Complex Clinical Ethics in Thyroid Disease Management

Though physicians routinely weigh therapeutic benefits against risks and institutions continually attempt to reduce medical errors, improve healthcare access, encourage cultural competency, and promote professional integrity, several clinical ethics issues are unique to thyroid disease management.

In a paper published in the June 2014 issue of Endocrinology and Metabolism Clinics of North America, M. Sara Rosenthal, PhD, of the University of Kentucky, pointed out that many different types of healthcare professionals — from endocrinologists, to genetic counselors, to nuclear medicine specialists — manage thyroid disease.

Rosenthal also noted that the core principles of medical ethics sometimes compete against each other when managing autoimmune thyroid disease and thyroid cancer. For example, providers have an obligation to respect patient autonomy, but they are also obligated to protect patients with limited decision-making capacities.

Beginning with Graves’ disease, Rosenthal discussed variations in the standard of care for different autoimmune thyroid diseases. Since medication, radioablation, and surgery are all equally effective in appropriate candidates, Rosenthal said patient preference should guide treatment decisions, though clinicians must first warn patients about the potential for severe hypothyroidism.

According to Rosenthal, an adequate consent process in Graves’ disease should include correcting patient misconceptions about treatment options, many of which originate from the patient’s own Internet research. Since many patients with hypothyroidism have some impaired cognition, sufficient informed consent is often difficult to obtain. Thus, Rosenthal reviewed the elements of decision-making capacity to help clinicians thoroughly assess patients and counsel them on the necessary components of informed consent.

While reviewing thyroid cancer management, Rosenthal said the treatment process is usually multidisciplinary, so issues of honesty in prognosis are crucial. She also covered the extensive differences between iodine-avid and iodine non-avid diseases in terms of appropriate treatment options.

Among the emerging issues unique to current events, Rosenthal discussed making end-of-life decisions in poorly differentiated thyroid cancers; managing pediatric and geriatric patients; setting priorities in drug shortages; and resolving clinical disagreement over standards of care.