Experts: Oncologists need to carefully consider information about self-pay treatment

A great responsibility comes with it if, as a cancer doctor, you draw attention to the possibility of effective but self-paid cancer treatment abroad or in the private sector, according to experts in ethics.

For several years, there has been criticism from many oncologists of the speed with which the Medical Council recommends cancer treatments that are approved by the European Medicines Agency EMA and can be available against personal payment in Danish private hospitals or abroad.

Veterinarians are often faced with a dilemma when they have a patient who, according to the European guidelines, should receive a given treatment, and who cannot be offered to them in the public health system.

As Niels Fristrup, renal oncologist and ward physician at Aarhus University Hospital, explains in a webinar held by the site Onkologisk Tidsskrift:

"We are in a big dilemma when many countries around us can offer a new treatment and we cannot. It often happens that I have a patient who, according to the European guidelines, should receive a certain treatment that I cannot offer them. We should have a discussion about whether to make a patient aware that there is better treatment elsewhere. But it is something that patients find difficult to understand, and it is actually also something that I find difficult to explain to them.”

Divided opinions about responsibility

Leif Vestergaard Pedersen, chairman of the Ethics Council and former director of the Cancer Society, believes that advice on self-paid treatment depends on the context:

"If the doctor is asked, he must always answer the patient's question honestly. But organize your information according to the patient's needs. If the patient does not ask, he must inform the patient, as long as the information is meaningful for the individual patient's situation," he says.

If you give too much information, you run the risk of disengaging the patient and, in the worst case, sabotaging the patient's course of illness.

"One should in each case assess whether the patient can use that knowledge constructively. If, for example, you have a patient who is on cash assistance, it does not make sense to tell them that they can buy a treatment in Sweden or Germany for half a million to a full million kroner," he says.

That is why doctors should do the 'aunt test', as he calls it.

"You should ask yourself what you would find appropriate to tell the patient if it were your aunt," says Leif Vestergaard Pedersen.

Information is binding

At the University of Southern Denmark, Anne-Marie Søndergaard Christensen, professor of health philosophy, agrees. She also does not believe that the doctor has a special duty to always, even unsolicited, tell the patient about other treatment options.

"If the patient has not himself asked about other treatments, then the doctor is not morally obliged to tell patients about treatment options that we do not offer in the Danish healthcare system," she says.

Her reasoning is, among other things, that as a doctor you are not obliged to have an overview of possible treatments other than those you can offer.

"Professionally, you have greater, but also more limited, obligations. You have the responsibility to have sufficient professional knowledge to carry out your work, and thus you of course also have an idea of new advances within your field of expertise, but the responsibility does not include that you know about all possible treatments that are not offered in Denmark, ” says Anne-Marie Søndergaard Christensen.

If the doctor nevertheless chooses to tell the patient about another treatment on his own initiative, he or she commits himself to the patient's further course.

"If you mention it unsolicited as a doctor, a great moral responsibility follows. As an expert, you must ensure that the treatment is not professionally problematic and that the patient is prepared to make a qualified choice based on the information you provide," she says.

According to her, it takes time to familiarize oneself sufficiently with the patient's situation and equip the patient to make that assessment, and this is problematic.

"Let's say that it takes half an hour or a full hour for the doctor to familiarize himself with the patient's situation and have a conversation that clarifies the advantages and disadvantages of seeking treatment elsewhere. It cannot be the healthcare system that has to create that framework and pay for the doctor to spend time advising on a treatment that we have not approved in Denmark," says Anne-Marie Søndergaard Christensen. So one must consider how to live up to the very fundamental principle of being able to guide the patient in the best possible way.

The patient's doctor, not the system's

According to Leif Vestergaard Pedersen, that principle applies in general to the practice of medicine.

"Regardless of whether it is cancer treatment, choosing a rehabilitation site or an operating hospital, it is the doctor's responsibility to guide the patient. It can be by drawing attention to better treatment elsewhere, when the doctor knows that the patient will be referred for an operation or a rehabilitation course that can be carried out better elsewhere."

"A bad rehabilitation offer often haunts the patient for the rest of his life - but not many doctors are aware that it is also their job to help the patient get the right offer here," says Leif Vestergaard Pedersen.

"You are the patient's doctor, not the system's doctor, so you must first of all take into account what benefits the patient the most," he says.