To deceive or not to deceive… that is the question

My dermatology colleagues and I recently discussed an interesting ethical scenario that occurs in the clinic several times a year: an elderly patient comes into the office requesting a prescription refill to treat the “shingles” that recurs on their buttocks several times a year.  Upon further questioning, it is discovered that a primary care provider (PCP) diagnosed the patient’s “shingles.”

Now…

Anyone who has ever taken a microbiology course knows that a recurrent herpetic eruption in a specific body location is likely to be from the herpes simplex virus (HSV) and not the varicella-zoster virus (VZV) that is responsible for shingles.  

Why would a clinician knowingly give an elderly patient the incorrect diagnosis?  

Shingles, although a miserable and painful dermatitis caused by a reactivation of the chicken pox virus (i.e. VZV), is a simpler diagnosis for clinicians to deal with.  HSV eruptions, on the other hand, recur in the same body location and are transmitted through direct contact with an infected person.  When HSV is observed on the buttocks, it is typically considered a sexually transmitted infection (STI).  Patients newly diagnosed with an STI require careful counseling, and older patients can be particularly confused and emotional about the diagnosis.  Shingles is a “softer” diagnosis – it’s not sexually transmitted, everyone knows someone who’s had it, and it’s no one’s fault when shingles develops.  HSV is a chronic and recurrent condition, while VZV tends to be isolated and acute.  However, both conditions are part of the herpesvirus family and are treated with similar antivirals… so is this really a big deal?  

Several questions come to mind:

• Is it worth it to upset an elderly patient by informing them they have an STI when the condition is already being managed successfully with antivirals?  Will this information disrupt the patient’s family relationships?  Will this information disturb the patient’s relationship with their PCP? 
• Does this patient have the right to know that their recurrent rash is actually an STI?  Do they have the right to investigate where they may have contracted HSV?
• Is it best not to upset this patient and allow them to continue to think the rash is shingles?  

There are interesting ethical arguments regarding whether it is ever okay for a clinician to deceive and tell a patient a “white lie” if the clinician feels the deception is in the patient’s best interest.  Next week, we will explore arguments for and against “medical deception.”

Until then, have a great weekend, APP Colleagues.

Nikki Rataj Casady, DMSc, PA-C   

email@appcolleague.org