AMA Journal of Ethics^®

Case

Mrs. May took her 4-year-old daughter to Dr. Smith because she had a cold. Dr. Smith had not seen the child before, and asked Mrs. May who the girl's primary care doctor was.

She responded, “I just haven’t been able to find a doctor who is right for my daughter. I took her to a general pediatric clinic 3 weeks ago when she had a rash on her back, and 1 week later we went to an acute-care clinic because she was vomiting and had diarrhea.”

Dr. Smith examined the girl and found that she had an upper respiratory infection (URI) that would probably resolve in the next day or so and did not need treatment. He explained this to Mrs. May.

“My daughter needs some sort of treatment to help her get over the infection,” Mrs. May said. “She is not going to get better without it.”

Dr. Smith told her that if the condition did not resolve in a couple of days, Mrs. May could bring her daughter back in or give him a call and he would reconsider.

At the end of the visit, he asked, “Can we schedule your daughter for a follow-up well-child visit in a few months?”

“Let me think about it,” said Mrs. May. “I am not sure that we are ready to commit to you as our primary pediatrician quite yet.”

Two weeks later, Dr. Smith saw Mrs. May and her daughter at his office, but they were visiting one of the other doctors, Dr. Moore. Dr. Smith asked him about the visit.

“She had another URI,” said Dr. Moore. “Her mom was concerned so I gave her some antibiotics for the girl to take."

“Were you able to set up a follow-up visit?” asked Dr. Smith.

Dr. Moore replied, “Mrs. May said that she will bring her daughter in next month for a well-child visit.”

“You know Mrs. May probably wants you as her primary provider because you will do whatever she wants you to,” said Dr. Smith.

“I don’t think that it is especially harmful to give a kid some antibiotics, even if in all likelihood she has a viral infection,” said Dr. Moore. “Anyway, I was able to get Mrs. May to agree to a follow-up visit so that the girl is going to receive care from me rather than from random physicians. I think that it was a small compromise to make in order to ensure a better level of care for the child.”

Commentary 2

To analyze ethical issues that arise in the story of Dr. Smith, Mrs. May, and her daughter, it’s useful to look at the scenario in three parts—roughly following the chronology as given. What the analysis shows is missed opportunities by Dr. Smith and questionable judgment by Dr. Moore.

In the initial encounter between Dr. Smith and Mrs. May (we do not hear from the 4-year-old girl), we learn that Mrs. May is concerned that her daughter has a cold and that Dr. Smith is interested in whether the girl has a primary care physician. Such an exchange is not unusual, but we should note that they begin their dialogue in two different places. Mrs. May, looking for a response to her child’s illness, initially finds an inquiry into her relationship to pediatric care. Nothing is made of this in the scenario itself, but it is worth pausing to recognize that this kind of exchange can undermine trust. Rather than reflecting Mrs. May’s concern—an indication that he is listening and that “we are in this together”—Dr. Smith turns to his own (well intentioned, I suspect) concern for good primary-care continuity.

Given Dr. Smith’s line of inquiry, it is striking that, when Mrs. May states that she has not “been able to find a doctor who is right" for her daugther, Dr. Smith follows by asking about other recent visits to the doctor. This is a missed opportunity. Crucially, Dr. Smith does not ask what seems to me to be the reasonable follow-up: “What kinds of things are you looking for from your daughter’s primary care physician?” This question allows Dr. Smith to elicit Mrs. May’s story—at least as it relates to her child’s health care—and provides the opportunity to develop common ground before the exam and diagnostic discussion occur. Again, we quickly see two incidents in the brief communication where Dr. Smith’s responses are not those of someone who is listening carefully and engaging directly the concerns of the patient’s mother.

