“Why Can't I Move, Doc?” Ethical Dilemmas in Treating Conversion Disorders

I first encountered a patient with conversion disorder about 20 years ago. I was a new attending physician, and the woman was admitted to my inpatient rehabilitation service with a diagnosis simply of "quadriplegia." The diagnosis of an underlying conversion disorder was ingeniously cinched by a video that documented normal movement during sleep. But, during her waking hours, she was as disabled as if she had had a spinal cord injury, that is, she was unable to move, she was dependent in her self–care, and she was still subject to the problems of immobility. What to do? On the one hand, I understood that conversion disorder was a physical manifestation of an unconscious psychological conflict. The longer the condition persisted, the less likely it was to improve. On the other hand, without treating and resolving the underlying psychiatric conflict, "curing" her condition was also unlikely. Yet psychiatric treatment requires the active and willful engagement of the patient, and she (like many patients with conversion disorder) was not amenable to psychotherapy. Psychiatric inpatient units also tend to be uncomfortable with accepting patients who have significant physical disabilities. Did rehabilitation have a legitimate role to play? What should she be told about her condition and treatment plan? How likely was it to be successful? When Geoffrey Smith, MD, from the University of Virginia, brought the ethical issues that underlie the care of patients with conversion disorder forward, it was not difficult to decide to pursue an ethics column on the topic. Indeed, the issues that he raises remain controversial and unresolved. What follows is his presentation of a woman with conversion disorder with whom he had direct care responsibilities as a resident. After the case presentation are several questions raised for discussion by our invited commentators (see below). The column concludes with an epilogue by Dr Smith about how the case was resolved, and his reflections years later. As always, we welcome your comments and reactions, or suggestions for future columns! A woman in her mid 20s was evaluated in an outpatient neurology department for subacute hemiparesis. An extensive neurologic workup showed no organic cause for her hemiparesis. She subsequently was referred to the physical medicine and rehabilitation department for rehabilitation. The diagnosis in the medical record was "hemiparesis without evidence of abnormalities on imaging or neurophysiological studies," qualified with adjectives such as "functional " and "behavioral." Although the official medical record did not explicitly state the diagnosis of conversion disorder, the neurologists who evaluated the woman did communicate this diagnosis to the consulting physiatrist over the telephone. The physicians overseeing both her acute care and rehabilitation management instructed the team that the patient not be told her diagnosis of conversion disorder, nor should it be recorded in the chart. The plan of care was to address the somatic impairments with a behavior-focused rehabilitation program. If, as William May has said, "the task of ethics in the professional setting might be called, at least in part, corrective vision," then any ethical judgment on patterns of treating conversion disorder must begin with an accurate description [1]. Failing to see the situation clearly will alter not only the appropriate prescriptive remedy but will also eventuate in some sort of self-deception, whether it comes as either the nagging presence of anxiety or the all too common form of resignation: "Let's be honest, we all lie." In our view, the path to an accurate description begins when we treat our basic intuitions as forms of instruction that reveal the moral quality of the situation itself. In this, the moral diagnosis is unavoidably clear: any course of treatment for conversion disorder that avoids discussing the known etiology of a presenting medical problem is mendacious. Even if there is no agreement regarding the morality of lying, if and when it is morally permissible to tell a lie, lies are moral facts. That is, lying describes some utterances and not others, some patterns of behavior and not others. Saint Augustine's definition of the lie is as elegant as it is simple [2]: "Therefore he who utters a false thing for a true, which however he opines to be true, may be called erring and rash: but he is not rightly said to lie; because he has not a double heart when he utters it, neither does he wish to deceive, but is deceived. But the fault of him who lies, is, the desire of deceiving in the uttering of his mind." Any description, therefore, of the scenario described above that either denies that there is a moral problem in the wilful misleading of a patient with conversion disorder or denies the fact that it involves mendacity misperceives the situation. But, as May would no doubt agree, insisting upon a proper moral description of an act is important to the degree that it aids another central task of ethics, namely, judgment. In this, the question of the proper treatment of conversion disorder would appear to be another occasion for the perennial debate about the morality of lying. What is unique about this case, however, is