Bryan Caplan  

Bizarre Tales from the Delivery Room

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Go See Matt Ridley... Robin Hanson is Incurable...
I've cross-examined doctors before, but never like thisOffsetting Behavior's Eric Crampton remained enough of an economist to argue with the anaesthesiologist while awaiting the delivery of his second child:
There was some risk that Sue might wind up needing a transfusion as things got a bit complicated...

As I'm O negative, I noted that should Sue only need a small top-up, I'd happily provide. The anaesthesiologist said that would not be possible. The rest of the conversation went roughly as follows:
Me: Why not?
Her: Well, we'd need to do the blood tests to make sure it was all clean for transfusion.
Me: So, that would take too long then?
Her: No, that's not the problem. Rather, if we ever found something that the other partner might find cause for concern, we'd then face an ethical problem. So there's a rule banning these kinds of husband-wife transfusions.
Me: Ethical problem?
Her: Imagine the case where we find the one partner has an STD which the other partner would find out about because we wouldn't be using the blood.
Me: So if Susan needed a kidney and I were a match, I'd be banned from giving it then?
Her: No, we'd just make sure there were proper pre-counselling available so everyone were ready in case such a thing were found.
Me: Is there anything that ethicists don't completely screw up?
Her: Well, it's a complicated issue. I suppose if someone jumped up and down a lot and got a lawyer in...
In a rare instance of clarity, I realized that arguing medical ethics with the anaesthesiologist during the caesarean section might not be the very best idea...
After a healthy delivery, Eric blogged what he would have told the anaesthesiologist:
There is, of course, a dead simple mechanism design solution to the ethical problem here. The blood is taken, the donor and the recipient both signing a form that if any ethically troublesome problem is found in the blood, blood from the standard donor pool would instead be used without additional notice to the recipient; the donor would later confidentially be informed of the ethical problem encountered. Problem solved.
Personally, I'm puzzled by the view that medical confidentiality should apply via-a-vis spouses in the first place - and baffled by view that medical confidentality should protect people's right to risk infecting their spouse with STDs.  If marriage were contractual, who'd agree even to basic confidentiality - much less confidentiality that put the life of the other partner at risk?


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COMMENTS (7 to date)
Robinson writes:

While I think it's incredibly slimy to keep information about an STD from one's partner, I suppose the medical confidentiality argument would be that if someone had an STD, they should be able to go to a hospital and get treatment without fear of their spouse being informed. (After all, if they avoid treatment for fear of discovery, everyone ends up worse off).

Doc Merlin writes:

"Personally, I'm puzzled by the view that medical confidentiality should apply via-a-vis spouses in the first place - and baffled by view that medical confidentality should protect people's right to risk infecting their spouse with STDs."

Well, the people who make the rules don't want their spouse finding out about their STDs.

This is similar to how the privacy rules for grades at universities were made. A someone told someone's grades to their parents when they were in college. That shamed college student grew up and became a congressman.

Zach writes:

I'd have to agree with this poster, "Well, the people who make the rules don't want their spouse finding out about their STDs."

This has nothing to do with medicine, and everything to do with medical liability. People sue hospitals and physicians for all sorts of crazy things. From 'wrongful birth' to 'emotional damages', someone is always looking to exploit some odd situation to make a buck.

Moderation in everything. There's a place for laws and 'protections', but then at some point you get to the point where you have 'Do not use in the shower or other standing water' labels on hair-dryers...

pjsw writes:

It seems to me that the burden of proof is on whoever thinks that medical confidentiality should change or be forfeited upon marriage to explain why. Is it just because the spouses are sleeping together? If so, then confidentiality should also be dropped in cases of non-married sexually involved patients.

Medical confidentiality is not for the purpose of protecting a patient's right to infect his or her spouse with an STD - in fact, people probably have no such moral right. Confidentiality is to protect privacy, to which patients do have a right. This cannot be accomplished without incidentally helping a patient to hide STD status.

