However, in the current case, it seems doubtful that another negative test would be the end of her requests. In addition, it is increasingly apparent in our current healthcare environment that medically unnecessary testing cannot be sustained, and the ethical tenet of distributive justice must also be considered. The principle of distributive justice implies that healthcare resources should be distributed fairly in society. Therefore, although an additional laboratory test, imaging study or procedure may seem insignificant, when magnified on a national scale, the economic cost of these “inconsequential” decisions becomes large. It is not unethical to withhold nonindicated treatment, and one of the reasons is the pursuit of distributive justice.
We must carefully consider the balance between respecting the patient’s right to share in the medical decision making & the physician’s responsibility to avoid patient harm.
But what if I decline a test & miss something diagnosable?
Societal, legal and professional pressures add to physicians’ fear of missing a diagnosis. This is compounded in disorders when symptoms are purely subjective. When dealing with medical uncertainty associated with vague or subjective symptoms, physicians may agree to patient requests that do not present undue risk to the patient. However, the testing should be rational, medically justified and part of a comprehensive, well-documented management plan.
Back to the Patient
A critical goal of this patient’s physician is to reassure her that there is not an underlying disease being missed. The assumption in this encounter is that the patient feels information that can be obtained from a biopsy is more convincing than the physician’s clinical judgment regarding her diagnosis.
Additional investigation into the patient’s request reveals some important information: A friend was recently diagnosed with polymyositis, and she is concerned she may have this as well. After review of her current workup, education about fibromyalgia and its differences from autoimmune disorders, as well as the risk of the procedure compared with the expected benefit, the patient ultimately agrees a muscle biopsy is not required. Although she is still apprehensive about her diagnosis, she agrees to initiate a treatment plan with the reassurance that she will have ongoing monitoring for any changes in symptoms and reevaluation as necessary—plans that can only be implemented in the context of a strong physician–patient relationship.
Have you had an experience in which patients requested tests or treatment that you felt was not indicated? How did you handle the request? If you have comments or questions about this case, or if you have a case that you’d like to see in Ethics Forum, e-mail us at [email protected].
