Ethical dilemmas of medically unexplained symptoms

Medically unexplained symptoms (MUS) are common across health settings. These are defined as “physical symptoms that prompt sufferer to seek healthcare but remain unexplained after an appropriate medical evaluation” (1). Expectedly, MUS are often associated with significant health-seeking behaviours that add to the burden on health resources.

There are ethical dilemmas in the management of symptoms that are purely subjective and cannot be confirmed objectively. Three key ethical dimensions manifest when a physician deals with a person with MUS. The first is related to communication about MUS. The symptoms cause distress to the patient but the cause is not understood by the physician and no explanation is offered.The difficulty arises in discussing MUS with the patient and family members. They may think that the patient is “faking” or reporting a symptom which is absent or unproven by the examination and investigations. This can cause further distress to the patient with MUS. On the other hand, the uncertainty might lead the patient to wonder whether this is an indication of some dreadful disease. In such situations, health professionals find it difficult to explain (something that has no explanation) and wonder whom to inform – patient or the relatives.

Ethically, the physician should explain with honesty and transparency about the uncertainty regarding MUS both to the patient as well as family members. They need to be explained that investigations have limitations. The physician needs to be empathetic so that the family members do not doubt his/her intentions.

The second ethical dimension is related to investigations. To understand the cause of MUS, physicians would like to repeat investigations or prescribe new, unusual and uncommon investigations. Hence, there is a risk of over-investigation and danger of under-investigation. This needs to be discussed tactfully with the patient and family members to enable them to make informed decisions about investigations.

The third ethical aspect is related to treatment or intervention. In MUS, the treatment is symptomatic to relieve the distress and suffering. Therefore, medications and non-medical therapies need to be used rationally. Use of placebos or multivitamins in MUS is an ethical issue. In such situations, the patient and family may prefer complementary and alternative medicine (though the scientific validity and efficacy of such systems is unproven).

In India, a patient’s preferences and decisions are usually influenced by family members. Ethical dilemmas concerning MUS leave the professionals and families confused. Thus, ethical issues need to be handled sensitively within the framework of the financial constraints and well-being of the patient.