All that being said, I think the design solution above is ethically defensible, within the dominant framework of biomedical ethics (which I happen to teach at the college level).

Brian Clendinen writes:

@pjsw

Did you read the part were Bryan is stating the part about viewing marriage in a contractual arrangement. Your lack of understanding assumes the ethics is related to sex. Unless a contract explicitly states specific information related to business cannot be disclosed to other partners then it must be. Bryan is implying no sane business partner in a true partnership of equals (which is what marriage should be) would agree to something like that. Yet medical ethics assumes otherwise? So what you are saying is information which could significantly harm a party in a partnership if it is withheld is unethical because it is private and might hurt the party who wants full disclosure? So that means I can commit financial information fraud by withhold critical information and shareholders have no right to know the information because the fraud would harm me personally due to loosing my job and getting jobs in the future? Yet you claim medical information is somehow different?

I love privacy but you assume privacy is a legal right on level with other natural rights in the constitution. Most of the privacy as a right in legal code have been established by the courts not by legislators. Your burden of proof statement assumes privacy is a personal constitutional right or common religious moral right and should be the de-facto way everything is under the law. Therefore your burden of proof is always on a party who wants information the other party might consider private in even a relatively small % of the time. I find that legally, ethical, morally, and just from common sense view point a ridiculous burden of proof. You need to argue in a specific case why privacy is correct for both parties based on experience (not hypothetical’s). So the burden of proof is actually on you.

You realize there are only two constitutional amendments related to restrictions on persons. One the 13th which makes it illegal to own slaves , and the 18th which was Probation, that was latter repelled 13 years later. So there is only one personal restriction on individuals in the constitution . All others are restrictions on government. So other than the fact of all the legal law suites and doctors wanting no information off limits due to fear of exposure by the patient, I see no sweeping overriding legal status to rational your argument.

If you read the example, Eric did not care if his wife knew the information that the blood test might reveal, that is what we think is really crazy. So how is the burden of proof on Eric for doctors to protect his privacy when he thinks his wife has a right to know his medical information and he signs a simple disclosure?


FC writes:

Apparently that guy never studied industrial organization. It would be far quicker to just go get some blood from the blood bank - tested, packed and ready to use - than to go through the whole process with him. Not to mention his wife might have needed more blood than he could safely give.

My God, academics think they know everything but they are usually idiots.

Jim Glass writes:

The blood is taken, the donor and the recipient both signing a form that if any ethically troublesome problem is found in the blood, blood from the standard donor pool would instead be used without additional notice to the recipient; the donor would later confidentially be informed of the ethical problem encountered. Problem solved.

What real-world problem solved? They were going to take the blood from the standard blood pool anyhow. So this is a whole bunch of to-do about nothing.

The whole episode sounds like a self-absorbed academic playing the theorizing academic to distract the doctor while he was trying to get a pretty important job done -- yeah, probably not the best time for that.

I've been in the room during childbirth three times. Not once while new life was being born did I disctract myself into argument about theortical diversions. Especially while the birth got "complicated"!

What were this guys's priorities?

Personally, I'm puzzled by the view that medical confidentiality should apply via-a-vis spouses in the first place...

Not sympathetic to conflct-of-interest issues between spouses, eh?

Try being a lawyer who has a married couple walk in as a "joint" client.

Or even a just tax return preparer. Every time a joint tax return is filed there are massive potential conflict-of-interest issues for the return preparer who represents both spouses, that can result in huge malpractice liability. The preparer had better have made all the disclosures, have all the disclosure forms signed, and malpractice insurance premiums paid up.

I'm taking it you haven't been through a bitterly contested divorce, yet. May it not happen to you.

I'll tell you though, If I were a woman going through childbirth, and it was "getting complicated", and I heard my husband distracting my doctors with academic "what-if" arguments like this, I'd be thinking about getting the number of a matrimonial lawyer in my phone book.

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