AMA Journal of Ethics^®

Case

Mr. and Mrs. Green took their 11-year-old son, to see Dr. Frank, a pediatrician. This was the first time Dr. Frank had seen the boy, who was in the sixth grade and had played piano since he was five. He loved music and showed exceptional promise. Within the preceding month, however, he had been struggling with piano lessons and practice. The boy told Dr. Frank that piano was very important to him and that he really wanted to be accepted into a special school for the performing arts. His audition for the school was to take place in six months. But he had been having trouble concentrating and therefore had been practicing less. His parents said that "until now," the boy had never exhibited any behavioral or emotional problems at home or at school. Mr. and Mrs. Green wondered whether he had attention deficit hyperactivity disorder (ADHD) and whether medication could help their son with his concentration, at least until after his audition.

Dr. Frank asked the Greens if their son had been evaluated by a school psychologist. They replied that he attended a small private school with no psychologist on staff. To determine whether he met the criteria for a diagnosis of ADHD, Dr. Frank asked the Greens about symptoms of inattention, hyperactivity and impulsivity. The Greens said that, in addition to trouble with piano practice, his math teacher had contacted them regarding his forgetfulness, distractibility and daydreaming in class. Their son had always done well in math, but now he was struggling to keep a C. They stressed several times that their son's piano teacher was especially concerned about his recent distractibility.

Dr. Frank asked the Greens about the boy's mood, and they admitted that he had become somewhat withdrawn. Every day he sat down at the piano after finishing his after-school snack. Mrs. Green had noticed that he played for a few minutes and then stopped, and she would find him staring off into space, still sitting at the piano, 15 or 20 minutes later. He exhibited no signs of hyperactivity. The Greens said that there had been no major changes at home and no incidents at school that they were aware of, such as fights with friends or teachers.

During most of the appointment, the boy sat quietly in a chair with his head down. When questioned by Dr. Frank about his mood and concentration, he responded mostly with "yes" and "no" answers, and a few times he said, "I've just been having trouble concentrating." Dr. Frank did not believe that the boy met the criteria for a diagnosis of ADHD and, because the changes had only occurred in the last month, Dr. Frank was not yet concerned. He recommended some dietary changes, told Mr. and Mrs. Green to monitor their son's sleeping and activity habits, and said that he would like to schedule another appointment in six weeks to see whether the dietary changes had had any effect. Mr. Green got very angry and said, "This is ridiculous! There's clearly something wrong with the kid. Why can't we just get a prescription to try for a few months?"

Commentary

This is a complicated but common situation for primary care physicians. The child is a new patient. Dr. Frank is challenged with the task of physically examining the boy, getting a full medical history and performing a meaningful psychiatric evaluation. These challenges are further complicated by the variable of time: most first visits to a pediatrician last from 20 to 30 minutes. In contrast, first visits to a child psychiatrist range from 45 to 60 minutes. Dr. Frank cannot possibly achieve all of the above objectives in one visit. His task is to initiate care in the most effective and appropriate manner.

One ethical principle at play in any clinical encounter is that of beneficence—the duty to help or to do good. In clinical terms, this implies figuring out what is wrong (in some instances actually making a diagnosis) and offering some possible solutions. In this case, the boy and his parents complain of his lack of concentration. The differential diagnosis for this particular symptom is broad. For example: he could be depressed, have generalized anxiety disorder or attention deficit disorder, or there could be an underlying organic cause for his lack of concentration, such as poor nutrition or low iron. In addition to these codable diagnoses, a social stressor might well have prompted this change, for example, new-onset drug use or, perhaps more likely, the upcoming piano audition.

The Greens seem to insist on framing the issue in a somewhat narrow fashion: "if you want to help us you will give us medicine." It is often the case that patients come to their physicians not only with a sense of what they think is wrong but also with certainty about what they need to get better. The demand for antibiotics to treat viral illnesses is a good example of such a scenario. The duty of a doctor (which comes from the Latin word for "teacher") in any circumstance is partly to educate. To that end, Dr. Frank should broaden the Greens' understanding of what is wrong, or could be wrong, and what help might be available.

The meaning behind a parent's request

As a psychiatrist, I am struck by the many possible meanings that the Greens' request may have. They may be asking for medicine to treat ADHD because that is the language most readily accessible to them: they might really be saying, "We need help because we recognize something is wrong." Certainly, it is also possible they have been too demanding of their son all along, and this desire for perfection is playing out now as his piano auditions approach. Dr. Frank not only fails to elucidate the meaning behind their request; he also fails to recognize the most essential content: The boy and his parents are in distress and asking for help.

It should also be pointed out that Dr. Frank is not appropriately concerned by the change in the child. He is relieved to find out that the problem is a new one and misses the relevance of sudden behavioral change as a marker for something more significant. Moreover, he does not initiate a medical workup or the gathering of collateral data from teachers; nor does he take the important step of talking to the boy alone.

Finally, in failing to educate the family or to reframe the visit, Dr. Frank misses an opportunity to alleviate the very real suffering in the boy's presentation regardless of the cause. The family is left with the advice to vary their son's diet and to keep track of his sleep, and they are told to follow up in six weeks. It is here that Dr. Frank both neglects to do "good" and begins to do "harm."

With an act of unintentional harm, Dr. Frank may violate a second ethical principle, that of nonmaleficence, often stated as "first do no harm." Dr. Frank may already be engaged in balancing potential harms: the possibility of doing harm by prescribing stimulants is weighed against the possibility of doing harm through inaction. The problem is that his solution does several potentially harmful things. He does not educate the family; he does not properly initiate a work-up of the patient; and, most significantly, he does not provide any relief to the boy or to the Greens. In this context, we can understand better Mr. Green's anger and his demands.

Prescribing can stifle other interventions

But what if we take Mr. Green's request at face value? Would there be a problem with Dr. Frank prescribing stimulants under these circumstances? Yes. Certainly, the boy could be harmed by taking a medication to treat a disorder he might not have. In prescribing medication as "the answer" to the problem, Dr. Frank would collude in the inappropriate framing of the encounter. This may stifle the possibility of another intervention (for example, decreasing the intensity of the boy's piano practices). Finally, just as with the overprescription of antibiotics, there are larger social implications in the overprescription of stimulants for children without clear disease. Inevitably, as people in the community share information, more children receive stimulants, and more parents interpret their children's behavior as indicative of ADHD, causing them to go to the pediatrician's office with requests like that of the Greens. It is not difficult to imagine an overall increase in stimulant use—in fact, we are living in that world now. But overuse of stimulants is not the only problem. Rather, prescribing medications might prevent an adequate consideration of patient issues. Caught in this dilemma about whether or not to prescribe, practitioners may miss the chance to fully help their patients. Dr. Frank certainly did.