Portal de Periódicos da CAPES

“Why Can't I Move, Doc?” Ethical Dilemmas in Treating Conversion Disorders

2012; Wiley; Volume: 4; Issue: 4 Linguagem: Inglês

10.1016/j.pmrj.2012.03.008

1934-1563

Kristi L. Kirschner, Geoffrey R. Smith, Ryan M. Antiel, Philip Lorish, Frederick Frost, Richard Kanaan,

Traumatic Brain Injury Research

I first encountered a patient with conversion disorder about 20 years ago. I was a new attending physician, and the woman was admitted to my inpatient rehabilitation service with a diagnosis simply of "quadriplegia." The diagnosis of an underlying conversion disorder was ingeniously cinched by a video that documented normal movement during sleep. But, during her waking hours, she was as disabled as if she had had a spinal cord injury, that is, she was unable to move, she was dependent in her self–care, and she was still subject to the problems of immobility. What to do? On the one hand, I understood that conversion disorder was a physical manifestation of an unconscious psychological conflict. The longer the condition persisted, the less likely it was to improve. On the other hand, without treating and resolving the underlying psychiatric conflict, "curing" her condition was also unlikely. Yet psychiatric treatment requires the active and willful engagement of the patient, and she (like many patients with conversion disorder) was not amenable to psychotherapy. Psychiatric inpatient units also tend to be uncomfortable with accepting patients who have significant physical disabilities. Did rehabilitation have a legitimate role to play? What should she be told about her condition and treatment plan? How likely was it to be successful? When Geoffrey Smith, MD, from the University of Virginia, brought the ethical issues that underlie the care of patients with conversion disorder forward, it was not difficult to decide to pursue an ethics column on the topic. Indeed, the issues that he raises remain controversial and unresolved. What follows is his presentation of a woman with conversion disorder with whom he had direct care responsibilities as a resident. After the case presentation are several questions raised for discussion by our invited commentators (see below). The column concludes with an epilogue by Dr Smith about how the case was resolved, and his reflections years later. As always, we welcome your comments and reactions, or suggestions for future columns! A woman in her mid 20s was evaluated in an outpatient neurology department for subacute hemiparesis. An extensive neurologic workup showed no organic cause for her hemiparesis. She subsequently was referred to the physical medicine and rehabilitation department for rehabilitation. The diagnosis in the medical record was "hemiparesis without evidence of abnormalities on imaging or neurophysiological studies," qualified with adjectives such as "functional " and "behavioral." Although the official medical record did not explicitly state the diagnosis of conversion disorder, the neurologists who evaluated the woman did communicate this diagnosis to the consulting physiatrist over the telephone. The physicians overseeing both her acute care and rehabilitation management instructed the team that the patient not be told her diagnosis of conversion disorder, nor should it be recorded in the chart. The plan of care was to address the somatic impairments with a behavior-focused rehabilitation program. If, as William May has said, "the task of ethics in the professional setting might be called, at least in part, corrective vision," then any ethical judgment on patterns of treating conversion disorder must begin with an accurate description [1]. Failing to see the situation clearly will alter not only the appropriate prescriptive remedy but will also eventuate in some sort of self-deception, whether it comes as either the nagging presence of anxiety or the all too common form of resignation: "Let's be honest, we all lie." In our view, the path to an accurate description begins when we treat our basic intuitions as forms of instruction that reveal the moral quality of the situation itself. In this, the moral diagnosis is unavoidably clear: any course of treatment for conversion disorder that avoids discussing the known etiology of a presenting medical problem is mendacious. Even if there is no agreement regarding the morality of lying, if and when it is morally permissible to tell a lie, lies are moral facts. That is, lying describes some utterances and not others, some patterns of behavior and not others. Saint Augustine's definition of the lie is as elegant as it is simple [2]: "Therefore he who utters a false thing for a true, which however he opines to be true, may be called erring and rash: but he is not rightly said to lie; because he has not a double heart when he utters it, neither does he wish to deceive, but is deceived. But the fault of him who lies, is, the desire of deceiving in the uttering of his mind." Any description, therefore, of the scenario described above that either denies that there is a moral problem in the wilful misleading of a patient with conversion disorder or denies the fact that it involves mendacity misperceives the situation. But, as May would no doubt agree, insisting upon a proper