When a Doctor Stumbles on a Family Secret

CASES

Tuesday, September 16, 2003

By Barron H. Lerner, M.D.

NYT Health Writer

What about the larger questions raised by concealment? Dr. Nancy K. Newman, a family physician at the University of Minnesota, worries about the perpetuation of "toxic secrets" that "involve the erosion of trust in relationships within the family or between family members and others." Dr. Newman said she did not believe that doctors should disclose all secrets.

NYT
group of health professionals were evaluating potential donors for a kidney transplant recently when they received a surprise. Through routine genetic testing, the group inadvertently learned that one of the adult children was not the child of the man with kidney failure.

The transplant team struggled with the question of what to do with this information. Should the family be told? To whom did the knowledge belong? Was it ethical to use the child's kidney without telling him?

Keeping family secrets used to be a routine part of medicine. But over the past few decades, as patient autonomy and informed consent have come to dominate clinical practice, disclosure has become more commonplace. Every now and then, however, physicians confront complicated family secrets. What they should do about them is far from clear.

Much of the earlier secrecy stemmed from the Hippocratic Oath, the code that stresses doctor-patient confidentiality.

This principle led generations of doctors to keep their mouths shut. For example, psychiatrists preserved the confidences of patients who threatened potentially violent actions against family or friends. Similarly, physicians concealed venereal diseases, even when patients' spouses were at risk of infection.

But in the 1970's and 80's, as American society increasingly questioned the authority of doctors and promoted individual rights, things changed. Thus, in the 1976 Tarasoff case, a court in California ruled that a psychiatrist should have disclosed his patient's homicidal thoughts to the man's girlfriend. The woman, never warned, had been killed by the patient.

And as AIDS spread, states passed laws to require notification of partners, something previously recommended only for venereal diseases. Doctor-patient confidentiality was no longer absolute if others were at risk.

But as the case of the kidney transplant shows, the boundaries of such disclosures are not always clear. Incidental information obtained about false paternity during transplant screening, warns Dr. Francis L. Delmonico, a professor of surgery at the Harvard, can be "a disaster for a family."

If a test is conducted in connection with a possible transplant, Dr. Delmonico says, a good case can be made for concealment. Indeed, that is what occurred in the recent case: the patient did receive a kidney from his non-biological son.

Linda Wright, an ethicist at the University of Toronto, pointed out the potential advantages of such secrecy in the journal Seminars in Dialysis, noting that disclosure could stigmatize the child, direct anger at the mother or compel the child to withdraw as a kidney donor.

Yet when a transplant team in Toronto recently confronted its own case of false paternity, it chose to disclose the information — gradually and carefully — to the potential donor and her family. Ms. Wright listed several justifications for doing that: the duty to be truthful, respect for autonomy, the medical value of telling children their true genetic heritage and the risk of future disclosure.
(More: NYTimes.com)

2003 © The New York Times Company.

Dan