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Should Patients be Told of Better Care Elsewhere?

This was a question posed by Denise Grady in an article in the New York Times earlier this month. Her piece outlined the arguments in a PLoS Medicine debate on the ethical responsibilities of doctors towards their patients that was published back in October.

The debate examined the question of whether a surgeon treating patients with cancer whose treatment results are not as good as those at another hospital, has an ethical obligation to tell to his or her patients about the better results at hospitals elsewhere. And although the debate did not attract a lot of attention in the wider media when it was published, it has recently fuelled considerable and thoughtful comment on the New York Times site and on blogs.

Recounting the experience of a relative who had rectal cancer and who chose to travel to receive better treatment despite trusting her local hospital, Denise Grady moves on to discuss each point of view in the debate.

Leonidas Koniaris and Nadine Housri – at the University of Miami – argue that physicians do have a responsibility to inform patients of these disparities in treatment results. In major cancer surgery in particular, they say, the experience of the medical team is especially important and can lead to very different outcomes. Koniaris – a specialist in cancers of the gastrointestinal tract and sarcomas – stated that he has informed his patients about other doctors who have better results than him at treating pancreatic cancer and liver tumors.

The New York Times article also summarizes the argument taken by David Shalowitz in the debate. Shalowitz, a bioethicist, says that this obligation to disclose information about other medical centers would lead to untenable conflicts of interest. And further complications to the apparently simple question are drawn out by Robert Weil, a neurosurgeon, who discusses the logistical hurdles when it comes to comparing hospitals.

Does the burden of disclosing data fall on the hospital or on the doctor? How can a local community hospital be compared with a big teaching hospital and is it fair to compare across states, populations or even nations, Weil asks. (Seizing this last point, a physician writing in response to the New York Times article felt obliged to tell American readers that they could “receive better care in Canada, Norway, Great Britain, France and most other industrialized countries… [that] do not allow health insurance executives to make your health care decisions for you in order to increase their profits.”)

Many of the 111 comments in response to the New York Times article were vehemently of the view that doctors have a responsibility to inform patients of better care elsewhere. But other interesting discussion points were raised, including whether, in the age of the internet, patients have a duty to better inform themselves about their their own health problems and who is best to serve them.

Sharing the new interest in the debate – which, according to Google Analytics, was downloaded twice as many times in the week following the New York Times article than it had been for the preceding three months put together – were the blogs Pure Pedantry and Target Health.

Pure Pedantry, a blog by a PhD/MD student at the Mount Sinai School of Medicine, suggested that multiple sclerosis may be another example aside from cancer where the experience of a team treating the disease was crucial and therefore the right to inform patients of the success of other hospitals is particularly important.

“This sort of informed consent does not need to be adversarial; it is just admitting your strengths and weaknesses”, the blog argues.

This echoes the outlook of Marcel Horowitz, a physician who submitted a reader response to the PLoS Medicine debate. He suggests that the “personal maturity and personal ethics” that come with the ability to inform patients about your limitations as a physician should form part of medical training.

What do you think? Contribute your thoughts on the debate.

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