moral description of an act is important to the degree that it aids another central task of ethics, namely, judgment. In this, the question of the proper treatment of conversion disorder would appear to be another occasion for the perennial debate about the morality of lying. What is unique about this case, however, is the manner in which what it brings to light is something that most moralists would most easily dismiss as immoral: namely, the lie of convenience. In the case of conversion disorder, rather than go through the messy and time-consuming process of identifying and treating the true cause of the patient's pain, it is simply easier (for all involved, presumably) to be duplicitous. So, the question then becomes, if the medical treatment of conversion disorder is not only fundamentally mendacious but also the particular type of duplicity born of convenience, then what best describes the pressure that physicians feel to lie? Are those pressures internal to the practice of medicine? Are they more prevalent in some structures than in others? Are they the result of malformed moral character? The patient-physician relationship has undergone a metamorphosis in recent decades. In an effort to deter abuses of physician power, medical ethics has rightly emphasized respect for patient autonomy as a counterbalance to the dangers of hard versions of paternalism. Yet, respect for patient autonomy should not be elevated to a moral absolute. As Childress and Siegler [3] have shown, the emphasis on autonomy has fostered at least 6 new models or metaphors of the patient-physician relationship. These models are the following: "paternal," "partnership," "rational contractors," "friendship," "technician," and their favored model, "negotiation." Pellegrino and Thomasma [4] outline 2 dominant models: the consumer model and the negotiated contract model. In the former, health care is understood to simply be another commodity to be purchased. The physician is reduced to a provider and/or adviser. The latter model is based on contract, a mutual agreement irrespective of ethical norms so long as both parties follow through with the articulated agreement. These models represent what Pellegrino [5] labels the "commodification of medicine." Indeed, physicians have complied with these new models, and, as a result, productivity, efficiency, and market growth have become dominant virtues for the modern physician. This is where the difficulty of the patient with conversion disorder lies. The source of the physician's frustration in cases of verified conversion disorder is the sense that they disrupt that most modern of virtues: efficiency. The dilemma that the patient poses is that full disclosure of the etiology of his or her disorder is often met with frustration and anger displaced on the bearer of news. (Currently, our society is obsessed with labeling everything as a medical diagnosis. That is, as long as that diagnosis is not psychiatric. We seem to be comfortable with medical labels being placed upon an ever-increasing amount of life, so long as those labels do not imply we are "crazy.") Thus, the busy and well-meaning physician faces a dilemma each time he or she cares for a patient with conversion disorder. Should the physician devote the time and energy to educate the patient about the true etiology of his or her disorder or should simply confirm no "serious" conditions are present and refer the patient on to physical therapy? The latter avoids multiple difficult and demanding conversations that attempt to help the patient see the need for consultation with a mental health provider. Furthermore, the lie of convenience becomes all the more appealing when the physician is convinced that the patient's symptoms should subside after a few physical therapy sessions. In our judgment, it is the commodification of medicine that encourages therapeutic deception. If we now understand medicine as a commodity to be purchased and the patient-physician relationship as based on a negotiated contract, then the value of truth telling is derivative of the more basic commitments to efficiency and effective management of time. It is a great irony, therefore, that models of the patient-physician relationship that have been instituted to protect the patient from the perceived harms of paternalism have begun to justify lying. Truth telling, in our day, takes second place to achieving desired outcomes, no matter how those outcomes are ascertained. Yet, as Dr Smith's case powerfully illustrates, respect for autonomy without truth telling will not result in truly beneficent medical care. Many of these patients will often undergo multiple invasive procedures and surgical operations because future health care providers act under the assumption that there is an organic cause to the disability. Thus, it becomes quite clear that therapeutic deception neither respects the patient's right to the truth about her condition nor meets her medical needs. Instead, it puts her at unnecessary harm. Personal autonomy is actually compromised without truth telling as a corollary. In this, we would do well to consider Paul Ramsey's insight that truth telling is basic to understanding medicine for the simple reason that our meaning and purpose as