Today’s Jam

I am a primary care physician with a specialty in developmental pediatrics, and am often called upon to make a relevant medical diagnosis for a child in my care who is struggling in school. Such diagnoses are often not a matter of strict science, governed by objective data and criteria, but instead a judgment call. And determining whether a developmental, cognitive/learning, or behavioral/psychological diagnosis is in order can have serious implications for my patient and his or her family. Often support services available for one diagnosis are not provided for a child with a different diagnosis, even though those same services would be equally if not more helpful for the latter child.

Recently, I evaluated a child for an autism spectrum disorder (ASD); he had already been diagnosed with Attention Deficit Hyperactivity Disorder (ADHD) by the school psychologist. There is some overlap in the neurocognitive features of the two diagnoses. The family was concerned that their son showed signs of possible ASD and asked me to evaluate him.

Based on my evaluation (and my considerable experience in the field), I don’t think that he has an ASD. But I cannot say that for certain — and with a diagnosis of ASD, he would receive behavioral support services (paid for by the school) that would unquestionably improve his functioning and success at school, and consequently, his mental health and self-esteem. With just his ADHD diagnosis, this support would have to be paid for privately; his parents simply cannot afford it, and their health insurance does not cover it. And this child is really struggling. I’ve been through this with many patients, and there are rarely other sources of funding available.

If I diagnose him with a mild ASD, even though it is not my professional opinion that he has one, the student will get support that he badly needs. Because this is such a murky area, my professional reputation is not at issue either way. What should I do? How should I make this decision?

Ben Kruskal, MD says…

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Questions like this are not uncommon for most physicians.

In the abstract, one could phrase your question as whether it’s OK for a doctor to lie to a third party for a patient’s benefit. But the specific content and context matters a great deal in considering this question. For example, a classic situation in the infectious disease realm is whether and how to share the news of a patient’s STD status where it is suspected that their intimate partner is abusive.

We often have to weigh honesty, professional integrity, and legal requirements on one hand, and various benefits and harms to our patients and various third parties on the other. In this case, if you go against your judgment and assign your patient an ASD diagnosis, he will receive services you feel he needs and cannot get otherwise, but the harm to others would be the cost to the school system.

However, there’s an additional way of thinking about this that may be helpful. When attempting to make a diagnosis, we often have a list in our head of possible diagnoses with relative probabilities (known as the differential diagnosis), and sorting them out may require seeing how the situation evolves over time, or how a patient responds to a treatment.

Thinking about it in this light: Do you feel that there is a meaningful probability that the patient has an ASD, even if the probability of ADHD is greater? And if he does, is there a reasonable likelihood that it contributes to his school problems? If the answer to both questions is yes, then in your shoes — with a not insignificant possibility that the less-likely diagnosis is correct, and the ability to evaluate it over time — I might feel justified in making the second (ASD) diagnosis that would facilitate the provision of support services by the school.

Ben Kruskal, MD, is a primary care pediatrician and Chief of Infectious Disease at Atrius Health in the Boston, MA area. He has a particular professional interest in safety and quality of patient care.

Rabbi Leonard Sharzer, MD writes…

Leonard A. Sharzer
Dr. Francis Peabody said in a 1926 lecture at Harvard Medical School: “The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient. It is an art, based to an increasing extent on the medical sciences, but comprising much that still remains outside the realm of any science.” You clearly understand this when you note that what you are being asked for is not strict science but a judgment call, which you must take context into account.

If he does have ASD and you say that he does not, he will lose out on beneficial treatment. If he does not have ASD and you say that he does, he will receive beneficial treatment, but he will also carry forward that diagnosis which might have negative consequences. He will also pose an unnecessary cost to society.