the manner in which what it brings to light is something that most moralists would most easily dismiss as immoral: namely, the lie of convenience. In the case of conversion disorder, rather than go through the messy and time-consuming process of identifying and treating the true cause of the patient's pain, it is simply easier (for all involved, presumably) to be duplicitous. So, the question then becomes, if the medical treatment of conversion disorder is not only fundamentally mendacious but also the particular type of duplicity born of convenience, then what best describes the pressure that physicians feel to lie? Are those pressures internal to the practice of medicine? Are they more prevalent in some structures than in others? Are they the result of malformed moral character? The patient-physician relationship has undergone a metamorphosis in recent decades. In an effort to deter abuses of physician power, medical ethics has rightly emphasized respect for patient autonomy as a counterbalance to the dangers of hard versions of paternalism. Yet, respect for patient autonomy should not be elevated to a moral absolute. As Childress and Siegler [3] have shown, the emphasis on autonomy has fostered at least 6 new models or metaphors of the patient-physician relationship. These models are the following: "paternal," "partnership," "rational contractors," "friendship," "technician," and their favored model, "negotiation." Pellegrino and Thomasma [4] outline 2 dominant models: the consumer model and the negotiated contract model. In the former, health care is understood to simply be another commodity to be purchased. The physician is reduced to a provider and/or adviser. The latter model is based on contract, a mutual agreement irrespective of ethical norms so long as both parties follow through with the articulated agreement. These models represent what Pellegrino [5] labels the "commodification of medicine." Indeed, physicians have complied with these new models, and, as a result, productivity, efficiency, and market growth have become dominant virtues for the modern physician. This is where the difficulty of the patient with conversion disorder lies. The source of the physician's frustration in cases of verified conversion disorder is the sense that they disrupt that most modern of virtues: efficiency. The dilemma that the patient poses is that full disclosure of the etiology of his or her disorder is often met with frustration and anger displaced on the bearer of news. (Currently, our society is obsessed with labeling everything as a medical diagnosis. That is, as long as that diagnosis is not psychiatric. We seem to be comfortable with medical labels being placed upon an ever-increasing amount of life, so long as those labels do not imply we are "crazy.") Thus, the busy and well-meaning physician faces a dilemma each time he or she cares for a patient with conversion disorder. Should the physician devote the time and energy to educate the patient about the true etiology of his or her disorder or should simply confirm no "serious" conditions are present and refer the patient on to physical therapy? The latter avoids multiple difficult and demanding conversations that attempt to help the patient see the need for consultation with a mental health provider. Furthermore, the lie of convenience becomes all the more appealing when the physician is convinced that the patient's symptoms should subside after a few physical therapy sessions. In our judgment, it is the commodification of medicine that encourages therapeutic deception. If we now understand medicine as a commodity to be purchased and the patient-physician relationship as based on a negotiated contract, then the value of truth telling is derivative of the more basic commitments to efficiency and effective management of time. It is a great irony, therefore, that models of the patient-physician relationship that have been instituted to protect the patient from the perceived harms of paternalism have begun to justify lying. Truth telling, in our day, takes second place to achieving desired outcomes, no matter how those outcomes are ascertained. Yet, as Dr Smith's case powerfully illustrates, respect for autonomy without truth telling will not result in truly beneficent medical care. Many of these patients will often undergo multiple invasive procedures and surgical operations because future health care providers act under the assumption that there is an organic cause to the disability. Thus, it becomes quite clear that therapeutic deception neither respects the patient's right to the truth about her condition nor meets her medical needs. Instead, it puts her at unnecessary harm. Personal autonomy is actually compromised without truth telling as a corollary. In this, we would do well to consider Paul Ramsey's insight that truth telling is basic to understanding medicine for the simple reason that our meaning and purpose as human beings is premised upon the possibility of covenant [6]. With understanding all relationships in these terms, including the patient-physician relationship, necessitates faithfulness owed to those with whom we enter into a covenant. Importantly, this means that the physician's responsibility to the patient extends beyond the limits of contracts. It becomes morally