This case raises several issues. But before we discuss them the absurdity of the situation has to be faced. How do you keep a lay person, let alone a doctor, in the dark about treatment when he is being wheeled into the OR and then to the radiotherapy department for daily radiation treatments? It is not some pill that can be crushed and mixed into his meal or palmed off as a vitamin.

The foremost issue is that the patient must be allowed to make his own decisions. The only exception is when he is deemed incompetent. Therefore the first question is, is Dr. X competent? Competence is not an all or none phenomenon as a person may not be competent to understand financial dealings but may be “with it” enough to decide if they do or do not want a particular treatment. This should ideally be determined by a psychologist where legal issues are involved but in clinical situations his neurologist should be able to give an opinion based on a bedside mental status examination. We have to guard against the tendency in our society to treat the patient as a child with all decisions made by the doctors and the families.

Let us assume that he is competent. In that case, is there a valid argument to be made to keep the patient in ignorance of his planned treatment? The family maintains that they are doing so merely because he has been “stubborn” in the past. This could mean anything from opinions or actions that were truly not in his best interest to those that were eccentric and unusual from the family members’ point of view. Now that he is ill, are they trying to enforce their views on him knowing fully well that they are going against his wishes? If he is competent, the doctor should be able to discuss the benefits and risks of the procedure, helping him to arrive at a decision in keeping with his life choices. It would surely be good to know if the tumor is benign in which case it may be worthwhile to cajole, reason with and convince the patient into having the treatment. On the other hand if it is malignant with a slim chance of meaningful life after treatment, then the patient’s ideas about how much to do should be paramount.

Often families are trying to do what is best for the patient and we have to view their plight with sympathy. Perhaps the family is not really trying to keep the patient in the dark but this may be their way of dealing with a catastrophic event, imagining that they can “protect” their loved one from the agonising knowledge of a painful illness and possibly death. What the family would benefit from is psychological counseling that will help them deal with their feelings of guilt and helplessness that are showing up as “protection”. Also, one must not forget that it is the family that will have to take care of this patient after whatever treatment he chooses. Surely a responsible person recognises that and involves his care givers in the decision-making process. If he does not recognise this, his doctor must gently bring this to his attention.

Eventually, it was decided to tell Dr X who seemed to understand the situation, and did not put up any opposition. At present, Dr X is recovering from surgery and will shortly undergo radiotherapy. The family hopes for a recovery.