Telephone Consultations to Families and Other Health Care Providers

A registered nurse working in a busy emergency department receives a call from a mother whose two-year-old child has diarrhea and is vomiting. The mother wants to know what to do. At the same time, the physician on duty gets a call from a physician's assistant at an outlying hospital, asking for advice in managing a difficult emergency case. What are their responsibilities regarding telephone requests for help by patients and other health care providers?

Comment In general, these conversations are casual, without specific standards, and no records are generated.


What responsibilities to the patient do medical professionals incur through these tele­phone consults? In these circumstances, are the responsibilities of the nurse different from those of the physician? Does the consulting physician obligate herself to the patients she advises? Should health care professionals give advice over the phone to patients they do not know?

Commentary

There are two distinct but related ethical issues raised in this case. The first concerns the conditions under which medical advice can responsibly be given over the phone. The second concerns the responsibilities incurred by those who give such advice. This essay is concerned primarily with the first of these issues, though the discussion of this issue has implications for the second issue.

CONDITIONS UNDER WHICH MEDICAL ADVICE CM RESPONSIBLY BE GIVEN OVER THE TELEPHONE


If an ordinary person is asked to explain when medical advice can be given re­sponsibly, he would probably say that it can be given responsibly only when it is "sound" or "correct." Though this answer stands in need of clarification, it at least succeeds in stating the obvious and intuitive: it is unethical to give bad advice and is ethical to give good advice.


But what do we mean when we say that medical advice is "sound," "correct," or "good?" In general, we mean that it is the advice which, if followed, is the most effective in promoting or securing the patient's health and which is most likely to be followed correctly. In giving advice, particularly over the phone to variously qualified persons, medical professionals must take into account not only the effectiveness of a particular treatment for a patient but also the ability of the individual receiving the advice to carry out advice of varying degrees of complexity.

Correct medical advice is, thus, that advice which represents the optimal combination of medical effectiveness and simplicity required by the situation. Is it, then, the responsibility of those who give medical advice to give correct advice so understood? Surely not.


Incorrect medical advice can be given responsibly, and correct medical advice can be given irresponsibly. Consider the physician who gives advice over the phone to an individual with a patient facing an emergency situation. The physician takes every measure to insure that her advice is both medically effective if followed and likely to be followed correctly. Now suppose that the patient has an extremely rare and previously unknown allergic reaction which the physician could not have been expected to antic­ipate.

The advice, it turns out, proves disasterous, even though the physician who gave it took every reasonable measure to insure that the advice was sound. Now consider the medically unqualified "quack" who gives medical advice that, by chance only, turns out to be correct. If the only condition that must be satisfied in order for medical advice to be responsibly given is that it turns out to be correct, the physician has been irresponsible, and the "quack" has been responsible. But this is absurd.


That the medical advice given in a particular circumstance turns out to be correct tells us nothing about the respon­sibility of the individual who gave the advice. The ethical responsibility of those who give medical advice is to give advice they are justified in believing will be correct. The physician was justified in believing that her advice would be correct, even though it turned out to be incorrect. The "quack" was unjustified in believing his advice would be correct, even though it turned out to be correct.

For ethical purposes, the relevant difference between these two individuals is the justification, not correctness, of the advice they gave. So if we are to understand the nature of the responsibilities of those who give medical advice, we must understand the conditions under which they are justified in believing that their advice will be correct. Thus, the ethical demand made on those who give medical advice is to maximize the probability of their advice being correct.

JUSTIFICATIONS FOR BELIEVING THAT ADVICE IS CORRECT


The conditions which must be satisfied if medical professionals are to be justified in giving advice are knowledge conditions. When these conditions are met, the likelihood of their advice being correct is maximized. We can distinguish between two sorts of knowledge that will contribute to the likelihood of medical advice being correct: internal and external. Internal knowledge is the knowledge of medicine possessed by individuals.

This kind of knowledge is usually acquired exclusively by doctors, nurses, and other medical professionals during their formal, academic education and during their profes­sional careers. When we say that someone is competent to provide medical advice, we mean that they have the relevant internal knowledge required to determine the most effective treatment of the patient. Medical competence is thus entirely a function of an individual's internal knowledge.


But medical competence is only one factor which contributes to the ability of medical professionals to give advice responsibly. In addition, they must possess external knowledge. This is knowledge about the circumstances in which advice is being re­quested. External knowledge includes knowledge of the patient's physical condition and knowledge about the individual to whom the advice is to be given.

Knowledge about the patient's physical condition is usually, and ideally, acquired through a physical examination by a qualified medical professional. But when advice is to be given over the phone, physical examinations by trained medical personnel are not always possible. When this is the case, it becomes necessary to determine the medical and emotional competence of the individual to whom the advice is to be given.


This individual sometimes will be the only source of information concerning the patient's physical condition and the only individual who will carry out the advice given. Thus, external knowledge about the individual to whom medical advice is being given is sometimes necessary in order to determine accurately the physical status of the patient and the advice that is most likely to be understood and carried out effectively. In sum, medical professionals ought to give advice only when they possess the internal and external knowledge necessary to maximize the probability of their advice being correct.

