The Case of Herman: Rejecting Doctors Orders

Bioethics Forum, Winter 1996 

Case study prepared by Rosemary Flanigan, PhD, director of ethics committee education, Midwest Bioethics Center, Kansas City, Missouri.

Herman, a fifty-five-year-old farmer, has come into the office of Dr. X complaining of an increase in the symptoms of a chronic problem. Herman, who has had a recurring history of low back pain, now presents with complaints of constant pain with movement or at rest, as well as intermittent episodes of numbness and tingling down his left leg.

Like many farmers, Herman has never had insurance but he has promptly paid any bills for services rendered by Dr. X to himself, his wife, and his children. No one in the family frequents Dr. X's office; there is no record of routine physicals. As the only practicing physician in town, Dr. X, who is the same age as Herman, has responded only to accidents and other traumas in Herman's family.

But this time, Dr. X predicts correctly that the situation will take a different turn. In the first place, Herman agrees to a CAT scan and follow-up visit in which Dr. X shows him the herniated disk, points to imminent danger of nerve damage, and emphasizes the need for immediate surgery in the neighboring city. For the first time in their relationship, Herman refuses to follow the doctor's suggestion.

"I tell you what, Doc," Herman says, "I don't want nobody cutting on my spine. I'm going down to Doc

Jones and get one of his manipulations."

Dr. X is convinced, not only that chiropractic cannot help Herman, but that manipulations could cause irreparable damage.  There is a long-standing rift between the two doctors and Dr. X does not feel he can call Dr. Jones to discuss his fears. Dr. X knows that Herman is the decision maker.

  

 

Case Analysis:
In the ethical conflict between Herman's autonomy and Dr. X's beneficence, what advice would you offer?

 

Questions to consider:

1) When does persuasion become coercion?

 

2) When does Dr. X's prediction of nerve dam­ age resulting from chiropractic manipulation become scientific knowledge?

 

3) How much information does Herman need to make his choice? Can information become excessive?

 

4) Are facts (information) essential for Herman's informed choice to visit the chiropractor? Discuss the role information serves in decision-making?

 

5) Although Dr. Jones has an X-ray machine in his office, to Dr. X's knowledge, he has never been certified in performing or interpreting CAT scans. Should Dr. X attempt to share this data with Dr. Jones?

 

 

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