Annals of Behavioral Science and Medical Education 2014, Vol. 20, No. 2, 34–36
©2014 by the Association for the Behavioral Sciences and Medical Education 1075–1211/14
Case Study: Deception for the Patient’s Own Good Mariella M. Self, Ph.D.
Gabriel is a 15-year-old Hispanic male at University Hospital on the West Coast. He needs an implanted cardioverter-defibrillator (ICD) to treat an arrhythmia due to congenital heart disease. The ICD is a small electrical device placed under the skin on the chest that sends low-energy electrical impulses to interrupt life-threatening arrhythmias and restore normal rhythm. Affected patients can die within minutes if not treated. Gabriel’s mother, a single parent, accepts the diagnosis and recommendation for an ICD. She would like to have the surgery done as soon as possible, but she has been unable to convince Gabriel to agree to the implant. Gabriel says he is afraid of needles, doctors, and hospitals as well as being afraid that he may not wake up after the surgery. His mother feels frustrated that he will not agree to the implant. She does not want to override his autonomy, although she knows that she has the legal right to make the final decision for her minor child. The physician is aware that, according to the American Academy of Pediatrics, any child 7 years old or older should be asked for assent for any medical therapy or procedure done to them. The physician also knows that a parent or guardian has the legal right to give consent for minors for medical interventions. The mother then deceives Gabriel, with the physician’s agreement, by saying he needs to have blood drawn for lab tests, but once the IV is in place, Gabriel is anesthetized and the device is implanted. When Gabriel wakes up from the surgery, he is furious with his mother and the doctor for deceiving him, even though it was for his own good. Should Gabriel have been deceived for his own good? Should patients ever be deceived for their own good? Why or why not? Mariella M. Self, Ph.D. Texas Children’s Hospital 6701 Fannin Suite 1740 Houston, TX 77030 Email:
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Commentaries on Deception for the Patient’s Own Good R. Dennis Bastron, M.D.
syndrome. The procedure to implant the device is considered to be minimal risk and accompanied by minimal post-operative discomfort (i.e., very low risk: with very high benefit).
Sir William Osler stated that the “practice of medicine is an art, based on science.” I believe the art comprises observation skills, balancing probabilities, and communication skills. In the case of Gabriel, one should observe, for example, Gabriel’s affect, maturity, level of medical sophistication or naivety, personality, relationship with his mother, and presence or lack of male influence. Is he an immigrant, or if not, is he first generation or later in the US? Fifteen-year-old males can be rebellious or still very dependent. Similar personality observations need to be applied to his mother.
Poor communication is a primary cause of the majority of malpractice suits and, in my experience, ethics consultations. Osler taught students and residents to “listen to your patient, he is telling you the diagnosis.” He was emphasizing the importance of history taking, of course, but that would include probing into Gabriel’s fears. Fear of needles is common among teenagers and children, but his fear of doctors, hospitals, and not waking up after surgery needs to be explored. Potential questions are: Is English his first language? Does he distrust American doctors or the medical system and, if so, why (has he had a bad experience)? Would he be more comfortable with poviders of his own ethnicity? Does he really understand the
Balancing probabilities in this case is straightforward. Patients needing implanted cardioverter-defibrillators (ICD) are walking time bombs susceptible to sudden cardiac death (SCD) 34
