This is the third in a six-part series on general practice ethics. Cases from practice are used to trigger reflection on common ethical issues where the best course of action may not immediately be apparent. The case presented in this article is an illustrative compilation and is not based on specific individuals. In the first article, the authors provided a suggested framework for considering the ethical issues to assist practi-tioners in reaching an ethically justifiable decision.
This month we turn to ethical issues that arise when family members try to be involved in a patient’s care.
‘Dr Teh, it’s Margaret Wilmore here. I just wanted to have a quick chat with you about Mum. Do you have a few minutes?’
Dr Teh tries not to sigh audibly. Ms Wilmore rings him regularly about her mother. Mavis Grey is fiercely independent and at times ambivalent about her daughter ‘interfering’ with her care. Dr Teh understands that Ms Wilmore means well, but believes Mrs Grey is competent and able to make her own decisions.
‘I went with Mum last week to see Dr Giles, her cardiologist. He really seemed to rush things with Mum again this time and I’m worried she isn’t getting the care she needs. I’ve tried to get Mum to ask you if she can get a second opinion, but you know what she’s like. She doesn’t want to bother you. Do you think you could refer Mum to someone else for a second opinion?’
How should Dr Teh respond to Ms Wilmore?
What is ethically perplexing about this scenario and why?
The first issue in this case is whether Dr Teh should have a conversation with Ms Wilmore about her mother. To what extent can Dr Teh communicate potentially confidential information about Mrs Grey to her daughter, particularly if it is clear that Ms Wilmore is very familiar with at least some aspects of her mother’s care? A second issue concerns the degree to which Dr Teh and Ms Wilmore should respect Mrs Grey’s choices about which doctors she sees.
With her mother’s best interests at heart, Ms Wilmore wants Dr Teh to arrange a second opinion, but this may not accord with Mrs Grey’s wishes. Whose interpretation of Mrs Grey’s best interests matters here – Ms Wilmore’s, Mrs Grey’s or Dr Teh’s? Under what circumstances is it reasonable to override a competent patient’s wishes regarding their healthcare? There are also questions about how Dr Teh should respond to Ms Wilmore’s frequent calls about her mother’s health. What are her motivations? For example, is she struggling to manage her own anxieties about her mother’s mortality and ageing? What role should Dr Teh play in this relationship between mother and daughter? Finally, we might wonder whether communication between the general practitioner (GP) and cardiologist is optimal for Mrs Grey’s care.
If we look at this case from the perspectives of the key people involved – Dr Teh, Mrs Grey and Ms Wilmore – there are overlapping interests and values, but also points of difference. A helpful way to balance these perspectives is to focus on key ethical principles – respect for autonomy and the patient’s best interests – supported by consideration of the role of trust in the doctor–patient relationship. The first three principles in the Australian Medical Association’s Code of ethics emphasise these obligations.1
Confidentiality and respect for autonomy
Patients have a right to make their own decisions about their healthcare, including how much they wish to share those decisions and the process of making them with others. On its own, taking her mother to the cardiologist does not afford Ms Wilmore a say in Mrs Grey’s healthcare. Hopefully, Dr Teh has already discussed with Mrs Grey the extent to which she is willing for Ms Wilmore to participate in discussions and decisions about her healthcare.2 If Mrs Grey has made it clear that she does not wish to involve her daughter in her healthcare decisions, then Dr Teh needs to politely but firmly deflect Ms Wilmore. This is a legal as well as an ethical requirement. If he knows Mrs Grey is willing for her daughter to participate in her healthcare decisions, then it is reasonable to continue the conversation.
Mrs Grey clearly values her independence and is able to make her own decisions. However, this fact alone does not mean Dr Teh should simply accept Mrs Grey’s choices at face value, as she is not in a position to assess the professional competence of her cardiologist. Respect for autonomy requires supporting Mrs Grey in making informed decisions, taking into account her goals for her medical care. To do this, Dr Teh needs to understand how Mrs Grey perceives her cardiology care. On the one hand, Mrs Grey may have given careful consideration to her choice of doctor, and there may be aspects of the cardiologist’s care that she particularly appreciates, which are not apparent to her daughter. On the other hand, Mrs Grey may be concerned about her care, but feels awkward about raising her concerns or asking for a second opinion. Her responses are likely to be grounded in years of deference to medical practitioners. Dr Teh is well placed to help Mrs Grey appreciate her options, and to ensure she is able to interpret and use the information he provides to make an informed decision.