human beings is premised upon the possibility of covenant [6]. With understanding all relationships in these terms, including the patient-physician relationship, necessitates faithfulness owed to those with whom we enter into a covenant. Importantly, this means that the physician's responsibility to the patient extends beyond the limits of contracts. It becomes morally inescapable for every physician who understands medicine as a covenant to thwart the temptation that is therapeutic deception. Let us be honest, we all lie. The ability to pass our thoughts through a filter before they are communicated to others is a measure of our emotional competency. Lying has many names, including tactfulness, advertising, and statistics. Just a few decades ago, physicians thought that it was justified to withhold from the patient the diagnosis of terminal cancer. It is a common situation when the responsibility to do what is best for the patient comes into conflict with the responsibility to communicate our thoughts openly. The patient with conversion disorder brings this dilemma into full focus. Every physician filters, in a different way, the information that he or she passes to the patient. Physiatrists are often in the position of treating patients with the poorest outcomes; delivering bad news is part of the job. The complex processes of speaking and listening create a communication minefield. Blunt communication is perceived as mean and uncaring. I have seen it result in fractured relationships with patients and families. Our experiences encourage us to create a thick communication filter. Thoughtful clinicians choose their words carefully. Patients who receive positive explanations of their diseases have better outcomes [1, 2]. There are strong disincentives to telling the truth. Physicians with silver tongues and with vague, soft messages are said to have great "bedside manner." Patients give wide berth to physicians who tell them what they want to hear. The difference between smarmy and honest can be as simple as inflection of speech, posture, or a raised eyebrow. Telling the patient what he or she wants to hear is not just about avoiding conflict. Lack of time is the biggest problem. Saying yes to a patient takes only seconds, whereas delivering a "no" rarely does. A busy clinician, like a chess master, thinks a dozen moves ahead. It may be subconscious, but we control conversations in the interest of time. We learn to direct conversations in a way that avoids paths that have no outlet, diminishes our primacy, or leads to options that run counter to our recommendations. We prompt patients to ask questions that we can answer. In an ideal world, there would be unlimited time to talk to patients. This is not our world. To call this lying "out of convenience" is pure rhetoric. We direct conversations to conserve time and navigate through busy schedules filled with patients with seemingly endless needs. We need to help the person who is waiting in the next room, and we need to leave work at a reasonable hour. Communicating the truth requires a speaker and a listener. We cannot predict what the listener will hear. We can try to reduce the pain inflicted by blunt statements by using some conversational finesse. It is very hard to know when this finesse evolves into deception. Physicians who engage in such thick conversational filtering should not feel too bad. We are equal opportunity deceivers. We deceive ourselves too. We put too much emphasis on the exceptional cases in our careers. We convince ourselves that our decisions are based upon solid scientific evidence. If we were to dwell on the sad life events and twists of fate that deliver patients to our door, then we would be the ones left paralyzed. The population of patients with conversion disorder is not homogeneous. The physiatrist is likely to encounter many variations of factitious conditions, from mild to malignant. The lonely patient who is afraid of hospital discharge may suddenly develop physical ailments. The patient with a borderline personality creates symptoms to twist and manipulate his or her care providers and creates chaos in the hospital. Two of my patients with conversion disorder are featured in the media as testimonial cases for durable medical equipment products. In the outpatient clinic, the patient with a compensated work injury is a challenge. Conscious production of symptoms for secondary gain is always a possibility. But there are common themes in the conversion disorder group. A psychiatrist colleague once told me "There are no millionaire CEOs flying on private jets with supermodel girlfriends who develop conversion disorder." The patients with conversion disorder will maintain their physical restriction as long as it "works" for them. Do we enable the condition by admitting these patients to the rehabilitation unit and by maintaining a façade of physical illness through our communication with them, the staff, and the insurance company? When using this line of reasoning, would it be better to approach these patients with a "tough love," punitive approach? Perhaps the best thing would be to confront the psychiatric condition directly with a frank conversation, then we can congratulate ourselves for being