In our society and culture where family is of utmost importance, sometimes I wonder how much of a doctor’s duty is to the patient and how much is to the whole family. As a medical student, I remember being told by my professors that we should treat the patient as a whole and not focus on just one problem or organ system. Similarly when practicing medicine in Pakistan, one cannot treat the patient alone and ignore the family. How much should relatives’ wishes be taken into account when dealing with a patient Don’t patients have a right to their medical information When, how, and by whom can that right be waived What role does culture play when debating medical ethics

After graduating from the Aga Khan University Medical School in Karachi, Pakistan, I moved to the United States for postgraduate training in internal medicine and then gastroenterology and hepatology. Among the many things I learnt in those 10 years was that good medicine entails good communication with patients.

After completing my training in the United States, I began my practice as a gastroenterologist and hepatologist in my hometown of Karachi. One of the first patients I saw in my fledgling practice was a 65-year-old man with advanced esophageal cancer referred to me for palliative esophageal metal stenting. I spent a great deal of time explaining the nature of the disease to the patient and his family, as well as the somewhat limited options he had given the advanced state of his malignancy. I was greeted with blank stares and thought to myself “surely I am not the first one to explain these things to them and the doctor who sent him to me for a palliative procedure must have told them something”. The patient and most of his relatives thanked me and left the consultation room. One son stayed back and then angrily asked me “Why did you tell him these things He didn’t know he has cancer! What right do you have to disclose this to him As his family we know him best and know what is best for him and how much information he can handle.” I was dumbfounded and mumbled some apologies. The patient never returned to me for esophageal stenting.

Sine this encounter, I have seen many patients who are unaware of their diagnoses- usually malignancies and occasionally chronic viral hepatitis. In the majority of these cases a relative will poke their head in the door before the patient enters to say that he/she does not know their diagnosis and please do not tell them. When I ask why, the answer I invariably get is: “The patient’s spirit is too weak to absorb such news.” I have learnt that arguing with such logic is futile. I have had only one relative ask me if they are doing the right thing in hiding the diagnosis from a patient. The daughter of a patient with stage 4 colorectal cancer asked what I would do if I were in her place and are they doing the right thing in hiding the true nature of her father’s illness from him. She also said that I had recently returned from the United States and how are these issues handled in the West. As a doctor, I told her, I felt that it was my duty to tell patients the truth. I told her that if I were the patient, I think I would want to know if my days were numbered so that I could prepare myself, my family, and my affairs for my impending death. I also feel that patients probably know that they are dying and I don’t see what avoiding the subject achieves. She listened to what I had to say but I doubt I changed her mind.

There are limits to my concessions to these demands of secrecy. I refuse to do endoscopic procedures in patients who are unaware of the indication and potential risk of the procedure. I take informed consent seriously. Secondly, I refuse to initiate interferon-based antiviral therapy in patients who are unaware of their diagnosis of chronic viral hepatitis. I was quite taken aback the first time I was asked to start a patient on a six month course of thrice weekly interferon injections without telling the patient the true reason for the treatment. When I posited this dilemma to the relative making the request, I was told that the family would handle it and come up with a story to tell the patient. Furthermore, the entire family has to be on the same page. If there is disagreement within the family, then I feel the patient should be told the truth and the family can work out their differences later. I also try not to deliberately lie to patients. At their relative’s requests I may be vague and not voluntarily divulge certain information but if asked directly I don’t tell outright lies. What surprised me earlier on was how few of the patients would directly ask me about their diagnosis and life expectancy. As a result of needing self justification for dealing with patients this way, I tell myself that many of these patients themselves do not seem to want to know about their disease. I have yet to have a patient ask me directly what their disease is, saying they suspect their family is hiding something from them. However, I can not always be entirely sure of this. How does one know if a patient does not want to know the truth unless they explicitly say so

In our society and culture where family is of utmost importance, sometimes I wonder how much of a doctor’s duty is to the patient and how much is to the whole family. As a medical student, I remember being told by my professors that we should treat the patient as a whole and not focus on just one problem or organ system. Similarly when practicing medicine in Pakistan, one cannot treat the patient alone and ignore the family.

But I continue to feel conflicted about the issue[1]. How much should relatives’ wishes be taken into account when dealing with a patient Don’t patients have a right to their medical information When, how, and by whom can that right be waived By hiding a patient’s diagnosis, are we doing good or harm to a patient Finally, what role does culture play when debating medical ethics