Mrs. Z is a widowed 70-year-old mentally competent Russian immigrant who lives independently in a suburb outside Washington, DC. Her doctor discovers that she has an operable tumor and has her admitted to the hospital for surgery. Because she does not speak English, her 45-year-old son Boris Z translates for her but adamantly refuses to tell her that she has cancer. He tells her only that she needs surgery, because he says that "it will destroy her" to know the truth. The surgeon and other staff members argue that she must be told why she needs surgery in order for them to obtain informed consent for the procedure, but Boris will not allow the hospital's Russian translator to enter Mrs. Z's room. Boris explains that in his culture, the man of the family (in this case, the eldest son) makes the decisions and that his mother is quite willing to have surgery without knowing what it is for. Indeed, Mrs. Z has shown no curiosity about the nature of her disease, and is willing to undergo the procedure simply because the doctor says she needs it. Boris is absolutely convinced that knowing the truth that she has cancer will be detrimental to her health and peace of mind, and continues to refuse to explain it to her. The Hospital Ethics Committee meets and decides to get around the issue of informed consent by having Mrs. Z. sign a form stating that she refuses the hospital's translating services and would prefer that her son be her translator. [Actual case- thanks to Steven S for bringing it to our attention]
Can someone forego the right to be informed? Should the hospital inform her anyway? What do you think of the Ethics Committee's solution?
Mrs. Z is certainly within her rights to decline the right to be informed. So long as she signs the form declining the official translator, the ethical action for the physician is to respect the Z's culture.
ReplyDeleteI agree that the doc should respect the Z's cultural preferences and that Mrs. Z has the right to not know about her health if she doesn't want to know. I'm a little uncomfortable with taking her son's word for it, but that's probably just because I'm a Westerner and I don't really understand the worldview in which a patient wouldn't want to be fully informed about what's going to happen to her body and why. However, I'm not so sure about the method the committee used to get around the problem. Its very clever to do what they did but it doesn't address the issue at all or help solve anything for future cases. And I wonder if it would stand up in court if Mrs. Z changed her mind later and hired a lawyer. The hospital would say: "But she declined our translator and we told the son to tell her she has cancer. We can't help it if he didn't do so." There are many witnesses who could attest to the fact that the hospital knew full well that he wasn't telling her.
ReplyDeleteI do not agree with the decision of the hospital to designate the son as the "official" translator - as far as I know there is no legal status of translator, so while it appears to shield the hospital and staff from the legal consequences of their actions, it probably wouldn't hold up if pressed. On the other hand, the cultural situation provides a very clear course of action: have the son designated as the medical decision maker for his mother through a durable power of attorney. She seems quite willing to unofficially give him that responsibility. In this way, there are no problems regarding informed consent because the son would then need to be the one who is informed, which he is. Problem solved.
ReplyDeleteMrs. Z is willing to undergo the treatment just because the doctor indicates she needs it. She shows no curiosity about any details of her health status or the course of treatment. Her declining to be informed is fine as long as she is competent and has the capacity to make decisions about her medical care. I mean, there really isn't an issue here: A) she is mentally competent and B) she doesn't care to know anything about her condition or operation. If a patient is competent and doesn't care to be informed about certain aspects of their care, who is a physician to thrust unwanted information on them? Seems rather paternalistic. The patient agrees to the surgery recommended by the doctor, she just doesn't want to know why the doctor recommends it. And really, how many patients are in actuality totally privy to a doctor's decisions about their care?
ReplyDeleteI think her culture is paternalistic, not the docs who want to tell her about her condition. And while I agree that she shouldn't be forced to know things she doesn't want to know, it is worth acknowledging that in our culture we have an expectation and a legal requirement to obtain informed consent from a patient before doing a procedure. This is what I am having trouble with in this case: can we really say that her consent was "informed" if she doesnt know anything about it? What if the proposed surgery involves radical mastectomy? Is it really ok that she doesnt understand the potential complications? She's not mentally
ReplyDeleteincompetent so we can't go the route KPM suggested.