truthful! Sadly, this strategy is likely to backfire. The patient with the psychological sophistication to address his or her inner conflicts is unlikely to have developed conversion disorder in the first place. Conversion disorder is a primitive adaptive strategy. It might take years of intensive counseling to get to the point where a patient with conversion disorder could safely approach his or her inner conflicts. Taking a punitive approach to these patients may recreate the setting that triggered their psychopathology. Practically, the likelihood that the patient will access expensive, time-consuming ongoing psychiatric counseling is near zero. This is the fallacy of perfection. We cannot wait for the perfect world in which unlimited free psychotherapy is available. Sending the patient down the psychiatric road is recommending a treatment that is not available; a see-no-evil strategy. Instead, we use behavioral approaches, through the physiatrist, not the psychiatrist. The inpatient rehabilitation unit is the best place to treat patients with conversion disorder. These patients occupy a special place near the bottom rung of society, at the intersection of physical and psychiatric disability. I have noticed how often the staff on the rehabilitation unit, who are so accommodating with physical disability, can be intolerant to persons with mental illness. It almost seems as though there is a human limit to compassion. The physiatrist feels added stress and loss of control. The diagnosis of conversion disorder is one of exclusion. There is always a kernel of doubt that some undiscovered neurologic condition may be to blame for the patient's symptoms. In the ideal medical encounter, the patient and the physician are truthful with each other and are working in concert to relieve the problem. There is nothing ideal about the interaction in this situation. The patient is already being misled by the content of his or her paralytic delusion. Tolerating this delusion while helping the patient regain his or her physical function will help restore his or her autonomy [3]. Textbook cases of conversion disorder are rare. It is common to have patients with modest neurologic abnormalities that magnify their conditions into bizarre, inconsistent, and nonphysiological deficits. Because the diagnosis is complicated, the trajectory of improvement cannot be predicted. The rehabilitation unit offers a structured, caring environment that directly addresses the patient's symptoms of physical impairment. Conversion disorder is best treated as a chronic illness [4]. In this way, a stay on the rehabilitation unit is as important as a stay on the substance abuse unit for a patient with alcoholism. It removes the patient from the environmental vectors that enable the condition and provides a goal-directed strategy for community reentry. Observational studies indicate that these patients experience functional improvement on the rehabilitation unit [5]. The medical literature is mute when it comes to telling us exactly how to treat these patients. We will never see research that compares "lying vs not lying"; that study will never pass the institutional review board. Media, electronic medical records, and the Internet change how we communicate with patients about conversion disorder. Before fibromyalgia hit television commercials, patients were offended by the diagnosis. Because job markets remain tight and public entitlements become more attractive, it is likely that factitious conditions will be more common. Patients now have virtually unrestricted access to medical records, which sets the bar high for clear documentation. It is understandable that physicians are reluctant to label a patient with a diagnosis of exclusion, but it is no different than other labels we deliver, such "amyotrophic lateral sclerosis" or "alcoholism." The fact that a patient's functional status cannot be explained purely on the basis of a single neurologic lesion is not all that controversial. Treatment of the patient with conversion disorder demands the highest level of maturity on the part of the rehabilitation team. The patient with conversion disorder paraplegia is just as sick as the patient with a stroke in the next bed. Whispered comments, rolling the eyes, and snide remarks about the patient's "real problem" reflect a general contempt of mental illness. It is the opposite of the caring and concern that are expected of us when confronted with suffering. We must remind ourselves that it was a psychiatric illness, not a deficit in character that brought the patient to us. It requires that physicians admit that they cannot diagnose every problem and that they do not have a good understanding of how psychological stress affects physical disease. On that point, open conversations with the staff, the patient, and the family are at the base of developing a pragmatic therapeutic relationship, which is very different from telling the patient what he or she wants to hear. Lying to the patient happens more frequently than we would like to admit. It is wrong on many levels. We must guard against painting our patients into a corner with rhetoric and testimonials. As a very rudimentary step to combat this, we might start with the following filter; do our