Court Gives Doctors Leeway in Disclosures

Doctors are not always obligated to inform seriously ill patients of their statistical chances of dying, even if the patients have asked to be told the truth about their condition, the California Supreme Court held Thursday.

In a unanimous opinion written by Justice Armand Arabian, the court also held that doctors have no duty to give patients information pertinent to their non-medical interests, such as how much time they have to put their financial affairs in order.

The decision, which was anxiously anticipated by the medical community, ensures doctors wide latitude in how they inform a patient of his or her medical condition.

“We appreciate the California Supreme Court’s recognition that physicians are not prescient when it comes to patient’s non-medical interests,” said Alice Mead, legal counsel for the California Medical Assn., which represents 35,000 doctors.

But Marian Tully, an attorney for a family that sued four Southern California physicians for failing to disclose more fully a cancer victim’s prognosis, complained that the court has reverted to giving a “doctor full discretion about what to disclose to a terminally ill patient about his true medical condition.”

Tully represented the family of Miklos Arato, a Woodland Hills electrical contractor and part-time real estate developer who died of pancreatic cancer in June, 1981.

His family sued the doctors who treated him, charging that Arato would have rejected painful treatments and put his financial affairs in order had he been told he had only a 50% chance of living one year.

The doctors who treated Arato testified that they had told him such cancer is usually fatal, that after removing the tumor there would be a substantial risk of recurrence and that if it recurred, it would be incurable.

But Arato’s family said the physicians were upbeat in their prognosis, saying his case was different from the standard kind.

A Los Angeles jury decided for the doctors, but a state Court of Appeal in Los Angeles later held that Arato’s doctors had breached their duty to disclose all information relevant to the patient’s decision to undergo radiation and chemotherapy.

In a divided opinion, the lower court said the disclosures made by the doctors were meaningless because the physicians failed to tell Arato specifically how virulent pancreatic cancer is.

In its opinion Thursday, the state’s high court disagreed, citing the “intimate and irreducibly judgment-laden” relationship between doctors and patients. The court said physicians must conform only to the prevailing standard and disclose enough information for the patient to make an intelligent decision about treatment.

“Without exception,” Arabian wrote, “the testimony of every physician-witness at trial confirmed what is evident even to a non-professional: (Survival statistics) are inherently unreliable and offer little assurance regarding the fate of the individual patient.” Rather than mandate specific disclosures by doctors, the court said the rule should be that physicians have a legal duty to disclose to patients all information that would be regarded as significant by a reasonable person who must decide whether to accept or reject a medical procedure.

“The doctor gets to decide what is material,” said Tully, “and they have a vested interest in treating.”

Although a doctor may not misrepresent a patient’s medical condition, the court said, he or she has no duty to disclose “every contingency that might affect the patient’s non-medical” interests.

Marjorie M. Shultz, a professor of law at UC Berkeley, said the court has “turned us back to an era we thought we had left behind, an era when physicians decided what patients ought to know about their medical expectations and options.”

Although the court did not overturn previously accepted legal rules governing what doctors must disclose to patients, it interpreted those rules narrowly and “puts it back in the domain of letting doctors decide how much they are going to tell,” Shultz said.

Studies show that patients want to know more than doctors want to tell them, she said.

In a decade-old report by the President’s Commission for the Study of Ethical Problems in Medicine, only 41% of the doctors polled said they would provide patients with hard estimates of life expectancy, whereas 85% of the public said they wanted realistic estimates even if the outlook were bleak, she said.

In the Arato case, the doctors testified that the patient never specifically asked for mortality statistics even though he checked a box on a form saying he wanted to be told the truth about his condition.

His surgeon said Arato had great anxiety over his condition and it would have been medically inappropriate to give him specific mortality rates. The oncologists who cared for Arato said they did not want to deprive him of any hope of a cure.

All the physicians testified that statistical life expectancy information is not very useful because individual cases can vary significantly.

Ari Kleiman, an attorney who represented the doctors, said the opinion is significant because it says doctors need not provide patients information for non-medical purposes.

“That really would have opened up a whole new area and imposed a significant burden on physicians,” he said.

Under the ruling, doctors need provide statistical mortality rates only if it is a common practice in the medical community, he said.

“The court is not saying there is never an obligation to provide life expectancy information,” he said. “There might be a duty if that is the practice in the medical community, and only to the extent that it bears on the patient’s decision regarding medical treatment.”