AETCOM MODULE 3.

5: CASE STUDIES IN BIOETHICS - FIDUCIARY DUTY

Department of ENT, GMC- Alappuzha

Background

This module discusses doctor’s duty including fiduciary duty. The important parts of ethical care of the
patient are best learnt in a hybrid problem-based format with additional lectures and other sessions that
allow students to learn collaboratively with different learning styles.

HOURS: 5

i. Introduction of case (PPT by faculty)– 1 hour

ii. ii. Self-directed learning (8 small groups)– 2 hours

iii. iii. Student narrative – 1 hour iv. Discussion and closure of case – 1 hour
CASE 1

(cholecystectomy, a surgical procedure intended to remove the gallbladder).

A Surgeon accidentally nicks the patient’s bile duct with a surgical instrument. He/She immediately stitches
up the bile duct, and the damage seems fully repaired. He/She flawlessly performs the gallbladder surgery.
But while operating, notices a benign (noncancerous) tumor of the liver, known as a hemangioma. The
doctor knows that this type of tumor usually does not cause patients any problems and thus does not
require immediate removal, but recognizes that this condition could lead to bleeding during pregnancy or
after external trauma.

1. Whether the doctor expected to tell all these to the patient?

2. Despite a broad consensus that physicians have an obligation to tell patients about material risks
that emerge during treatment, some physicians fail to do so. Failure to disclose, why so?

3. Disclosure of emergent medical risk needed ?

4. CURRENT RESPONSES TO EMERGENT MEDICAL RISKS (EMRS)

5. Is there a THE NEED FOR A LEGAL DUTY TO DISCLOSE EMRS

6. WHEN AND WHAT TO DISCLOSE

7. What will happen if A BREACH OF THE FIDUCIARY DUTY TO DISCLOSE AN EMR

8. WHEN ANOTHER PHYSICIAN CAUSES THE EMR, are we supposed to disclose?

CASE 2

As you discuss a case with a colleague, she tells you that she has been trying a new approach with an
emotionally “needy” patient. She has extended the session time beyond the customary 45 minutes, seeing
him at the end of the day for 1½ hours. She also begins and ends each session with a hug, which she feels is
necessary to assure the patient of her care and concern. Is this behavior ethical?

1. Is this behavior a breach of fiduciary duty?

2. Identify, discuss & defend medico-legal, socio-cultural, professional and ethical issues as it pertains
to this physician-patient relationship

CASE 3

A patient under treatment in psychiatry ward has just informed the physician of a plan to kill someone. The
physician wants to ensure the other person’s safety, but also is concerned about confidentiality. What may
the physician ethically do?

1. Discuss on duties of doctor to society and to patient

CASE 4

A patient has been repeatedly resistant to treatment. He has missed numerous appointments, has not been
following treatment recommendations, and is abrasive when the physician raises concerns about such
behavior. Frustrated, the physician suggests that the patient seek treatment with someone else. He retorts,
“I hired you to be my doctor. I can fire you, but you can’t fire me!” Is he right?

1. Is he right?

2. Do we, as physicians, have the right to choose patients?

3. Identify and discuss physician’s role and responsibility to society and the community that she/he
serves

CASE 5

A physician suspects that a colleague has been abusing alcohol. One morning, while on hospital rounds, the
physician smells alcohol on the colleague’s breath.

1. Is the physician obligated to take action?

2. Reflect your thoughts

CASE 6
A 35-year-old man in the final stages of acquired immunodeficiency syndrome (AIDS) asks for the
physician’s help. He is in constant pain and homebound, with no appreciable quality of life. He would like to
overdose on medications to stop his suffering, but does not have enough of a stockpile to ensure a lethal
overdose. He informs the physician of his plan and asks the physician, who sympathizes with his plight, to
write a prescription for a lethal dose of narcotics.

1. What may an ethical physician do in this situation?

2. Suicide is currently illegal in India. Does the fact that it is illegal mean that it is wrong? Is there an
ethical right to suicide, despite the fact that it is illegal?

3. Can we rely on the perspective of a patient to trust that a logical decision about preemptive suicide
is being made?

4. In this case, the family supported the patient’s decision, what will you do?

CASE 7

A 10–year–old female undergoes elective inguinal hernia repair and unexpectedly is found to have testes in
the hernia sacs. A recommendation is made not to disclose the patient’s genotype to her father by her
mother. This case study addresses the ethical conflict of whether to disclose the patient’s male genotype to
the parent that has been raising the child as female.
 1. is it ethically acceptable to withhold medical information about a child from the primary caretaker?

2. What are the ethical risks and potential consequences later in life of not disclosing a patient’s sex?.
Conversely, what would the consequences be for disclosing?

3. Ignoring the medical precedents set now, do you believe the doctor in this case should have felt
remorse for not disclosing the full nature of the girl’s condition to her mother? Would her mother
have been equipped to handle that knowledge at that time?

CASE 8

See Malayalam movie Hridayam oru kshetram and reflect

• Points for discussion

1. Duty of a doctor

2. Balancing personal and professional life

3. Where to draw the line

4. The concept of fiduciary duty.