statements help our patients make free and informed decisions about their health care? Conversion disorder occupies a central place in the genesis of modern psychiatry, yet it is a condition that most Western psychiatrists today rarely see. However, as surveys suggest, this condition is of undiminished prevalence in secondary care [1], this decline in psychiatric encounters tells us only that it is now largely managed by physicians alone. Unfortunately, for many physicians there is considerable unease and some trepidation about managing, and even talking about, a condition they do not see as rightfully their responsibility [2]. Yet psychiatric services may seem unable to help or seem out of reach because referral would require the physician to disclose the diagnostic suspicions to a patient who may fiercely disagree. This unease over managing and communicating with patients with conversion disorder in a physical care setting is made unusually explicit in the case and questions introduced above. Conversion disorder is a challenging condition to treat, particularly for medical services. The prognosis can be poor, with refractory symptoms, frequent relapse, and high levels of disability disappointingly common. But what make patients with conversion disorder almost uniquely challenging for physicians are the difficulties in the physician-patient relationship. The patient may seem particularly uncooperative, ungrateful, or demanding when compared with the rest of the physician's patient population [3]. Physicians may believe that they do not have the skills to manage a patient with such complex psychological and social needs. They may believe that the patient is in the wrong place entirely, that they have been "dumped" with a patient who really should be treated by someone else (mental health services). They may have suspicions that the patient is actually deceiving them about his or her problems and is really a malingerer at worst or has factitious disorder at best [4]. In short, if any treatment is possible in such a relationship, then it may take place under an inauspicious cloud of mutual mistrust and resentment. Then there is the treatment itself. Why offer physical treatment for a mental problem? There is limited evidence that physical rehabilitation works [5], but there is limited evidence for a very diverse range of treatments, including hypnosis and herbal remedies, and a consequent suspicion that, if there is a therapeutic ingredient in rehabilitation, it may only be its effect as an acceptable placebo. So why use expensive rehabilitation as a protracted placebo when far cheaper, and faster-acting, placebos are available? A colleague told me, for example, of how an impressive-looking but entirely inert piece of machinery was used to effect dramatic cures on patients with conversion disorder. With all the manifest doubts, it can be easy to lose sight of the heart of this undeniably difficult problem: a sick patient. As a psychiatrist, my first reaction to the questions posed in the introduction was dismay. How, I might respond, could one justify not treating this patient? There are questions to be answered about whether this is the best treatment for the patient, but the evidence base does not allow us to answer that with confidence. We may expect psychiatric involvement to help resolve both the symptoms and the problems that gave rise to them, and thus reduce the risk of relapse, but the evidence for this is slim, and psychiatric involvement may be difficult to arrange [6]. So, given that they are under the physician's care, it is hard to see what principle might differentiate this patient's rights to care from those of any other rehabilitation candidate (insurance companies might have a different view, I imagine, but I will refrain from speculation on what principles they might operate under). The disability of patients with conversion disorder is high; their costs, in terms of care and carer time, can be among the highest; rehabilitation works reasonably well. Our unease and frustration should not enter the treatment equation. And while rehabilitation may be placebo, it may not be. In the complex attitude toward truth under which many of these patients are managed, that is a vital distinction. Covert placebo treatment is unethical, simply put, whereas treatment that only may be placebo is not. Physical rehabilitation is not without risks as a treatment for conversion disorder. The treatment may fail utterly; it may upset the harmony of the ward; it may demoralize the team. But it may also strike that precarious balance in the conflict between the goals of autonomy (as truth telling) and beneficence (as treatment efficacy) that physicians face when managing conversion disorder [3], a balance that risks being thrown off if the treatment itself is covert, as the second question from the introduction suggests. The communication with patients with conversion disorder can be equally challenging for physicians, for all the reasons given above. The diagnosis may be resisted by the patient, sometimes angrily. Although it formally requires a psychiatric formulation to make the diagnosis, this does not let the physician off the hook; referral to a psychiatrist is likely to raise the same