Bioethics Case Study: Concealing Information and Patient Autonomy

This bioethics case study explores the proposition of concealing information from patients in order to prevent the nocebo effect and its implications on patient autonomy. It analyzes the principles of autonomy, beneficence, non-maleficence, and justice in relation to this proposition.

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BIOETHICS CASE STUDY
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Introduction.
A standard approach to biomedical ethics was developed by Beauchamp and Childress in
their principles of bioethics (Beauchamp, 2019). These refers to a set of standards that must be
achieved for us to consider a medical intervention ethical. The aim was to protect individuals
who decided to participate in research in the phase of a developing world (Rothman, 2017) With
the heavy investment put in research, extensive research was a consequence. There was a need to
protect individual from the effects of research that may not be carried in the right manner or for
the right intentions. History had proved that it was possible for individuals to be abused and their
rights be violated in the process. A good example was when the Tuskegee syphilis study which
was aimed at identifying the natural history of Treponema pallidum infection. The study was
conducted on the illiterate blacks of Alabama, most of whom did not understand the what they
were consenting to (White, 2016). In addition, they agreed to the study following a misleading
advertisement. The issue of denying them treatment was considered as it caused more harm than
good.
With a background of such issues it becomes very essential to regulate the process of
conducting research. The bioethical principles mainly focus on the interest of the participants,
their ability to understand and consent, and ensuring that their lives are not put to unnecessary
risk. The intention of Tuskegee study would be considered a great stride in developing a cure
that will be for the greater good of all the people. However, the impact on the participants and
their families was very painful. Their rights were violated and their dignity disregarded. To avoid
a repeat of such issues, the bioethical principles were developed. They include: autonomy,
beneficence, non-maleficence and justice. This essay will focus on a proposition by Alfano to
conceal some information from the patient in the fear that it might influence their judgement

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which would consequently not be in their best interest. The various aspects of bioethical
principles in research will be analyzed with regards to this proposition.
Case study overview.
Alfano (2015) argues that informed consent may sometimes precipitate a nocebo effect.
In his argument, he states that if a patient has knowledge of the anticipated side effects, the
effects are more likely to occur. He suggested that the authorized concealment would involve a
doctor asking the not to disclose some of the information as it would have effects on the
expected outcome. A doctor may vaguely discuss the issue without clearly pinpointing the facts
that would affect the patient’s decision on the treatment option. An important fact in his
proposition was that this approach would be applied in situations where the side effects are
symptomatic. The dangerous and irreversible ones are excluded from this proposal. These
circumstances would require the patient to have all the necessary details as it they would have to
live with the effects the rest of their lives. Focusing on the reasons behind the reasoning of
Alfano, it might be argued that he was proposing this in the best interest of the patient (Ruan &
Kaye, 2016) However, taking such an action would have both legal and ethical considerations.
The action has an implication on the rights of the patients and their choice concerning the same.
The ethical considerations will be most important in this discussion.
Principle of Autonomy
From a bioethical perspective, the issue has an implication on the principle of autonomy.
This principle, in the healthcare setting brings out the importance of providing an informed
consent to whatever intervention the doctor proposes. An informed consent can only be given the
patient has all the necessary facts (Cohen, 2014). It requires that a patient should be able to get

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all the information; both the anticipated risks as well as the expected benefits. The choice made
should be voluntary. There should be no coercion from the doctor. This principle the doctor
helps to make a consideration of the patient wishes in the process of care. a consent may be
written or implied. In both cases, the patient has the right to decide what is in their best interest.
The doctor cannot make any assumptions. A valid consent can only be made by an individual
who has attained the minimum age to consent and is in the has the mental capability to do so. If
this is not possible, the law gives provisions on circumstances where a spouse or an attorney can
make give a consent. a consent is a legally binding document that states that the action stated
therewith can be carried out. It shows that an individual understands the risks and benefits and
has decided to move forward with the intervention
The suggestion to conceal some important information from the patient in an attempt to
prevent the nocebo effects may surmount to a contravention of the principle of autonomy
(Young, 2009). The patient need to know all the information regarding the drugs side effects in
order to weigh if they are worth taking the risk for. There is a possibility that this will precipitate
a nocebo effects but then the decision of the patient will be done without all the information. The
aspect of a patient being fully informed before making a consent may be disregarded. Alfano
tries to suggest away around this by proposing that the doctor should ask for permission to
conceal the information.
By this, the power to make the decision is virtually left in the hands of the doctor. The
doctor makes the decision on the information that the patient will have. There won’t be complete
autonomy indecision making. In a situation where the doctor does not do this in the interest of
the patient, they may end forcing the patient to make some decisions they would have not made
if they had all the information. This proposition places so much trust in the doctor and makes the

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assumption that their decision will be in the interest of the patient. It is worth considering that the
intention may be corrupted if they have a particular interest in the drug. An example is if the
doctor is conducting research on the efficacy of a certain drug that they are considering to use in
managing a patient’s condition. They may prefer prescribing that drug to prescribing another
whose efficacy has already been proved to be more superior through research. In such a
situation, they may even opt to avoid giving information that may influence the patient’s
decision. The decision of the doctor may be deemed as unjust and biased if it prevails.
Principle of Beneficence.
This principle requires that the intention of medical intervention or participation in
clinical trial should produce a positive and advantageous impact on the patient. It calls for an
audit of the risk incurred and the perceived benefit. The benefits should out do the risks. The
doctor is responsible for the health of the individual and should intervene in a way that upholds
care. it can be argued that through this principle, a doctor may decide to conceal some
information that may have adverse effects on the health outcome of an individual. Researchers
have identified the importance of the emotional and psychological support in the course of care
(Arnold, Finniss & Kerridge, 2014). In the nocebo outcomes following information, some may
argue that the concealing of information is good for their mental health. If the patient knows that
there are some anticipated effects and the fact that they have knowledge about this has a positive
association with the occurrence of the side effects, then this poses as a dilemma question on
whether the information was really necessary. There has been a group which has championed for
responsibility by medical care providers on the information that they will feed their patients with.
It may be considered that the best outcome will be achieved if the patient does not have the
knowledge about the expected side effects in a clinical trial.

