By ABIGAIL ZUGER, M.D.
Dr. Abigail Zuger on the everyday ethical issues doctors face.
A patient’s wife was on the phone, her voice hesitant, unhappy. She didn’t bother with small talk. “I need to talk to you about Tom’s drinking,” she said.
Only the pure shock of the moment justifies the first words out of my mouth. “Tom? You’re kidding me,” said I.
Every family has a tortured soul in a closet whose door doesn’t quite close. The demons inside are all too visible to friends and family, neighbors and doormen, even the staff of the emergency room. To the outside world, though, not a hint of a problem displays, and that includes colleagues, clients and always, especially, the doctor.
It is an extraordinary phenomenon, this saving of face in the doctor’s office, amusing and distressing in equal parts, spilling into every kind of medical evaluation. At its most basic, it is the patient recovering from the flu who announces — we must hear it once a day — “I was so sick last week, I didn’t know what to do.” So where were you? “Oh, I didn’t want you to see me like that.”
The same instinct lies behind the heartbreaking valor of the demented as they struggle to conceal every lost thought; the dying, who determinedly focus the conversation on any subject but mortality; the substance users, who jump through hoops to avoid medical help for their medical problem.
There are some tools to trap the elusive user, but not nearly enough. The standard implements of the trade sometimes come through: A physical exam can turn up the needle user’s track marks or the alcoholic’s swollen salivary glands. Routine lab work occasionally yields clues, as can studiedly casual chat (“What are you up to this weekend?”). A variety of more pointed questions (“Do you ever need a drink to get going in the morning?”) have been scientifically validated to pick up many serious problems.
But even good tools are useless when nobody bothers to use them. A new analysis from the Centers for Disease Control and Prevention estimates that of the 38 million problem drinkers in the country, only one in six have come clean to a health professional. Doctors are often just not in the mood for a long, fraught investigation. They may feel too much empathy and respect for a patient who is clearly a pillar of the community. They may be up to their armpits in the patient’s other problems (as I was with Tom’s), predictably forgetting, as studies have demonstrated, that addiction can be the source of most of those problems.
Then, suddenly, an unfamiliar voice is on the phone, and everything becomes crystal clear — clear but, alas, certainly no easier, as evidenced by my next words to Tom’s wife: “I’m so sorry. I can’t talk to you about that.”
Three separate considerations canceled our conversation before it began.
First, discussions behind an adult patient’s back are always a terrible idea. No matter how well intentioned, they instantly deform the connection between doctor and patient, transforming one into a pediatrician and the other into a child. Of course, since neither is either, this new relationship seldom works out, and the nonchild heads right out and finds a new doctor.
Ethical standards also hold that most aspects of the adult patient’s health are private, not to be discussed, even with a loving spouse, without specific permission. This mandate lapses only when patients are confused or comatose and urgent medical decisions have to be made.
A clear, imminent danger to the concerned party can also justify a breach. If Tom’s wife was a nondriver and he was planning to take her on a long cross-country road trip, weaving down Interstate 80 with a quart of vodka in his lap, then a lengthy conversation might be in order. Absent this kind of danger, Tom’s business remains his own.
And finally, the law is now involved. With the Health Insurance Portability and Accountability Act of 1996, or Hipaa, the federal government weighed in on patient privacy, to everyone’s great confusion. The convolutions of this legislation are often misinterpreted to affirm that no one can talk to anyone about anyone else’s health without written consent. In fact, most ordinary conversations are legitimate as long as the patient is consulted first and has no objections. Still, the law makes everyone just a little more cautious.
I told Tom’s wife I’d get back to her.
At his next appointment, I told Tom she had called. I didn’t say about what.
“Mind if I talk to her? Or maybe she can come to your next appointment with you.” And Tom, firmly and politely, said absolutely not.
So that’s where it ended. I never met his wife, never heard that sad voice on the phone again. But Tom suddenly found our health conversations heading in an entirely new direction. It turns out that even when moral, legal and professional considerations all forbade me to say a single word, nothing stopped me from listening and nothing made me forget.