Case and Commentary
Sep 2005

The "Slip," Commentary 1

Mark D. Fox, MD
Virtual Mentor. 2005;7(9):573-576. doi: 10.1001/virtualmentor.2005.7.9.ccas1-0509.

Case

Jenny is a third-year medical student on her internal medicine rotation at the Veterans Administration Hospital. The rotation has been a great learning experience; her patients are generally friendly and grateful for the care they are receiving.

One of Jenny's favorite patients is Mr. Hackman, a 53-year-old veteran who has been diagnosed with alcoholic cirrhosis and is currently on the transplant waiting list. Every afternoon Jenny talks with Mr. Hackman, and he often shares stories with her about the past. Jenny takes a genuine interest in the stories about his family and supports his attempts at sobriety. During one of their sessions, Mr. Hackman revealed that he had taken a drink at a friend's house 2 months prior. He swore that this was "the only drink I've had in the last 2 years." He pleaded with Jenny not to tell anyone about his transgression because he knew that alcohol abuse could affect his status on the transplant list.

Commentary 1

This case highlights a crucial aspect of Jenny's professional development. She should be commended for the rapport she has established with Mr. Hackman. He obviously trusts her, as evidenced by his willingness to disclose information that has potentially devastating consequences. The conflict posed by Mr. Hackman's request for confidentiality is heightened by the apparent blurring of personal and professional boundaries. Thus, Jenny's dilemma must be considered within the context of both personal and professional obligations. Moreover, because of the potential impact on Mr. Hackman's transplant candidacy, Jenny's actions have broader social implications regarding the allocation of scarce resources.

There is often a naïve presumption of "absolute confidentiality" on the part of both patients and clinicians. In fact, this presumption sometimes leads clinicians to promise more than they can deliver with respect to confidentiality. Clearly there are circumstances in which the risk to the patient (or an identified other) warrants, or even requires, breaching patient confidentiality. One of the developmental tasks for clinical trainees is to divine the limits of confidentiality and to place assurances regarding confidentiality in an appropriate contextual framework.

In this case, Mr. Hackman raised the issue of confidentiality only after disclosing potentially incriminating information. Fortunately, Jenny has not painted herself into a corner with any untenable promises. Nevertheless, it is worthwhile to consider the rationale for expectations of confidentiality, and doing so is necessary for discerning the appropriate course of action for Jenny.

The presumption of confidentiality serves a functional purpose. Clinicians can only provide optimal care when armed with complete information, and patients are more likely to disclose intimate details if they believe the information will be kept in confidence. There is, however, a more fundamental grounding of our commitment to confidentiality: in essence, it is part of a larger pledge to not take advantage of those entrusted to our care. The patient-physician relationship, even when it involves a physician-in-training, is necessarily characterized by a fundamental asymmetry of power. This asymmetry gives rise to a compelling obligation that the physician not use the information in ways that can harm the patient.

Several other aspects of this case are worth further exploration. First, it is not clear that Mr. Hackman divulged the information to Jenny in the context of a therapeutic relationship. It appears that their regular conversations may be more social than therapeutic in nature. (This is not meant to suggest that these interactions are not significant or relevant to Jenny's education.) If Jenny were simply his friend rather than on his medical team, Mr. Hackman might reasonably expect her to keep his confidence and support him in his efforts to maintain sobriety. Because their relationship is framed primarily by the clinical context, Jenny's obligations are shaped foremost by her professional commitments. Whether Jenny's responsibilities would be different if she were a student on the transplant, rather than the internal medicine, service remains an open question.

Another potentially troubling feature of this case concerns the nature of Jenny's relationship with Mr. Hackman, inasmuch as he is identified as one of her "favorite" patients. While it is perfectly natural to feel a particular affinity for, or develop a special connection with, certain patients, we are nevertheless obligated to treat them the same as we do all of our other patients. It would be disconcerting if Jenny felt a greater obligation to preserve Mr. Hackman's confidentiality simply because of their personal relationship.

