Physician-Patient Relationship

Physician-Patient Relationship: Case 2

A 16-year-old female presents to a family physician to obtain a referral for family therapy. She is estranged from her mother and stepfather, who see the same physician. For many years, this patient responsibly cared for her four younger siblings while their single mother worked. Since her mother's marriage, the family has become involved in a fundamentalist church. The patient moved out when she felt the social and moral restrictions of the family's religion were too burdensome for her. The patient seemed quite mature; she maintained a 3.5 GPA, along with a part-time job.

Physician-Patient Relationship: Case 1

During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical intervention.

CASE STUDIES

During a visit to her family physician, a 35-year-old woman discloses that she suffers from anorexia nervosa. She complains of fatigue, dizziness, depression, headaches, irregular menses, and environmental allergies. Each day, she uses 15 to 60 laxatives, exercises for several hours, and eats a salad or half a sandwich. At 5'2", she weighs 88 pounds. She demonstrates a good understanding of the diagnosis and the recommended therapy for anorexia. Despite receiving a variety of resource information, the patient refuses any medical intervention. She continues to present to the family physician, offering a variety of somatic complaints.

When a patient's preferences conflict with a physician's goal to restore health, which ethical principle should prevail, patient autonomy or physician beneficence? Does the patient's depression render her incompetent to refuse treatment for her anorexia?
 

Case Discussion

Since this patient could rationally discuss her treatment options and her reasons for declining therapy, she could not be considered incompetent. Respect for autonomy is a central principle of bioethics, and it takes precedence in this case. Although the principle of beneficence could be used to argue for coercion towards treatment, compliance may be better improved by providing an ongoing partnership with the patient. Maintaining a therapeutic relationship with ongoing dialogue is more likely to provide this patient with the eventual ability to pursue therapy.

A 16-year-old female presents to a family physician to obtain a referral for family therapy. She is estranged from her mother and stepfather, who see the same physician. For many years, this patient responsibly cared for her four younger siblings while their single mother worked. Since her mother's marriage, the family has become involved in a fundamentalist church. The patient moved out when she felt the social and moral restrictions of the family's religion were too burdensome for her. The patient seemed quite mature; she maintained a 3.5 GPA, along with a part-time job. She demonstrated a genuine desire for reconciliation, and the therapy referral was provided. She also requested and obtained a prescription for contraceptives during the visit, with the assurance that her sexual activity would be kept confidential. In follow-up, she reported that the therapist had informed her that if she mentioned anything about being sexually active with her adult partner, he would be obliged to report her to the state. The patient was very concerned about the conflict between this statement and the family physician's prior assurance of confidentiality.

Should this patient's confidentiality be broken?

Case Discussion

While the physician has a moral obligation to obey the law, he must balance this against his responsibility to the patient. In researching the Criminal Code of Washington, the physician learned that sexual intercourse with a minor, at least 16, but under 18, is a class C felony, and a reportable offense, if the offender is at least 90 months older than the victim. This patient's relationship did not actually meet the criteria for mandatory reporting. Had this not been the case however, the physician could be justified in weighing the balance of harms arising from the filing of such a report. There is little justification for informing the family of the young woman's sexual activity. Due to the family's strong fundamentalist beliefs, significant damage would have occurred in the family reconciliation process with this discovery. Although they would clearly disapprove of the patient's actions, her choices carry no risk of harm to them.