inescapable for every physician who understands medicine as a covenant to thwart the temptation that is therapeutic deception. Let us be honest, we all lie. The ability to pass our thoughts through a filter before they are communicated to others is a measure of our emotional competency. Lying has many names, including tactfulness, advertising, and statistics. Just a few decades ago, physicians thought that it was justified to withhold from the patient the diagnosis of terminal cancer. It is a common situation when the responsibility to do what is best for the patient comes into conflict with the responsibility to communicate our thoughts openly. The patient with conversion disorder brings this dilemma into full focus. Every physician filters, in a different way, the information that he or she passes to the patient. Physiatrists are often in the position of treating patients with the poorest outcomes; delivering bad news is part of the job. The complex processes of speaking and listening create a communication minefield. Blunt communication is perceived as mean and uncaring. I have seen it result in fractured relationships with patients and families. Our experiences encourage us to create a thick communication filter. Thoughtful clinicians choose their words carefully. Patients who receive positive explanations of their diseases have better outcomes [1, 2]. There are strong disincentives to telling the truth. Physicians with silver tongues and with vague, soft messages are said to have great "bedside manner." Patients give wide berth to physicians who tell them what they want to hear. The difference between smarmy and honest can be as simple as inflection of speech, posture, or a raised eyebrow. Telling the patient what he or she wants to hear is not just about avoiding conflict. Lack of time is the biggest problem. Saying yes to a patient takes only seconds, whereas delivering a "no" rarely does. A busy clinician, like a chess master, thinks a dozen moves ahead. It may be subconscious, but we control conversations in the interest of time. We learn to direct conversations in a way that avoids paths that have no outlet, diminishes our primacy, or leads to options that run counter to our recommendations. We prompt patients to ask questions that we can answer. In an ideal world, there would be unlimited time to talk to patients. This is not our world. To call this lying "out of convenience" is pure rhetoric. We direct conversations to conserve time and navigate through busy schedules filled with patients with seemingly endless needs. We need to help the person who is waiting in the next room, and we need to leave work at a reasonable hour. Communicating the truth requires a speaker and a listener. We what the will hear. We can to the by by some It is hard to when this into deception. 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As a at the I to with the morality of misleading less a patient. When I the I no that the of disclosure in cases of conversion disorder. Instead, I only to this of care of the truth based on evidence but without to the case on which this was I only one the of it was and in a by the Psychiatric but another with the from the and with the to I through only what to be endless to both the of autonomy in over paternalism and to our of I that our had with to for deception when with patients with I also that these do not to cases of conversion disorder as an attending physician I have had to my practice for treating patients with conversion disorder. I have that both disclosure and have the to those the but the physician, the and the patient-physician relationship are also this case of I the to the patient from future health care providers being about the true diagnosis. There is also the to the patient's in my is justified by but has been by I also a of my moral as an the of deceiving a patient to other patients to a therapeutic as an attending physician, if I to direct a to a patient, I would the understanding of the unique ethical of the situation. can also the patient-physician relationship, which on mutual and This is true on both an and these it is my practice to but the psychological of conversion disorder with my patients. That being said, I that full disclosure of the psychological etiology of the disorder cause harm. The patient's symptoms but the of this in the and long is the of with full disclosure is In the of and with at least some from the the I have to on the of disclosure and respect for the patient's Dr Smith has that might the patient described in this to others, but no have been The did not attempt to from this patient to this case from the patient for this case that the ethics of not the diagnosis of conversion disorder would disclosure of this diagnosis to the patient. Although the practice is to the diagnosis of conversion disorder to patients under his the for the patient as a under the of an attending this attending physician explicitly that the patient's diagnosis be from her for therapeutic Furthermore, both the and the attending physician of from the the that the diagnosis over the without appropriate psychological the patient's The has to information in the of the relationship to this discussion of ethics, with the of both future patients with conversion disorder and the clinicians who will care for