resistance. The physician who says that the problem is simply unexplained may be dismissed as incompetent; the physician who says the problem is psychiatric may be seen as implying a psychological failing or that the patient is malingering. A frank exchange thus jeopardizes the therapeutic relationship, which risks the patient walking out, registering a complaint, or worse [3]. By contrast, delaying or even concealing the diagnosis may keep the patient onside, which allows the possibility that a psychological understanding and/or therapeutic engagement may take place over time. So, telling the patient the truth may seem opposed to the patient's therapeutic interests. Most neurologists balance this carefully, judging the degree of disclosure on a case-by-case basis, disclosing as much as the patient's receptivity would allow, but no more [2, 3]. The scenario described is thus unique only in the extent and explicitness of the concealment. The neurologists and physiatrists may hope that the doctor-patient problems would be avoided by such a step. The patient will not feel in the wrong place, will not feel maligned or resentful, and will not resist the treatment. The placebo effect, if that is what the effective ingredient in rehabilitation is, may be enhanced. But the extent of this diagnostic concealment does represent an extremity in the ethical balance: can it be justified? Autonomy has become paramount in the weighing-up of most medical ethicists. Competent patients cannot be treated without their informed consent, even at the cost of their lives; doing otherwise is not only immoral but also illegal in many jurisdictions. However, are patients with conversion disorder competent? They have a mental illness, and one that may arguably affect their judgment about diagnosis and treatment, as shown by their resistance to appropriate therapy, for example. An argument could be made that they are incapable of decisions about their care and thus that their decisions should be made for them in their best interests. That does not seem to be the case here, nor, indeed, have I ever heard of someone doing so. As far as the scenario is described, the patient is being treated as competent, but the facts about the diagnosis are withheld. That is why I have provocatively called this treatment "covert." Although the physical therapy and other interventions were not concealed from the patient, their purpose may have been; whatever the patient agreed to, it does not sound like fully informed consent. Fully informed consent, however, is a counsel of perfection. There are good arguments that it can never be achieved in practice [7]. Inevitably, judgments need to be made about what the patient needs to know, would want to know, and would be able to understand. A commentator cannot judge the acceptability of what was said from afar without a more detailed knowledge of the patient and the encounter with the patient's physician, what was said and what was understood. Arguably, the mistrust in the doctor-patient relationship sanctions a degree of deception [8]. Arguably, the neurologist has no responsibility to deliver a diagnosis that he or she feels unqualified to formally make [3]. But, the details of this scenario, such as we have, suggest that the diagnosis is clear and that the deception is equally so. There are ways in which an element of deception can be justified, although this is increasingly against the ethical and legal trend. In conversion disorder, as in this case, it commonly takes the form of a conflict between beneficence and autonomy, although the deception may also serve to alleviate a difficult patient encounter. The clearly unfortunate outcomes of this case serve as a reminder that what is justified as beneficence may look very different in hindsight. As with much of the management of conversion disorder, the evidence for or against physical rehabilitation with diagnostic concealment is very limited, but the outcomes here are those that a psychiatrist would fear: an initial response then relapse and continuing, worsening medicalization. Although we should not read too much into a single case, such cases unfortunately constitute much of the evidence in conversion disorder management; to justify a concealment this explicit would require at least an evidence base stronger than that. As the resident who was to admit the patient, I was told by my supervising physicians that the patient had conversion disorder but that we would not confront her with or otherwise disclose this diagnosis. They explained that the standard of care in these situations was to avoid informing the patient that there was a psychological etiology to her somatic symptoms. After 3 weeks of inpatient rehabilitation, the patient showed dramatic improvement in her strength, sensation, and gait abnormalities. She was discharged to home with only mild, variable inversion tendencies of the ankle. The pattern of recovery confirmed the diagnosis of conversion disorder, but this diagnosis was never explicitly mentioned in her medical record. I personally contacted an academic physiatrist close to her home, arranged for follow-up with him, and verbally communicated the diagnosis to him. I called the patient 1 year after discharge to