarianism is an ethical framework focused on maximizing overall good or happiness for the greatest number of people, which is not the primary consideration in this individual clinical scenario. 1
Justice relates to fairness in the distribution of healthcare resources and equitable treatment, which is not the central ethical issue here. 1
Critical Clinical Considerations
The expression of suicidal ideation in the context of a serious diagnosis should raise suspicion about underlying mental health problems, but it is not definitively diagnostic of psychiatric illness by itself. 1 This desire for death can fluctuate over time and may be related to inadequate symptom management or existential distress. 1
Appropriate Response Framework
Rather than withholding the diagnosis, the physician should:
Assess for clinical depression and psychiatric comorbidities: Many patients with cancer experience depression or psychological distress, which are treatable conditions. 1
Provide comprehensive palliative care support: Adequate symptom management and psychosocial support can address many of the concerns that lead patients to express wishes for death. 1
Engage in honest, empathetic communication: The physician should disclose the diagnosis while simultaneously addressing the patient's emotional response and providing appropriate mental health support. 1
Common Pitfalls in Truth-Telling
While some cultures may emphasize family-based decision-making or protection of patients from distressing news, in the United States, legal requirements and ethical standards strongly support patient autonomy and the right to informed consent, which requires full disclosure of diagnosis and treatment information. 1 Withholding a cancer diagnosis violates these principles and potentially exposes the physician to legal liability.
The appropriate ethical response is to disclose the diagnosis while providing robust psychiatric and palliative care support, not to withhold information based on paternalistic assumptions about what the patient can handle. 1