Jenny's ultimate response to this dilemma may rest in part on her understanding of the requirement for abstinence from alcohol for transplant candidates with alcoholic liver disease, regardless of whether she is a part of the transplant program or not. Jenny is under no obligation to relay inconsequential information to other members of the health care team. For example, the fact that Mr. Hackman is a Cincinnati Reds fan or prefers chocolate ice cream to vanilla holds no consequence for the anticipated outcome following a transplant. The impact of various psychosocial factors on outcomes following transplantation is admittedly not well-characterized, but a minimum of 6 months of sobriety has become widely accepted as a prerequisite for transplant eligibility.

To some, the sobriety requirement may seem to have a punitive quality—penalizing alcoholics for their role in contributing to their disease. Others may view it as a means of rationing a scarce resource; abstinence serves as a hoop for patients to jump through to be eligible for a transplant. If Jenny were to perceive either of these rationales as the basis for the abstinence requirement, she may feel justified in honoring Mr. Hackman's request for confidentiality.

The requirement for abstinence from alcohol, however, is not rooted in a view of alcoholism as a moral failure. Rather, it reflects the recognition of the chronic nature of the disease, with a high risk of relapse. Although alcohol relapse has not clearly been shown to compromise post-transplant outcomes, there is a substantial risk of recidivism post-transplant and a trend toward decreased survival [1,2]. The rate of relapse cited in various studies ranges from 20-33 percent [1-3]. Abstinence for 6 months or longer has been identified as the best predictor that relapse will not occur [1,3].

As stewards of a scarce resource, transplant professionals have an obligation to exercise prudence not only in the selection of candidates for the transplant waiting list but also in the allocation of donor organs to recipients. Optimal allocation of donor organs seeks to balance considerations of medical urgency with the probability of a successful outcome. In addition, because of the limited number of transplantable organs, access and allocation necessarily entail consideration of unknown others. That is, while Mr. Hackman may well experience a survival benefit from a transplant (despite his continued alcohol use), there may be other patients, eligible for the same donor organ, who would fare better. This consequence of organ scarcity poses a significant challenge to the Hippocratic ideal of beneficent action on behalf of the patient entrusted to your care. Therefore, Mr. Hackman's use of alcohol, albeit allegedly as an isolated indiscretion, is certainly relevant to his suitability for transplantation at this time and needs to be communicated to the transplant team. Moreover, it is often a primary care provider, rather than the transplant staff, who is privy to these details during the waiting period.

While Jenny succeeded in initially establishing rapport with Mr. Hackman, she now faces a difficult professional challenge about how best to communicate this information to the transplant team. Ideally, Jenny could help Mr. Hackman appreciate the potential impact of his continued use of alcohol on his transplant outcome while playing a pivotal role in providing emotional support when he discloses his indiscretion to the transplant team.

One final consideration relates to the notion of nonabandonment. Regardless of the impact of Mr. Hackman's disclosure on his transplant candidacy (he could either be deferred or rejected from the wait list altogether), Jenny has an obligation to provide ongoing care for his chronic condition (within the scope of her clerkship). In the midst of navigating these challenging personal and professional concerns, Jenny must also communicate to Mr. Hackman her commitment to participate in his care.

References

  1. Lim JK, Keeffe EB. Liver transplantation for alcoholic liver disease: current concepts and length of sobriety. Liver Transpl. 2004;10(10 Suppl 2):S31-S38.
  2. Bjornsson E, Olsson J, Rydell A, et al. Long-term follow-up of patients with alcoholic liver disease after liver transplantation in Sweden: impact of structured management on recidivism. Scand J Gastroenterol. 2005;40(2):206-216.
  3. Miguet M, Monnet E, Vanlemmens C, et al. Predictive factors of alcohol relapse after orthotopic liver transplantation for alcoholic liver disease. Gastroenterol Clin Biol. 2004;28(10 Pt 1):845-851.

Citation

Virtual Mentor. 2005;7(9):573-576.

DOI

10.1001/virtualmentor.2005.7.9.ccas1-0509.

The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.