A 40-year-old man comes to the office for evaluation of difficulty with concentration. After reading a book on adult attention deficit hyperactivity disorder (ADHD), he thinks that he has ADHD and requests treatment with stimulants. The patient has no history of childhood ADHD but states that his parents were unaware of the disorder and never had him evaluated. He currently does not experience hyperactivity or impulsivity but says, "I just get easily distracted some days and know I could be more productive at work." The patient does not use alcohol or use recreational substances. Medical history is noncontributory. Vital signs and physical examination are normal. The physician shares that the patient's symptoms are not consistent with a diagnosis of ADHD. The patient insists that he will benefit from stimulants. Which of the following is the most appropriate statement?

Question

A 40-year-old man comes to the office for evaluation of difficulty with concentration.  After reading a book on adult attention deficit hyperactivity disorder (ADHD), he thinks that he has ADHD and requests treatment with stimulants.  The patient has no history of childhood ADHD but states that his parents were unaware of the disorder and never had him evaluated.  He currently does not experience hyperactivity or impulsivity but says, "I just get easily distracted some days and know I could be more productive at work."  The patient does not use alcohol or use recreational substances.  Medical history is noncontributory.  Vital signs and physical examination are normal.  The physician shares that the patient's symptoms are not consistent with a diagnosis of ADHD.  The patient insists that he will benefit from stimulants.  Which of the following is the most appropriate statement?

Quizplus · Accepted Answer

Ethical dilemmas frequently arise in the provision of patient care because basic ethical principles (ie, autonomy, beneficence, nonmaleficence, justice) can often conflict with each other. This patient comes to the office for evaluation of difficulty concentrating, but the specific concentration is limited to a single setting in a nonpersistent manner. In addition, he has no evidence of hyperactivity or impulsivity; therefore, the patient does not meet the criteria for attention deficit hyperactivity disorder (ADHD). However, despite this lack of diagnosis, this patient still requests ADHD treatment with a stimulant medication, which has a risk of adverse effects, including use disorder. In this case, the right of the patient to make personal health care decisions (ie, autonomy) conflicts with acting in the best interest of the patient (ie, beneficence), in particular the avoidance of unnecessary, potentially harmful interventions (ie, nonmaleficence). The patient's right to make personal health care decisions does not extend to dictating the physician's recommendations; therefore, the physician should state why the medication is not recommended to avoid potentially harmful interventions while also validating the patient's concerns (eg, by providing nonmedication options). (Choices A and C) This patient does not have ADHD; therefore, treatment with either psychotherapy or a nonstimulant ADHD medication are not appropriate. Providing either management option is not acting in the best interest of the patient. (Choice B) Although it is appropriate to explain to the patient that a stimulant is not indicated, the defensive tone of suggesting another opinion "if you do not agree" harms rapport and can limit the willingness of the patient to hear recommendations. (Choice E) Stating that the patient does not have ADHD is appropriate; however, recommending that the patient schedule a follow-up visit only if the symptoms worsen is dismissive of the patient's concern and suggests prolonged suffering is acceptable. Educational objective: Medical decision-making often involves balancing conflicting ethical principles (ie, autonomy, beneficence, nonmaleficence, justice). While recognizing patients' rights to make personal health care decisions (ie, autonomy), the provider has the responsibility to use specialized training to incorporate the best interests of the patient into the provision of care (ie, beneficence), which includes limiting nonindicated interventions.

A 40-Year-Old Man Comes to the Office for Evaluation of Difficulty