Part two of this scenario describes an exchange about treatment for the girl’s condition.  Here again, Dr. Smith loses an opportunity to connect. While acknowledging that the girl has a URI, Dr. Smith indicates it is not something that needs treatment. Mrs. May disagrees. Rather than providing a “wait and see” response, Dr. Smith could have stopped here to acknowledge that the girl is, in fact, ill. This simple acknowledgment can establish a connection with Mrs. May, who clearly worries about her child’s health (as evidenced by the several trips to a physician she has made in the last few months). Dr. Smith, then, could continue by moving from this common point to explore why Mrs. May believes her daugther will only get better with treatment. Through this he may be able to help distinguish actions that can help relieve troubling symptoms from “treatment” intended to cure underlying conditions. If he is correct that the URI is viral in origin, a “curative” treatment may not be available, but he should also not allow Mrs. May to have the impression that “no treatment” equals “nothing can be done to help your daughter.” Our language often betrays us, and we do not work carefully to make sure we are understood and that our patients and parents are understood as well. Had a conversation about what can be done occurred, Dr. Smith’s comment about reconsideration if symptoms did not subside in a few days could be taken in light of having done somethingrather than nothing. Part two ends with a reprise of the primary care physician inquiry, and, again, Dr. Smith drops the ball. When Mrs. May states she is “not sure that we are ready to commit to you as our primary pediatrician quite yet,” Dr. Smith should react to the comment not as if it ends the conversation but as an invitation to explore what Mrs. May is looking for in a primary care physician and to reassure her that he has the goal of providing the best health care for her daughter—a goal they share.

Behind the exchange between Dr. Smith and Mrs. May resides a fundamental ethical tension in pediatrics—given the medical expertise of physicians, how far should parental authority be allowed to operate? Or put another way, who gets to decide what is best for the pediatric patient, and why? Assuming that children (especially 4-year-olds) do not have decisional capacity for such medical considerations, others must speak in their behalf. Our society strongly supports a broad scope for parental authority, and yet parental demands for treatment in the face of physician disagreement create a tension that challenges this authority. Dr. Smith, if correct in the diagnosis (and that is still questionable), is right not to provide antibiotics, but, as noted above, no antibiotic treatment is not the same as no treatment at all.

The scenario’s final section describes an exchange between Dr. Smith and his partner Dr. Moore after Mrs. May brings her daugther to see Dr. Moore some weeks later. Here, a number of ethical issues arise. First, while it may be natural curiosity on Dr. Smith’s part, he should, in fact, refrain from asking about another physician’s patient. Unless he is consulted, Mrs. May’s current visit to Dr. Moore establishes a relationship exclusive, not inclusive, of Dr. Smith. Here, Dr. Moore errs too, for, even if asked by a partner, he should not give confidential information about his patient to a (now) unrelated party. While it is not uncommon for colleagues to have such conversations, sharing an office is not equivalent to sharing patients—if it were, Dr. Smith would not need to distinguish between Mrs. May’s choosing him or Dr. Moore as a primary care physician. Mrs. May appears to be making a distinction, even within the same office, and part of the importance of the distinction is the trust she places in the person chosen as the primary care physician. Confidentiality is an expected extension of that trust. Further, it is clear that Dr. Smith and Dr. Moore have more to talk about concerning their own professional relationship.

One more issue remains. Dr. Moore, unlike Dr. Smith, provides antibiotics to Mrs. May. Given that this is a recurrent (or sustained) URI within 2 weeks of the previous visit, medication may, in fact, be indicated, though it would seem that the intent in prescribing antibiotics, according to Dr. Moore’s own comments, is not so much about the girl’s present illness but her long-term care. Should medications be used for reasons other than to cure a disease or alleviate symptoms? Dr. Moore is simply wrong in saying that no harm comes of giving an antibiotic to a child who does not need it, even though he is certainly not alone in this belief and practice. Medications are not benign and should be directed at signs and symptoms, not the psychology of the patient’s parent. While Dr. Moore’s desire to provide long-term continuity of care for the girl is laudable, the ends, here, do not justify the means. The girl may need antibiotics, and to that end they should be prescribed, but Dr. Moore’s rationale does not speak to alleviating infection as their intended purpose, and that is troubling.

This case presents missed opportunities and misplaced intentions; it demonstrates the need for a good preventive ethic that can help mitigate, if not completely avoid, troubling issues that surface when careful communication and forethought are not marshaled.