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`What should we do?/What would you do?'
Joanna, a woman with spina bifida, is nineteen weeks pregnant. She and her husband Paul have just learned that Joanna is carrying a fetus with spina bifida. They ask their physician, Dr Ricardo, "What should we do?" Dr Ricardo evades the question by responding, "I can't tell you that," and immediately shifts the discussion to procedural matters by saying: "If you decide to terminate the pregnancy, I should book you in as quickly as possible." A day or so later, still agonising over the decision about whether to continue the pregnancy, Paul returns to see Dr Ricardo and asks her: "What would you do?" Dr Ricardo again evades the question and focuses on procedural matters.(1)
The questions asked of Dr Ricardo are not unusual. Patients and members of their families faced with difficult health care decisions for themselves or their loved ones often will approach their physicians with apparent requests for advice and guidance. How their physicians understand and respond to such requests is the focus of this paper.
For some, Dr Ricardo's responses are ethically appropriate. The underlying reasoning is as follows. Questions such as "What should we do?" and "What would you do?" are requests for a professional recommendation. Professional recommendations, not unlike personal recommendations, are necessarily value-laden as the information that physicians choose to disclose to patients and the manner in which they do so is necessarily informed by the values they hold (many of which may be the result of professional socialisation). To avoid imposing their values on their patients, physicians should refrain from offering professional recommendations. On this view, by saying "I can't tell you that," Dr Ricardo acts in an ethically appropriate manner that is consistent with an ethos of value neutrality and the practice of non-directive counselling in the area of reproductive choice. She thereby avoids imposing her values (and treatment goals) on her patients.
For others, however, Dr Ricardo's responses are ethically inappropriate. Here, the guiding assumption is that physicians have a moral obligation to provide patients with a professional recommendation as part of the informed choice process. According to Tom Beauchamp and Jim Childress, for example:
"Professionals are obligated to disclose a core set of information, including (1) those facts or descriptions that patients or subjects usually consider material in deciding whether to refuse or consent to the proposed intervention or research, (2) information the professional believes is material, (3) the professional's recommendation, (4) the purpose of seeking consent and, (5) the nature and limits of consent as an act of authorization."(2) (Emphasis added)
Consider also the following classic statement by Franz Ingelfinger:
"The physician should recommend a specific course of action. He [sic] must take the responsibility, not shift it onto the shoulders of the patient. The patient may then refuse the recommendation, which is perfectly acceptable, but the physician who would not use his training and experience to recommend the specific action to a patient ... does not warrant the somewhat tarnished but still distinguished title of doctor."(3)
On this alternative view, in side-stepping Joanna and Paul's questions and failing to provide them with material information--information that would reasonably be expected to affect their decision making since they expressly requested the information--Dr Ricardo abdicates her moral …