APPLICATIONS TO THIS CASE


We can determine the ethical responsibilities of those giving medical advice by attending to their internal and external knowledge and the knowledge of those being given the advice. To see this, let's turn to the original case. Here, a nurse must decide whether to advise a mother concerning the mother's two-year-old child, and a doctor must advise a physician's assistant concerning the assistant's emergency patient at another hospital. What are their responsibilities? What advice, if any, ought they provide?

Consider first the doctor's situation. Her first concern is to acquire external knowledge. She must determine whether the information she is receiving about the patient is likely to be accurate. She can be confident that it is accurate because it is being provided by a trained physician's assistant. She must then determine the likelihood of her advice being followed correctly.


Once again, because she is talking to a physician's assistant and the assistant has the facilities of a hospital available, she can be confident that her advice will be followed correctly. Now she must determine whether her internal knowl­edge is sufficient to provide the most effective medical advice. If the problem the phy­sician's assistant faces is highly sophisticated and falls within the domain of a specialist, the emergency physician should defer to the relevant specialist.

If the problem is one that falls well within the domain of her medical competence, the emergency physician should provide the appropriate advice. The process of determining what advice, if any, the physician ought to give amounts to taking an inventory of the knowledge that both she and the assistant must possess in order for the advice to be likely to be "correct" in the sense we defined earlier.

Let's now turn to the nurse's case. She must go through the same process we have just outlined. First she must acquire knowledge. Is the information she is receiving about the mother's child likely to be correct? The mother has reported that her child has diarrhea and is vomiting. There is very little chance that the mother could be mistaken about these symptoms, so the nurse can be confident that the mother's description of the child is accurate.


If she needs to know more, she must, of course, ask the mother. If no expertise is required to answer the questions the nurse must ask, we may assume that the nurse can acquire all the relevant information about the child's physical con­dition. The nurse must now determine the competence of the mother to follow instruc­tions accurately. If the nurse has reason to believe that the mother may not presently be able to understand and follow directions, she should advise the mother to come into the hospital where treatment can be competently rendered.

If the situation is too serious to wait for the mother to bring the child in, the nurse must do her best to provide advice that is easy to understand and carry out and is likely to sustain the child until the child can be brought in. The second concern of the nurse is to determine whether her internal knowledge is sufficient to provide effective advice. In some areas, nurses are clearly competent to provide medical advice. In others, only physicians possess the necessary medical knowledge.

The ethical responsibility of the nurse is to give advice when she knows she is competent to do so but to defer to competent individuals when she has any doubt about her expertise in the relevant area.

GIVING ADVICE IN DIFFICULT CIRCUMSTANCES


This sketch of the reasoning involved in determining the responsibilities of indi­viduals who are asked to provide medical advice illustrates the role of external and internal knowledge in determining what advice, if any, ought to be given in particular cases. We advanced what might be thought of as two "knowledge conditions'' which must be satisfied in order for medical advice to be given responsibly.

The medical advisor must possess the necessary internal and external knowledge to insure that the advice she gives will have a high probability of being correct. But this sketch is admittedly highly idealized. Physicians and nurses often face emergency situations in which lengthy reasoning procedures are impractical, individuals with the relevant expertise are not always available, and the patient is facing a severe, if not life-threatening, situation.


There is no simple recipe for determining the responsible course of action in these cases. Often, we must attend to the particular features of each case to determine the respon­sibility of those being asked to give advice.

But we can say that, in general, the respon­sibility of medical professionals facing less-than-ideal circumstances in which they are required to give advice is to come as close to meeting the relevant knowledge conditions as possible. They must attempt to find the "second best" strategy for dealing with the case at hand, and the second best strategy is that one which, of all feasible strategies, best matches the knowledge of the medical advisor with the knowledge and capacities of the advisee and the condition of the patient.

RESPONSIBILITIES INCURRED BY THOSE WHO GIVE ADVICE


Now that we have some understanding of the conditions under which medical advice can be given responsibly, we can ask what responsibilities are incurred by those who give medical advice. Does the doctor who advises the physician's assistant now assume complete responsibility for the physician's assistant's patient? Does the nurse assume complete responsibility for the health of the child whose mother she has advised?


We may say with certainty that the medical professional who provides medical advice is exclusively responsible for ensuring the effectiveness and safety of that advice. But this is only to say that the advisor is obligated to provide medical advice responsibly. If the medical professional who provides medical advice does not take those measures necessary to ensure that the knowledge conditions discussed above are satisfied to the greatest extent possible, she has acted irresponsibly and is accountable for any negative effects of her advice.

But if the advice is given responsibly and every effort is made to satisfy the knowledge conditions to the greatest extent possible, the medical advisor has fulfilled her ethical obligation and cannot be held accountable for any untoward effects of her advice.


Those who give medical advice must do all they can to increase the probability that their advice is correct, but they are not responsible for guaranteeing success. Even in ideal circumstances, with the necessary experts and the necessary facilities, medicine does not always succeed. In highly pressurized, emergency situations, where the nec­essary experts and facilities are not always available, medicine is even less likely to succeed.

The primary responsibility for the patient's health remains with the patient and the medical staff directly charged with caring for him. Those who consult, whether in person or over the phone, are responsible only for the integrity of their advice, not the ultimate fate of the patient their advice concerns.

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