DERMATO-ETHICS – WHAT TO DO WHEN?
Dr Geeta Sundar
Registrar, Neurosurgery, KMC Manipal.
When I think of Ethics, in general, it’s like a large 20 GB file downloads in my mind, exploding a mile a minute, as I try to compartmentalise the data to fit the bill on the theme of this edition. Trust me, there are far too many to recount.
As a growing resident or young physician, in any field of medicine, it’s an unsaid but completely understood concept that ethics exists in many forms and shapes across the work we do – in morality, conversation, confidentiality, treatment, plagiarism, in addition to decision making, advertisement, favours, harassment, and many more such horizons.
But when conversing about dermato-ethics, the following are some salient aspects partial to dermatology –
- Ethics involving venereal/sensitive diseases
The patient denies a history of STDs, or the patient denies the right to inform his sexual partners about his seropositive status, or the patient denies treatment for the STD as he/she believes they don’t have it.
Build a rapport, have the patient keep visiting you, counter and ask gently when it comes to sensitive questions, counsel and garner trust to inculcate healthier habits, and advise and pursue the ethical standard in informing partners about the status
- Ethical behaviour towards fellow colleagues/favours from patients
You ask a rich, famous patient of yours for a personal favour, or gain, or you see a patient referred to you from another fellow dermatologist and are not happy with his judgement or treatment.
This is a difficult water to navigate. Asking for favours creates disharmony in the trust and rapport a patient has with his doctor. There is a fine line we should be aware of when we walk this path – to ask should not be implied as manipulation, or at the cost of the treatment we can provide, and patients should not feel obligated to have to do what we request so as to maintain the same level of a relationship. Noting that another doctor colleague has not done something in the manner you would have, is one matter, and you could always have a personal conversation with him/her but never mention those in front of the patient as it creates mistrust, scepticism and doubts in their minds against us.
- Ethics in consumer-provider-pharmaceutics, advertisements, and telecommunication
India is also adapting to direct provider-to-consumer delivery. A patient might prefer to use something/try a procedure (for eg: to combat hair fall) that he noted via the TV/Internet, via an advertisement, or brochure, which while listing the side effects, depicted imagery with happy results, far less convincing to believe in. Patients under the spell of these ads may present with a strong conviction to get a prescription out of you.
Informed consent is very crucial here. Explain the bad, the good and the ugly. Let them know the other options, state the mistakes in those ads, and those videos and counsel on the right approach. But the final decision is theirs. If it doesn’t seem right to your instinct or principles, don’t advocate it. If in telecommunication consult with a patient, it’s always best to be specific about your plan of action, respect the patient’s autonomy, and uphold beneficence.
- Ethics in prescription, transfer of patient care, teratogenic medications
A young woman, of childbearing age, with severe acne, would benefit from retinoids but is not abstinent, or a woman who is on retinoids but refuses to use minimal 2 forms of contraception, but wishes to continue the treatment because it is working, or a patient who wishes to have “stronger medications” because they seem legit based on his/her understanding as they have seen another doctor do the same before.
Counselling, explanation, judgement, and experience play a major role. If you can’t trust your patient to abstain, then it’s best to avoid the teratogenic medications completely. Openly tell her all the risks, advantages, disadvantages, and complications, and doubly note them in the documentation. It’s finally her decision. In cases of conflict with another doctor’s prescription/treatment, avoid questioning their integrity in front of the patient, respect their judgement (if it is reasonable) and explain to your patient why you think that treatment might not work. But, if in instances, it can’t be done, and you feel your patient won’t follow your advice, and you aren’t keen to prescribe medications that don’t convince you, refer them to another dermatologist with clear documentation on your consultation with the patient and ensuring adequate alternatives.
- Ethics in treating cancer/therapeutic privilege –
A patient has been diagnosed with cancer. He refuses to listen or believe about the options you offer him. He wants you to try some other treatment he read on the internet, and threatens to sue you if you don’t agree to that, or the patient comes prepared about the management options he read online and refuses to budge unless you try out his technique, or a patient’s brother requests you to not share details of the diagnosis with his sister as he fears she will “die of a failed heart”.
Follow your moral code. First ‘do no harm’ as far as possible. Try to convince the patient, show the facts, the journals and the recommendations, and imply the best course of reasonable action to be taken, and if despite that they don’t agree, then kindly refuse treatment and understand the patient’s autonomy that he is expressing by deciding for himself. In cases of dealing with bad news and requests to not share information with the patient, it is always better to wish to know what the patient wants and tailor the conversation from there, with the BREAKS/SPIKES protocol.
- Ethics in unsolicited, requested, harmless advice
You notice something abnormal, the colour of the lesion, the appearance of the skin, the tumour, the shape, the melanoma, it’s obviously staring at you. How far would you go to make it known and obvious to someone who casually asks your opinion or informs someone you know closely?
Offering a piece of advice when not asked, or when asked in a casual manner can be answered, but there is no moral obligation to do so. If it’s an emergency, inform anyway, despite the backlash or denial. You are to observe and notice these things, and maybe 50% of such people you interact with, might actually benefit from such a conversation.
If I could go on, I’d be able to cover a whole book of more ethical situations that we can be presented with, and even then, we may have not covered them all. These situations are controversial, not easy to navigate, especially for young doctors and require calm, loyal and logical decisions.
- Image credits- Google image search
- Dermatoethics contemporary ethics and professionalism in Dermatology by Lionel Bercovitch and Clifford Perlis