follow-up. The patient was not available, but the answering family member volunteered that the patient's ankle inversion deformity had worsened. She had stopped following up with the academic physiatrist with whom I had arranged follow-up. Instead, she had sought treatment by a local orthopedic surgeon. The surgeon had operated on the ankle twice, but the inversion deformity continued to recur. I assumed that this surgeon had not known the underlying diagnosis because none of our medical records stated it. The surgery was presumably based on the assumption that there was an organic cause to her deformity; not only had we misled the patient, but it seems we had unintentionally misled her future health care provider. As a trainee at the time, I continued to struggle with the morality of misleading anyone, much less a vulnerable patient. When I searched the literature, I could find no scientific studies that explored the benefit of nondisclosure versus disclosure in cases of conversion disorder. Instead, I found only references to this standard of care of withholding the truth [1], presumably based on anecdotal evidence but without references even to the case studies on which this was based. I could find only one explicit recommendation against the traditional approach of deception; it was cited and endorsed in a psychiatry textbook published by the American Psychiatric Association [2], but another textbook with the same publisher from the same year and with the same editors continued to recommend nondisclosure [3]. Unsatisfied, I searched through bioethics textbooks, finding only what seemed to be endless caveats to both the "triumph of autonomy in American bioethics" over paternalism and to our "obligations of veracity" [4]. I discovered that our psychiatry colleagues had worked with lawmakers to formally legislate opportunities for deception when dealing with patients with psychosis; I also discovered that these laws do not apply to cases of conversion disorder [5]. Now, as an attending physician myself, I have had to develop my own practice for treating patients with conversion disorder. I have realized that both disclosure and nondisclosure have the potential to harm those involved. Potential victims obviously include the patients; but the physician, the trainees, and the patient-physician relationship are also potential victims. From this case of nondisclosure, I saw the potential harm to the patient from future health care providers being deceived about the true diagnosis. There obviously is also the affront to the patient's autonomy, which, in my mind, is justified by tradition but has been untested by science. I also experienced a crisis of my own moral integrity. Especially as an impressionable trainee, the experience of paternalistically deceiving a patient tempted me to deceive other patients to conveniently achieve a therapeutic end. Now, as an attending physician, if I were to direct a trainee to deceive a patient, I would make the trainee demonstrate understanding of the unique ethical considerations of the situation. Finally, nondisclosure can also harm the patient-physician relationship, which depends on mutual trust and honesty. This is true on both an individual and societal level. For these reasons, it is generally my practice to gently but openly discuss the psychological basis of conversion disorder with my patients. That being said, I recognize that full disclosure of the psychological etiology of the disorder could cause harm. The patient's symptoms could worsen, but the likelihood of this in the short and long term is unknown. Likewise, the probability of recurrence with full disclosure is unknown. In the absence of scientific data, and with at least some support from the subjective literature (albeit the minority view), I have chosen to error on the side of truthful disclosure and respect for the patient's autonomy. Dr Smith has deleted details that might make the patient described in this article recognizable to others, but no details have been altered. The author did not attempt to obtain informed consent from this former patient to publish this case study. Obtaining informed consent from the patient for this case study that explores the ethics of not disclosing the diagnosis of conversion disorder would require disclosure of this diagnosis to the patient. Although the author's current practice is to disclose the diagnosis of conversion disorder to patients under his care, the author cared for the patient as a trainee under the supervision of an attending physician; this supervising attending physician previously explicitly requested that the patient's diagnosis be withheld from her for therapeutic reasons. Furthermore, both the author and the supervising attending physician live hundreds of miles away from the patient; the author believes that disclosing the diagnosis over the telephone without appropriate psychological support capacities could adversely affect the patient's health. The author has chosen to publish de-identified information obtained in the context of the physician-patient relationship to facilitate this discussion of associated ethics, with the hope of benefiting both future patients with conversion disorder and the clinicians who will care for them.