Abstract
Prognostication, the process offormulating and communicating a prognosis, isno longer considered by most physicians to bean essential task in caring for patients withserious illness. Because of this fact, it isnot surprising to find that when physiciansattempt to engage in prognostication, they doit poorly. What may be surprising to thoseoutside the medical community is the extent towhich professional norms have developed whichactively discourage physicians from engaging inprognostication. This article explores thecauses of this state of affairs and thejustifications offered for it. The conclusionis reached that physicians have a professionalresponsibility to competently engage inprognostication based upon the doctrine ofinformed consent, and that a failure or refusalto do so has not only potential legalramifications, but serious negativeimplications for many of the core issues inbioethics, such as the use of advancedirectives, palliative medicine, and medicalfutility.
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NOTES AND REFERENCES
Rothman DJ. Strangers at the Bedside: A History of How Law and Bioethics Transformed Medical Decision-making. New York: Basic Books, 1991.
Katz J. The Silent World of Doctor and Patient. New York: Free Press, 1984.
Morgan JP. American opiophobia: customary underutilization of opioid analgesics. Advances in Alcohol and Substance Abuse, 1985; 5: 163–173; Zenz M., Willweber – Stumpf M. Opiophobia and cancer pain in Europe. The Lancet, 1993; 341: 1075–1076.
Christakis NA. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press, 2000.
Stedman's Pocket Medical Dictionary. Baltimore: Williams and Wilkins, 1987.
Newland S. How We Die. New York: Alfred A. Knopf, 1994: 248.
Ibid.:248–249.
Wanzer SH. et al. The physician's responsibility towards hopelessly ill patients: a second look. The New England Journal of Medicine, 1989; 320: 844–849.
Nuland, op. cit.: 252–253.
Annas G. How we lie. Hastings Center Report, 1995; 6: S12–S14.
Wear S, Milch R, Weaver WL. “Care of Dying Patients.” In: McCullough LB, Jones JW and Brody BA. eds. Surgical Ethics. New York: Oxford University Press, 1998: 179 (emphasis in original).
Hippocrates. History. Epidemics, T. Cadell, trans. London, 1780.
Christakis N, Iwashyna AB. Attitude and self-reported practice regarding prognostication in a national sample of internists. Archives of Internal Medicine, 1998; 158: 2389–2395.
Christakis N. The ellipsis of prognosis in modern medical thought. Social Science and Medicine, 1997; 44: 301–315.
Foucault M. The Birth of the Clinic: An Archeology of Medical Perception. NewYork: Vintage Books, 1975: 97.
For further explication of the discontinuities between the curative and palliative models of medicine see Fox E. Predominance of the curative model of medical care – a residual problem. JAMA, 1997; 278: 761–763.
Rich BA. An ethical analysis of the barriers to effective pain management. Cambridge Quarterly of Healthcare Ethics, 2000; 9: 54–70.
Christakis N, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. British Medical Journal, 2000; 320: 469–473.
Reiser SJ. Words as scalpels: transmitting evidence in the clinical dialogue. Annals of Internal Medicine, 1980; 92: 837–842.
Christakis, op. cit., 2000: 142–143.
Christakis found that prognostication is often viewed by physicians as being “hubristic to the point of representing a godlike presumption.” One respondent suggested that whereas diagnosis and therapy were his rightful professional province, prognosis was “God's alone.” Another declared: “My family, religion, education, and upbringing forbid ‘definitive’ statements of prognosis as a false god.” Christakis, op. cit., 2000: 93.
In addition to his own research and clinical observations, Christakis cites the following authorities: Mauss M. A General Theory of Magic, trans. R. Brain. New York: Norton, 1972; Fox RC. The Sociology of Medicine. Englewood Cliffs, N.J.: Prentice Hall, 1989.
For a comprehensive discussion and analysis of the doctrine, see Faden RL, Beauchamp, TL. A History and Theory of Informed Consent. New York: Oxford University Press, 1986.
Canterbury v. Spence, 464 F. 2d 772, 784 (D.C. Cir. 1972).
Robinson v. Bleicher, 559 N.W. 2d 473 (Neb. 1997).
Johnson v. Kokemoor, 545 N.W. 2d 495 (Wis. 1996).
Furrow BR et al., Health Law (St. Paul, MN: West Group, 2nd ed. 2000): 325–327.
Kai I et al., Communication between patients and physicians about terminal care: a survey in Japan. Social Science and Medicine, 1993; 36: 1151–1159.
Katz, op. cit.: 82–84.
858 P. 2d 598 (Cal. 1993).
Feinstein AR. An additional basic science for clinical medicine: 1. the constraining fundamental paradigms. Annals of Internal Medicine 1983; 99: 393–397, 393.
Ibid.: 394.
SUPPORT Principle Investigators. A controlled trial to improve care for seriously ill hospitalized patients: SUPPORT. JAMA, 1995; 274: 1591–1598.
Gelder M. Life and death decisions in the intensive care unit. Cancer, 1995; 76: 2171–2175, 2173.
Much to his credit, Christakis has offered his own analysis of the implications of his research for bioethics. See Christakis M. Prognostication and bioethics. Daedalus, 1999; 128: 197–214.
Chevlen E. The limits of prognostication. Duquesne Law Review, 1996; 35: 337–354, 354.
Schonwetter RS et al., Estimation of survival time in terminal cancer patients: an impediment to hospice admissions? The Hospice Journal, 1990; 6: 65–79.
Rich, 2000, op. cit. See also Hill CS.When will adequate pain treatment be the norm? JAMA, 1995; 274: 1881–1882.
Seneff M, Knaus W. op. cit.
Lynn J et al., Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy. New Horizons, 1997; 5: 56–61.
Quoted in Waisel DB, Truog RD. The cardiopulmonary resuscitation-not-indicated order: futility revisited. Annals of Internal Medicine, 1995; 122: 304–308, 306.
The most thoughtful and concise statement of the ethical considerations implicit in good care for dying patients remains Wanzer et al., op cit.
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Rich, B.A. Defining and Delineating a Duty to Prognosticate. Theor Med Bioeth 22, 177–192 (2001). https://doi.org/10.1023/A:1011466711211
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DOI: https://doi.org/10.1023/A:1011466711211