Informing patients of the risks and benefits of hormone replacement therapy: Nephrologists’ ethical obligation

Do nothing 

The nephrologist concludes that considering the benefits of HRT for this patient is not the reason for the nephrology referral, and by advising the patient the nephrologist risks alienating the referring physician. Thus, no action is taken. This approach can be eliminated almost immediately by asking the first ethical question: Whose interest should be primary in the clinical encounter?

This approach is obviously the least desirable option, although it is understandable, given time constraints and the risk of offending the referring physician. However, it cannot be justified from either a clinical or an ethical perspective. Doing nothing denies the patient and the referring physician an opportunity to consider improving health outcomes on the basis of new data. This approach also ignores the ethical principle of medical beneficence and does not respect patient autonomy and the right of patients to make decisions for themselves on the basis of the best currently available information. Here, the consultant has potentially beneficial health information that is being withheld for what could be viewed as reasons of self-interest or peer pressure and not for patient benefit.

Talk to the patient first 

The nephrologist concludes that he or she has a duty to immediately offer the patient information about the current HRT recommendations and contact the referring physician afterward either in writing or by telephone.

A key factor in considering this option is the strength of the data upon which the duty to inform is based. In this particular case, the data are relatively clear. The nephrologist’s opinion that the patient should not be taking HRT is based upon recent research from 2 large-scale studies. A decision by the consultant to inform the patient is clinically justified given the size of the studies, the conclusions reached by the investigators, and the fact that the data-monitoring boards stopped the studies early because of their concern that HRT increased risk in cases similar to that of the patient. The strength of evidence is sufficient to reassure the consulting nephrologist that the risks of HRT are a source of concern within the scientific community. Thus, discussion of ongoing HRT with the patient’s primary care physician is clearly in the patient’s best interest. Talking to the patient directly is one way to improve the likelihood that the nephrologist’s concern will not be lost among the many competing demands encountered by the referring physician. At least theoretically, no one is more motivated to clarify a treatment plan’s safety and efficacy than the person whom it affects most directly, the patient.

Two additional points must be considered concerning the appropriateness of this option. First, patients who are naïve or less knowledgeable need more of the protection inherent in the fiduciary relationship. These patients are at least theoretically more vulnerable. In our case, the patient does not know about the risk associated with continuing HRT. Her health-care providers have the responsibility of making the data available so she can make appropriate use of the information. Second, talking to the patient directly acknowledges and formalizes the fact that the nephrologist’s primary responsibility is to the patient and secondarily to the referring provider and to the nephrologist’s own financial interests. This point should be kept prominently in the foreground of practice for ethical and legal purposes.

The ethical justification for the above approach is fairly clear. This proposed option protects and promotes the universal ethical principles of respect for patient autonomy and beneficence.6, 7 The virtues of honesty, integrity, and trustworthiness are preserved, and the appearance of conflict of interest is avoided. These goals are compatible with a quarter of a century of work in biomedical ethics that suggests, “…moral responsibility in medicine ideally should be conceived in terms of fundamental principles, rules, rights, and virtues.”7 Patient autonomy and medical beneficence are 2 of the 4 universal medical/ethical precepts, the preservation of which is certainly desirable. (The other 2 universal principles are just distribution of goods and services and nonmaleficence.6)

Contact the referring physician only 

The nephrologist decides to work through the primary care physician out of respect for the referring physician’s status as the overseer of the patient’s health care and out of concern that the referring physician will be offended by the consultant’s “interfering” in primary care issues.

This approach is frequently used by consultants and is possibly more typical of the traditional relationship between the consultant and the referring physician. It demonstrates a more paternalistic view by suggesting that all information about a patient’s health should be funneled through the primary care physician before the information is discussed with the patient. By conveying the information to the referring physician, this approach preserves beneficence, but by failing to speak with the patient, it ignores the principle of patient autonomy. This approach is also less certain to achieve the desired end. It might or might not accomplish the consultant’s goal of conveying information on HRT risk. If the referring physician chooses to ignore the data and not inform the patient, then the nephrologist is left with the dilemma of how to gracefully execute his or her fiduciary duties. This option ultimately ends up being a middle ground approach that may or may not accomplish the goal, and it suggests that the primary obligation of the consulting physician is to the referring physician and not to the patient.