AMA Journal of Ethics^®

Case

Dr. Robinson, an internist, entered the exam room to see his next patient, Mr. Kelly, for continuing care of chronic hepatitis. The two had had a long-standing, positive relationship for several years.

Dr. Robinson noticed that Mr. Kelly appeared to be jaundiced with mild ascites. Mr. Kelly said he had been taking his medications properly, so Dr. Robinson suspected that his patient's hepatitis had progressed. He told Mr. Kelly that he would need a liver biopsy and that, based on these new symptoms, he might be a candidate for a liver transplant.

Aware that he might need a transplant at some point, Mr. Kelly had been diligently researching the topic, and he was prepared when Dr. Robinson began discussing the details of the procedure and the logistics of getting on a list. Dr. Robinson said he generally referred his patients to the university organ transplant unit, since he was an affiliate of that health system. Dr. Robinson noticed that Mr. Kelly looked uncomfortable when he heard this, so he asked Mr. Kelly what was disturbing him.

Mr. Kelly reminded Dr. Robinson of the recent media frenzy about the university's transplant unit. News articles claimed that the institution had extremely high mortality rates and had urged that an external regulatory body be appointed to certify the organ transplant unit.

Mr. Kelly asked Dr. Robinson how he could still send patients to that apparent "death trap." Dr. Robinson, surprised at having his judgment questioned, found himself in a bind. He had worked loyally and successfully with the hospital unit for many years and was skeptical about the media reports. He figured that, since the university accepted more critical patients, the mortality rates were undoubtedly skewed. He considered offering this information to Mr. Kelly because he believed the university hospital was the best and safest place for the surgery. On the other hand, he didn't want to stress his relationship with Mr. Kelly or convince him to take a course that might cause unnecessary anxiety.

Commentary

This case is about a patient, Mr. Kelly, who has a medical decision to make, but this process is being influenced by negative news coverage of the hospital where his procedure would take place. It is also a story about Mr. Kelly's physician, whose duty is to educate his patient regarding the best treatment, and who suspects that the media has become an obstacle to this education. An overriding theme in this story is the role of the media in medical matters and whether it contributes to or detracts from the patient-physician relationship.

The media has a mixed record as a medical educator. Though there have been examples of good investigative reporting and excellent, unbiased and well-documented health programs, particularly by public radio and television, there have also been disclosures labeled as "education" that conflicted with physician attempts to better inform their patients.

Television dramas, for example, have raised unrealistic expectations about the efficacy of cardiopulmonary resuscitation [1]. News stories have emphasized the benefits of certain chemicals and food products as well as medical and surgical procedures at times when they were still controversial in the scientific community. It has even been suggested that some segments presented as medical reporting were really hidden advertisements [2].

Besides touting medicine's benefits, the media has also disseminated unsubstantiated reports of negative effects of many previously accepted foods, drugs and procedures. A prominent recent example was the widespread warning to the public that childhood immunizations could cause autism. This "education" led some parents to forgo immunization of their child, despite the fact that the claim was controversial and remains unproven [3].

Finally, direct-to-consumer pharmaceutical advertising poses the question of whose interest the media are serving. Drug ads are broadcast to millions of viewers who do not have the disorders that the marketed drugs treat. This type of advertising can result in misinterpretation of symptoms and inappropriate indications for drug use. It could also engender unnecessary anxiety and concern on the part of otherwise healthy individuals. Under these circumstances, the statement at the end of each ad—"talk to your doctor"—may be more than simple advice; it may further the goals of the drug marketing firm by making doctors more aware of a new "in-demand" drug.

Where does Dr. Robinson's allegiance lie?

Organ transplantation is of particular interest to the general public and to patients alike because of the scarcity of the available organs and because the need for a transplant is usually associated with a life-threatening illness. Therefore, the public can be expected to have concerns about inequities in the allocation of organs or poor transplant surgery outcomes. It is pertinent to the story of Mr. Kelly and Dr. Robinson that the media, through diligent research, have uncovered and disseminated disturbing information about the hospital's role in the procurement and the transplantation of organs, which demonstrated questionable medical practices and outcomes. The Los Angeles Times, for example [4], has reported on one or more of these violations occurring in three separate hospital systems in southern California. Such stories, if found to be factual through a prompt administrative investigation, can bring about system corrections and promote better informed consent and decision making both by patients and their doctors.

In our case, Mr. Kelly is under stress, having learned that he needs a liver transplant. It is understandable that, because of his own situation, whatever information he already has learned from the media, whether valid or erroneous, has made an impression that will surely influence his personal treatment decision. It is doubtful whether Dr. Robinson can ever provide, even if available, supportive documentation that could ease his patient's concerns about agreeing to a liver transplant at the university's hospital.

The physician's professional obligation to the patient in this sort of predicament has been well documented in the literature [5]. A major ethical question is, to whom does Dr. Robinson owe his fiduciary responsibility? Does the trust the hospital puts in Dr. Robinson to support rather than discredit the hospital trump the trust Mr. Kelly has put in Dr. Robinson to give him the best advice, care and avoidance of harm? Surely not. The duty to honor the patient's trust comes first. Because of that, Dr. Robinson may find it necessary to secure a site for the transplant that has not aroused media controversy; one that has a record for performance that is acceptable to both Dr. Robinson and Mr. Kelly. This is not to say that Dr. Robinson should not present his patient with relevant documentation and information about the university hospital's skills and record. He may even help Mr. Kelly consider explanations that might dispute the media's conclusions. But in the end, if Mr. Kelly remains unconvinced about the university hospital, Dr. Robinson must identify another facility for the planned surgery.

The fact that the media serve as a primary source of information for the public, patients and physicians is a double-edged sword. On the one hand, it may uncover true evidence of harmful medical practices that would otherwise have gone undetected and unpublicized. On the other hand, the media may exaggerate, overplay or apply research findings inappropriately. With its daily and attention-grabbing presentations, media dominate the public's exposure to medical information in contrast to the occasional and time-limited doctor visit.

Medical education disseminated by the media differs from that provided by a physician because of the intent and the responsibility of the latter. Broadcast information is intended for all who care to watch, listen or read and has no direct and personal applicability to any particular individual (though we hope responsible journalism serves society in the aggregate). The physician, however, tailors the information to a specific individual whose personal medical situation, values and goals the physician understands. The individual patient would be better served if the media simply supplemented the physician's medical knowledge by offering generally applicable, realistic and accurate information. Perhaps there should be more cooperation between the media and the medical profession about how this could best be done for the benefit of the patient. Unfortunately, if the information given by doctors' stories that shape patient decision making is not echoed by the news media, the dilemma faced by Dr. Robinson and his shaken patient may occur more frequently.