Factitious Illness: An Exploration in Ethics

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FACTITIOUS ILLNESS: AN EXPLORATION IN ETHICS NEALJAY MEROPOL, CHARLES V. FORD, and RICHARD M. ZANER* A 40-year-old woman had been hospitalizedfor 44 days for the diagnostic investigation and treatment òfafever ofunknown origin. While she was away from her room, her belongings were searched; syringes and a spittle cup Werefound. On confrontation she admitted to the selfinjection cf saliva. [1] A 35-year-old nurse presented to a hospital emergency room with neurological symptoms due to severe hypoglycemia. An extensive diagnostic evaluation demonstrated no etiology. In fact, this nondiabetic had been routinely injecting herselfwith insulin* A 25-year-old woman presented a containerfull ofcalculi to her physician , claiming that she had recovered them from her urine. Laboratory analysis revealed that the stones were composed of 100 percent cholesterol; in fact, the patient's mother had recently had a cholecystectomy, and had displayed the recoveredstones on her mantlepiece. The daughtersimply tried to "pass" the calculi as her own. Factitious illness is uniquely problematical for the physician. There are a large number of reports concerning a wide variety of factitially produced diseases [2], and the prevalence of this type of illness appears to be increasing [S]. Diagnosis is difficult, frequendy characterized by an uncertainty as to how one ought to gather confirmatory evidence when factitial etiology is suspected. Furthermore, disagreement has beeh reported among health care professionals regarding the actions one ought to take subsequent to diagnostic confirmation. The word "ought," as employed above, suggests an entrance into the realm ofmoral theory. Ih fact, it may be that what makes a patient who presents with a factitious disorder so interesting, so confusing, and often so enraging is that he or she raises ethical questions diat have solutions that are unfortunately remote. *School of Medicine, Vanderbilt University, Nashville, Tennessee 3Í232.© Ì985 by The University of Chicago. All rights reserved. 0031-5982/85/2802-0424$01.00 Perspectives in Biology and Medicine, 28, 2 ¦ Winter 1985 | 269 In this communication we shall outline several of the major moral issues suggested by factitial illness. None of these issues has gone unrecognized in the literature of biomedical ethics; however, there has not been a complete discussion of these concerns in the unique context of factitious disease, although interest has recently been initiated in this area [4, 5]. Three major topics will be considered: (1) the oftenconflicting duties ofthe physician to the patient, the patient's family, and society; (2) the doctor-patient relationship; and (3) patient autonomy versus the physician's use of invasive "detective" diagnostic techniques without informed consent. We shall also briefly consider the important issues of patient competence, the definition of illness, and a patient's right to indulge in self-harm. Vignettes from our clinical experience or abstracted from the medical literature will be used to illustrate moral dilemmas presented by patients who have factitial disorders. Before proceeding, it is necessary to define more precisely what is intended by the term "factitious disease." According to Webster's International Dictionary, a factitious disease is one that is deliberately caused by human action with or without the intention to produce a lesion or disease. However, in general medical usage, the term refers to patientproduced disease rather than to iatrogenic disease. Factitious disorders may be distinguished from malingering on two counts. First, while factitious illness is often chronic, malingering is usually situation specific. Furthermore, although malingering is motivated by manifest secondary gains, in factitious illness there are no apparent goals "other than the bizarre psychological significance of being a patient" [6]. Factitious diseases are characterized by surreptitious behavior and deceit, with the deliberate attempt to confuse those charged with establishing the diagnosis . These patients consciously conceal from their caretakers (and others, such as family members) the means and methods by which their symptoms are produced, yet they repetitively and contrarily seek diagnostic studies and treatment for their illness. TL· Physician's Duty to Patient, Family, and Society A 61-year-old retired school teacher was hospitalized numerous times over eight years for symptoms ofabdominal pain, vomiting, and marked weight loss. Symptoms were unchanged by multiple diagnostic studies and an eventual cholecystectomy. A nurse accidentally discovered the patient inducing herselfto vomit. When confronted by...

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