MEDICAL MATTERS:Ethical dilemma is looming over role of carers, writes MUIRIS HOUSTON
‘COULD YOU see Mr M’s wife on her own? She wants to talk to you about him,” the receptionist asked. He had an appointment, but his wife didn’t. These requests can be tricky. My standard response is to ask if I can see both people together, with the patient’s permission of course.
In this case, Mr M is fully independent but by his own admission doesn’t look after his health very well. His wife takes the lead on issues such as medication and hospital appointments. It soon became clear that although her husband had consented to her joining the consultation, he didn’t want her to discuss some new symptoms he was having. Or rather that she thought he was having, the nature of which precluded him from being aware of them.
We had a lengthy discussion and formulated a plan of action. And while I think it was for the best that I was told about the symptoms, when they left I wondered whether Mr M’s autonomy had been fully respected.
Traditionally doctors have given primacy to the doctor- patient relationship. Ethical guidelines advise doctors not to disclose information, even to close relatives, without the patient’s consent. Here is the relevant section from current Medical Council guidelines:
“While the concern of the patient’s relatives and close friends is understandable, you must not disclose information to anyone without the patient’s consent. If the patient does not consent to disclosure, you should respect this except where failure to disclose would put others at risk of serious harm . . . If the patient is considered to be incapable of giving or withholding consent to disclosure, you should consider whether disclosing the information to family and carers is in the best interests of the patient.”
With an ageing population, carers are set to play an ever increasing role in healthcare. According to the Carer’s Association, in the 2006 census more than 160,000 people said they were carers. This amounts to almost 5 per cent of the population over the age of 15. Their value in preventive terms is probably incalculable. As early warning systems, carers ensure early intervention in acute illness. They prevent medical errors and help communicate with a myriad health professionals.
Last week, the American College of Physicians published a position paper about the ethical challenges involved in collaborating with patients and caregivers. The paper defines caregivers as relatives, partners, friends, and neighbours of patients who assist with activities of daily living and complex healthcare needs.
It outlines four primary principles for physicians: respect for the patient’s dignity, rights and values should guide all patient- physician-caregiver interactions; effective communication and physician accessibility are fundamental to supporting the patient and family caregiver; the physician should recognise the value of family caregivers as a source of continuity regarding the patient’s medical and psychosocial history; and when the caregiver is a healthcare professional, the physician should draw appropriate boundaries to ensure the caregiver is not expected to function in a professional capacity and that he or she receives appropriate support, referrals, and services.
Historically, the patient- physician relationship has focused on the patient’s rights and interests with less attention to the patient’s experience within the context of family and social relationships, the authors note. They argue that patient information provided by the carer may be as relevant as a doctor’s written record.
Set against this is a doctor’s obligation to respect a patient’s decision-making rights and privacy.
Advance healthcare planning is a growing feature of modern medicine. The Medical Council says an advance treatment plan has the same ethical status as a decision made at the time of the illness and should be respected by doctors.
With our national health policy advocating a paradigm switch to home care, the ethics of patient care are set to clash with the reality of carers’ involvement.