The Case of Mary Jo Hoffman: The Wanted, Unwanted Doctor

Bioethics Forum 16 (3)
Case by David Emmott, MD, and Helen Emmott, RN
Discussion Questions Compiled by Robert Potter, MD, PhD.

Mary Jo Hoffman, a lovely forty-nine-year-old female, came to Dr. Clarke, urologist, after being seen by her primary doctor multiple times for hematuria. After a thorough evaluation, including a cystoscopy and bladder biopsy, Dr. Clarke determined that Mary Jo had invasive bladder cancer, which would require removal and reconstruction of her bladder. She and Dr. Clarke talked about her options. Mary Jo was surprised and reluctant to agree on a treatment plan, so Dr. Clarke suggested that she obtain a second opinion. She didn’t know about that. She said that she would talk with her husband of many years and get back with Dr. Clarke.
More than two weeks passed before Mary Jo finally called the office to speak with Dr. Clarke. She and Bob, her husband, had done extensive research on the Internet and had made up their minds to seek alternative and holistic care. Mary Jo told Dr. Clarke that she appreciated his help, but that she was going to a health spa in the Caribbean where a special diet, acupuncture, meditation, and yoga were used to cleanse the spirit, mind, and body of diseases such as hers. Dr. Clarke fought the urge to tell her that he did not believe in such modalities, but instead told her the truth: he knew nothing about such treatments. As their conversation concluded, he made her promise that she would return for follow up with him after the 90-day treatment was completed.
He hung up the phone feeling much ambivalence. He believed that without surgical intervention, Mary Jo Hoffman would have less than a 25 percent chance of living two years.
Four months passed, and Mary Jo returned to Dr. Clarke’s office. She was tan and feeling better than ever. However, a sample of her urine revealed blood cells just as before. She agreed to another look into her bladder. A repeat biopsy confirmed the high-grade invasive tumor. Dr. Clarke called her with the biopsy results. He said, “Mary Jo, you have a killer cancer that doesn’t appear to be going away.” She responded,” I have simply never felt better! What about trying the treatments for another three months?”
Dr. Clarke had had it. He believed that Mary Jo was making a big mistake. “You are really making me mad,” he said. “This is not a personal thing. I just want you to get this taken care of, anywhere, but soon. You are running a huge risk. It really looks like I cannot be your doctor anymore!” She replied softly, “Then who will be my doctor?”
Dr. Clarke’s head was spinning as he left the office that night. “Damn her! I wonder if I could have done more. Is she in denial or what? Does she really believe in this stuff?”

Questions:
• What makes this a difficult patient-physician relationship? What beliefs and preferences are in conflict between Dr. Clarke and Mary Jo Hoffman?
• Was Mary Jo Hoffman being “difficult” by not agreeing with the doctor’s recommended therapy?
• What authority does the Internet exert on the belief system of Baby Boomers? Does the fact that the bladder tumor is completely invisible and produces few symptoms, while the Internet is totally visible and convincing, have any influence on the patient’s preference to follow the Internet?
• Did Dr. Clarke do all that he ethically could to persuade Mary Jo Hoffman to agree with his recommendation?
• Would it have been more persuasive to show the patient pictures of the bladder disease, consult with both the patient and her husband together, insist on referral to another urologist, or refer to other specialists?
• Would Dr. Clarke have been more ethical if he had not reported the second biopsy over the phone, but rather talked to the patient in person? Why did he not call on the patient’s primary doctor as an ally?
• Did the doctor’s reluctance to tell the patient the truth about his beliefs compound the difficulties in this relationship?
• Did the doctor make an adequate effort to understand the patient’s point of view?
• Was anger an appropriate emotion for the doctor to feel or express? Did the patient feel any anger toward the doctor?
• Was Dr. Clarke being manipulative when he announced that he could no longer be Mary Jo’s doctor? Was it reasonable of the patient to assume that Dr. Clarke would continue to be her doctor if she would not take his advice? Does the rejection of the doctor’s recommendation also mean rejection of the patient-physician relationship?