Welcome to Ethics Consult -- an opportunity to discuss, debate (respectfully), and learn together. We select an ethical dilemma in patient care, you vote, and then we present an expert's judgment.
Last week, you voted on if it was OK to keep an elderly immigrant woman's cancer diagnosis from her, as requested by family members. Here are the results from more than 1,400 votes:
1. Would you inform the patient through a translator directly?
Yes: 944
No: 543
2. Should immigrant patients' cultural norms supersede American medical ethics standards?
Yes: 510
No: 975
And now bioethics scholar Gregory Dolin, MD, JD, weighs in:
As more and more medical students are being taught, recognizing cultural differences in treating patients is important. However, cultural differences cannot override patient autonomy and the rights that the patient has under U.S. laws. In this country, it is the patient and not the relatives who has the ultimate say on the course of treatment. Thus, the physician is obligated to disclose the relevant information to the patient, provided that she is competent.
Indeed, the physician's prior use of family to translate is itself against the best practices recommended by the profession. The reason it is recommended that outside interpreters are used is precisely the fear that the family -- relying on their own cultural norms, traditions, or perhaps just plain conflict of interest -- will fail to properly and adequately translate the information provided by the physician.
Even if the family is not encumbered by such issues, family members may themselves not be perfectly fluent in English and may misunderstand and commit errors in translation, causing problems -- such as the patient taking a wrong dose of medication or failing to communicate to the physician important information.
Although HIPAA regulations permit using family members as translators, they limit such use to situations . If the patient has absolutely no ability to speak English, it may be hard to ensure that she has agreed to have the family serve as a translator, and arguably disclosure of her medical information to the family in this situation may violate HIPAA.
None of this is to say that the family is obligated to pay for the patient's treatment. That issue should be resolved within the family. The medical staff, however, may have a responsibility to ensure that the elderly patient is not subject to elder abuse. They may have an obligation to report abuse (whether physical or financial) if it is suspected. Nor does it mean that, given the age, chances of survival, and comorbidities, the physician is obligated to treat the patient. That is left to the professional judgment of the physician. If the physician declines to treat the patient for whatever reason, he will have to transfer her to a different doctor who would be willing to follow the patient's wishes.
The bottom line, though, remains the same. Whatever the differences in cultural norms and understandings, in the U.S., the physician is obligated to share the medical information with the patient and receive the patient's consent on the proposed course of treatment (or the withholding thereof).
, is associate professor of law and co-director, Center for Medicine and Law at the University of Baltimore, where he also studies biopharmaceutical patent law. His work includes a number of scholarly articles, presentations, amicus briefs, and congressional testimony.
And check out some of our past Ethics Consult cases: OK to Give Babies Experimental Drug Not in Trial?, Deaf Couple Only Wants Deaf Baby, and Critical Patient With DNR Tattoo.