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In this question, it will important to establish the causal relationship between the
information to be given and the health outcome on the patient. If this is the only principle to be
considered than it concealing of information or requesting the patient to so will be justified.
There is no need to reveal the information especially when the effect is just temporary and may
end up being unnoticed if they are not informed of their possibility to occur. An example is used
to illustrate the importance of concealing some information. Having knowledge about the
occurrence of a side effect may lead to triggering of the autonomic nervous system. Fear is one
of the humanly perceptions that can has an influence on the autonomic system. Autonomic
effects will manifest following the perception of fear. One of the effects might be one of the
expected side effects. It may have exacerbated more than if they had no prior information. If a
patient has a chronic condition that the doctor perceives might be affected by the knowledge,
then, this will be enough justification to allow them to conceal the information on nocebo effects.
The principle of justice.
Medical interventions should be made in such a way that they abide by the requirements
of the law of the land. The law has been formulated to ensure fairness respect of human rights
and to uphold human dignity. There are laws regarding the seeking and giving of consent. it
mentions the validity of a consent and provides for punitive actions if the laws are disobeyed. In
the same spirit, the patient has the right to be given all the information pertaining a particular
drug irrespective of the feeling of the doctors (Widdershoven, Meynen & Metselaar, 2017).
There have not been very clear grounds under which the right to information may be limited. If a
doctor does not give all the information about an intervention and one of the expected risks
occur, then the patient can sue the doctor. The doctor will be liable for concealing information.

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According to the principle, it will be unfair to conceal information regarding their health.
The patient is the sole decision maker in a healthcare setting. The principle of justice
recommends that the patient should make the decision after receiving all the information. The
patient may change their mind if they feel that they cannot withstand the nocebo effect.
Withholding information is a way of depriving them this right. It will be unfair to make a
decision without all the necessary facts. If this principle was to be considered alone, then we
would conclude that the suggestion by Alfano will not portray justice to the patient.
Principle of non-maleficence.
It requires that any intervention will not cause harm to the patient or their families.
Alfano feels that concealing the information will prevent associated with knowing the nocebo
effects from begetting the patient. The patient trusts that the doctor has their best interest at heart.
It can be argued that the information will be conceals in the best interest of the patient (Aguilera,
B. and Beca, 2018). The patient does not have to suffer the consequences of some action which
could otherwise be prevented.
However, concealing the information may be perceived to cause more harm than
revealing the information. If the nocebo effect has a potential of causing permanent damage, the
patient might do well if the has been initially been informed of the possibility. An intervention
may be beneficial physically but the emotional effects from its nocebo effects may be more
devastating. A good analysis of the intended benefits and risks will be beneficial to determine
the impact of concealing or revealing information to the patient.
Conclusion.

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The patient has the right to make choices concerning the treatment options (Miller &
Colloca, 2011) Their choice should be voluntary and the doctor should be totally honest in giving
the information. The doctor patient relationship depends on this openness. However, the doctor
does not conceal the information without the consent of the patient (Wells & Kaptchuk, 2012).
To allow this particular proposition to take effect, then the value of concealing the information
should be significant enough to warrant it. I feel that information should be concealed where the
benefits of doing so outweigh the disadvantages therewith.
References.

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Aguilera, B. and Beca, J.P., 2018. Partial disclosure of information in the presence of presumable
nocebo effects: an ethical analysis. Revista medica de Chile, 146(4), pp.518-522.
Alfano, M. 2015, ‘Placebo effects and informed consent', American Journal of Bioethics, vol. 15,
no. 10, pp. 3-12.
Arnold, M. Finniss, D. & Kerridge, I. 2014. 'Medicine's inconvenient truth: the placebo and
nocebo
Beauchamp, T.L., 2019. A Defense of Universal Principles in Biomedical Ethics. In Biolaw and
Policy in the Twenty-First Century (pp. 3-17). Springer, Cham.
Cohen, S. 2014, ‘The nocebo effect of informed consent’, Bioethics, 28: 147–154.
companion to bioethics, Wiley-Blackwell, Malden, MA. pp. 530–540.effect', Internal Medicine
Journal, vol. 44, no. 4, pp. 398-405.
Miller, F, & Colloca, L. 2011, 'The placebo phenomenon and medical ethics: Rethinking the
Parliament of Victoria, Research Papers, Voluntary Assisted Dying Bill 2017. Retrieved from:
Philosophy, vol. 30, no. 1, pp. 27-44.
Rothman, D.J., 2017. Strangers at the bedside: a history of how law and bioethics transformed
medical decision making. Routledge.
Ruan, X. and Kaye, A.D., 2016. Nocebo Effect of Informed Consent in Interventional
Procedures.
Wells, RE, & Kaptchuk, TJ. 2012, ‘To Tell the Truth, the Whole Truth, May Do Patients Harm:
The Problem of the Nocebo Effect for Informed Consent’, American Journal of Bioethics, 12(3),
22–29.

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White, R., 2016. Fever of the Tuskegee Study.
Widdershoven, G., Meynen, G. and Metselaar, S., 2017. Dealing with the nocebo effect: Taking
physician–patient interaction seriously. The American Journal of Bioethics, 17(6), pp.48-50.
Young, R. 2009. ‘Informed consent and patient autonomy’ in Kuhse, H., Singer, P. (eds.) A