1. There will, of course, be instances where multiple diagnoses are at issue, particularly early on in the work up of a patient. Such situations are not rare and will surely complicate the detail of this section. Two caveats seem to bear making: (1) a balance would need to be struck between mentioning all of them, some of which may be theoretical possibilities only, and emphasizing the main possibilities. What would actually be said might be determined by the intervention at issue, especially if it is diagnostic and relates to one of the possibilities. Also, one should be hesitant to assault patients with an extended list of possibilities that will do little more than alarm them and cause needless worry. Our aim throughout is to present important information and encourage patient insight, not engage in “truth-dumping”. But (2) it is as potentially disastrous not to identify such uncertainties to the patient up front, as the clinician’s credibility, and with it trust, may evaporate if he is forced to modify treatment toward one of the other possibilities later. A good example here would be a patient who presents with shortness of breath and a temperature, but also with a x-ray containing a suspicious lung opacity. The patient probably has an infiltrate, but this may be superimposed upon a malignancy that also will need to be investigated. To neglect to mention the latter possibility early on not only will strain trust but deprive the patient of time to prepare for the latter discussions. To not even mention the possibility sets the whole process up for failure and may well cause more problems than it solves.
2. See especially the first section of chapter four.
3. E. Haavi Morreim, personal communication.
4. This scenario is discussed extensively in the eighth chapter regarding patient waivers of informed consent.
5. This designation is used in passing by Faden and Beauchamp, 1986 on pg. 315. I make no claim as to whether they would tend to accept the “operational” recommendations which I am making here.