Jewish thought places great value on the attribute of humility. It is the most salient characteristic of our greatest teacher, Moses. Rashi, commenting on the talmudic statement “The best of doctors are bound for Gehenna” (Kiddushin 82a) explains that physicians sometimes act haughtily. You are aware that your assessment may be wrong. In addition, the oath of Asaph and Yohanan, Jewish physicians in the sixth century CE, says: “Do not harden your heart [and turn it away] from pitying the poor and healing the needy.” The great Jewish law code Shulchan Arukh asserts that the physician is given permission to heal and treat by the community, which implies an obligation to the community itself.

If you are certain that this is not ASD, that is what you must say. But otherwise, I would not frame the question as one of lying to a third party. Rather, the issue here is balancing your obligation to your patient against your obligation to the community. In that situation, your obligation to your patient must take precedence, and since ASD is a possibility and the consequence of not treating it is damaging to your patient, you should act so that the patient gets the treatment.

Leonard A. Sharzer entered the rabbinate after a 37 year career in medicine. He has devoted his rabbinate to issues in Jewish bioethics and serves as Associate Director for Bioethics of the Finkelstein Institute for Social and Religious Studies of the Jewish Theological Seminary.

Shani Bechhofer, PhD says…

Shani BechhoferGiven the lack of diagnostic clarity regarding this child, and our still-evolving understanding of these disorders, I agree that you don’t have enough information to rule out an ASD. The system requires a yes/no response, so err on the side of a tentative positive diagnosis. The efficacy of intervention should be monitored over time by interdisciplinary teams, who will reassess diagnoses as a deeper understanding of the child’s needs emerges.

To be clear: I’m not advocating that you get services for a child with ADHD by claiming ASD, but rather that you get him services for the possibility of ASD.

We have each have found a way to negate the ethical quandary of potential fraud in this case, but let’s not dismiss the larger issue. The principle of mid’var sheker tirchak (“keep far from deceit”) — from Exodus 23:7 — derives from the prohibition against false testimony. Like a witness, you have been invested with the authority to make assertions with legal consequences. Stay far away from false reporting. There is no end to that path once you embark on it, and manipulating diagnoses opens you to responsibility for many unforeseen outcomes.

Many of us in education must consider at one time or another whether to “game” an unjust or sub-optimal system for distributing resources. From a Jewish perspective, your obligation is not simply to lessen the community’s financial burden (as noted by the other respondents), but to help build a more just and virtuous society. Can you do that by diverting resources from other children to benefit your patients? Behind the “veil of ignorance,” whose needs would you prioritize? Would you want to live in a world where doctors use their diagnostic authority to undermine social policies with which they disagree?

The current allocation system is deeply problematic; it lacks distributive justice, and fosters competition and guile rather than clear thinking and collaborative problem solving. But a better approach will still rely on diagnosticians, educators, clinicians, and caregivers to provide accurate information and exercise professional judgment with integrity.

Don’t use diagnoses to ameliorate the effects of bad social policies or institutional practices. Instead, I strongly encourage you to use your authority and expertise in other ways. Learn to advocate effectively for policy change. Position yourself to participate in decision-making at the school, district, and/or state level. Help improve the system rather than trying to game it.

Dr. Shani Bechhofer is a teacher, scholar, researcher, and senior consultant to principals, boards, programs, and philanthropists involved with Jewish day schools and yeshivot. She holds a PhD from Northwestern University, and serves as Senior Researcher and Policy Analyst on Schools and Education for the ARCC Institute for Applied Research. Shani lives in Monsey with her husband Rabbi Yosef Gavriel Bechhofer and is a proud mother and grandmother.

Now, what do YOU say?

Should doctors’ and psychologists’ diagnostic decisions be shaped by the implications of those decisions for their patients’ treatment? How can clinicians ethically get the best care for the children in their care in a very imperfect educational and health care system?

And of course, if you have a dilemma you’d like us to address in the Ethical Jam, send it to EthicalJam@timesofisrael.com

Ethical Jam is a project of the Center for Global Judaism of Hebrew College, Newton Centre, Massachusetts, which is working to create a rich pluralistic discourse on issues of vital concern to the Jewish community and to the world at large.

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