The patient’s best interests
Respecting Mrs Grey’s choices and confidentiality, and securing her best interests are both important. Mrs Grey’s views about her interests are paramount but, as noted above, are inherently linked to her understanding of her health and the options available for her care.
Ms Wilmore has a legitimate interest in her mother’s wellbeing and healthcare.3 However, even in situations where family members have legal responsibilities for decision-making, it may be difficult to decide when such powers are to be exercised. In the current situation, where there are no formal legal powers, Ms Wilmore’s views, while not determinative, deserve some consideration. This is because she has extensive knowledge of her mother’s day-to-day wellbeing, and is involved in supporting her to live independently.
Dr Teh needs to be confident from his perspective that Mrs Grey’s best interests are being served regarding the quality of healthcare provided by the cardiologist. Are the matters that Ms Wilmore raised of clinical importance, or are these a matter of etiquette or preference? The first step in answering these questions is for Dr Teh to talk to the cardiologist. However, Australia’s health system does not necessarily make it easy for doctors to do this. In our fee-for-service system, there is no remuneration for his conversation with Ms Wilmore or for a short chat with Dr Giles.
There is also the time-consuming matter of trying to assist Mrs Grey and Ms Wilmore to come to a better understanding of each other’s views. What sits beneath the apparent differences of opinion between Ms Wilmore and her mother? Is this a serious rift that might have a negative impact on Mrs Grey’s health? There are obviously limits to the extent to which any doctor should pursue their patients’ best interests (broadly speaking). Situations such as this case, where the line between health and social care blurs, can be particularly challenging.
Trust and the doctor–patient relationship
This case highlights the power and fragility of trust in relationships between doctors, patients and their families. A trusting relationship between Dr Teh and Mrs Grey will help her accept Dr Teh’s professional recommendations, including seeking a second opinion. However, trust can easily be undermined if, for example, Mrs Grey comes to believe Dr Teh and Ms Wilmore are conspiring behind her back. Trust can also be undermined if Dr Teh takes Mrs Grey’s compliance for granted. He needs to be cognisant of the influence he can exert over Mrs Grey, simply because she trusts him and is likely to act on his recommendations.
The next stage in our ethical analysis is to consider how to balance the various perspectives outlined above. Dr Teh should try to help Mrs Grey articulate any concerns she may have about the care provided by her cardiologist, and to support her if she wishes to seek a second opinion. If, following a discussion with Dr Giles, Dr Teh has reservations about Mrs Grey’s care, he ought to strongly encourage her to see another practitioner. These measures address Ms Wilmore’s concerns about her mother’s care without jeopardising the relationship between Mrs Grey and her GP. Finally, Dr Teh can check his decision by rehearsing how he might explain it to colleagues.
In summary, Dr Teh should provide advice and guidance aimed at ensuring Mrs Grey receives high-quality secondary care that is consistent with her goals and preferences. This episode also provides a trigger for him to discuss advance care planning with Mrs Grey,4 and the extent she wishes her daughter be involved in her care.
Annette Braunack-Mayer BMedSci (Hons), PhD, Head, School of Public Health, University of Adelaide, Adelaide, SA. firstname.lastname@example.org
Wendy Rogers BMBS, BA (Hons), PhD, MRCGP, FRACGP, Professor of Clinical Ethics, and ARC Future Fellow, Department of Philosophy and Department of Clinical Medicine, Macquarie University, Sydney, NSW
Competing interests: None.
Provenance and peer review: Commissioned, externally peer reviewed.
- Australia Medical Association. AMA Code of Ethics 2004. Editorially Revised 2006. Canberra: AMA, 2006. Available at http://amaq.com.au/page/About_Us/ama-code-of-ethics [Accessed 19 June 2015].
- General Medical Council. Confidentiality. London: GMC, 2009. Available at www.gmc-uk.org/Confidentiality___English_0415.pdf_48902982.pdf [Accessed 9 April 2015].
- Pérez-Cárceles MD, Lorenzo MD, Luna A, Osuna A. Elderly patients also have rights. J Med Ethics 2007;33:712–16.
- Advance Care Planning Australia. Available at http://advancecareplanning.org.au [Accessed 10 August 2015].