Benefits of Initial Diagnosis Withholding in Stigmatizing Diagnoses

In certain cases, such as in patients with delusional infestation, there may be benefits to withholding their diagnosis until the patient is recovered, according to commentary published in the AMA Journal of Ethics. 

Delusional infestation is a subtype of delusional disorder, during which patients believe that they are infected by parasites. Because this is a psychotic illness, antipsychotic drugs are the typical and often only effective treatment for the disorder.

When diagnosing delusional infestation, physicians must establish and maintain rapport with the patient. If the physician immediately diagnoses a patient with delusional infestation, the patient may feel invalidated and cut off contact with medical professionals.

Although initially withholding a diagnosis seems ethically objectionable, the researchers provide criteria that they have determined must be satisfied to ethically justify this “benevolent deception.” The criteria are as follows:

1. The patient is incapable of making an informed decision because of the delusions and associated lack of insight.
2. The patient would likely experience harm without the prescription of antipsychotic medications.
3. The patient lacks insight and would not take an antipsychotic medication if it were prescribed.
4. The typical means of providing treatment without patient consent are unavailable or inappropriate.

Even if a physician prescribes antipsychotic drugs without labeling them as such, the researchers note that they still must disclose possible side effects. Additionally, physicians should avoid blatant lies, such as saying “This is not an antipsychotic.”

After the patient has recovered, the person will need to continue taking antipsychotic medication. The researchers suggest that the physician reveal the diagnosis, provide a rationale for the treatment, and tell the patient that the treatment started without the rationale being revealed. They suggest accompanying this with an apology. The patient can then make an informed decision whether to continue or discontinue antipsychotic treatment.

“Delusional infestation provides rare examples of cases in which physicians are justified in temporarily withholding a diagnosis from their patients,” the researchers wrote. “However, physicians should embark on this kind of deceit only if certain criteria are met.”

Reference

Bartels J, Ryan CJ. How should physicians use their authority to name a stigmatizing diagnosis and respond to a patient’s experience? AMA J Ethics. 2018;20(12):E1119-E1125.