Medical Decision Making: Patient Autonomy vs Physician Integrity
Patient autonomy is the right for patients to make their own personal medical decisions without these decisions being made by the patient’s physician. The professional duty of the physician is to educate the patient as best as practical considering the circumstances about the details of the illness and the diagnostic and therapeutic options which are available. The physician must explain the benefits to be expected in the procedures or treatments but also detail the risks that are also possible and to compare the options with regard to benefit vs. risks. Of course, there may be one option which cannot be left out and that is: to do nothing. The explanation must be in the form of true education, providing the patient the facts that are known and accepted and should not represent intentional physician bias to one direction or another.
Then, the patient decides and informs the physician. But does that end the decision-making process? If the patient makes, to the physician’s impartial knowledge the wrong decision, a decision that may be in the short or long term harmful to the patient, should the physician remain silent? Should the physician, having a professional duty to observe and maintain the trust that the patient must hold in the doctor for beneficence, speak out if the physician finds that the patient’s decision is wrong, inappropriate or harmful? If the physician had known from the outset that such a decision could possibly be to the patient’s detriment, should that option even have been mentioned in the first place? That option, noted above, which virtually all patients are aware and the physician might find as a wrong decision would be to do nothing. Should the physician accept that decision as was made by the patient?
Regarding any decision, should the doctor insist that the patient explain to the physician’s satisfaction, the patient’s basis for the decision? If the physician is dissatisfied with the explanation, then what? Or should the physician, in keeping with patient autonomy, accept and follow any decision made by the patient? Where does patient autonomy end and to maintain physician professional integrity degrees of physician guidance extending to decision rejection begin? That is the question I pose to my visitors. ..Maurice.
posted by Maurice Bernstein, M.D. @ 10:56:00 AM
6 comments
6 Comments:
I'm sorry Dr. B, but I object to the word "impartial" with respect to the clinician's position. The clinician is not impartial, rather they come at the problem from a medical perspective. Medical/clinical science is a wonderful tool, but it cannot be the only tool in decision making: Patients have to factor in the impact that their decisions will have on their lives and on their quality of life. Physicians are just as biased as patients, but their bias (unlike patients') generally comes from a single source.
In answer to your question, the physician is certainly entitled to ask the patient the reason for their decision, but the patient is in no way obliged to answer. The physician can certainly prescribe a course of treatment the patient disagrees with, but they should not then label the patient "difficult and non-compliant" when the patient does not adhere to this.
It is a more interesting question whether a patient requestin inappropriate treatment can challenge physician integrity--I think this is a distinct possibility. The physician, like the patient, has absolute right of refusal of treatment which is medically inappropriate to the patient's situation (though NOT treatment which the physician simply disagrees with on moral grounds), however they must expect that the patient may seek medical care more in line with their (possibly misguided) expectations.
In a final note, Dr B. you often suggest that patients have an equal share in keeping a good and open relationbship with their physicians, for speaking up when the are not happy, for complaining to the relevant authorities if their physician does them wrong. If this is the case, then surely this is a moot question--if patients have 50% responsibility for the relationship, they also have the right to make unquestioned decisions regarding their own care.
PG
PG, perhaps I used "impartial" wrongly in what I was trying to express. You are correct, the physician's evaluation of the patient's decision is certainly not impartial if one is to believe that in order to hold the trust of the patient, the physician's duty in the decision-making process is not toward him/herself (thus the doctor would be "impartial" with regard to his or her own self-interest) but yet must be "partial" toward the patient to assure what the patient's decision is truely for the patient's overall benefit.
With regard to requesting the patient to explain the decision, there are two reasons for doing this. One is in the rare occasion that there may be some question regarding the mental capacity of the patient to make their own medical decisions, one of the tests the physician must apply is whether the patient can rationally explain the basis for the patient's own decision. Otherwise, in the usual situation, the value of hearing the patient's explanation of their own decision is to establish whether the patient fully understood the information provided by the physician and whether some further explanation of the facts or providing additional information to the patient which was missed was necessary. In addition, the patient's explanation may provide the physician with better insight into the social, financial, psychologic or other factors which have contributed to the patient's decision and about which the physician had previously been unaware.
I should stress further that a physician is never obligated to follow any request of a patient which is either inappropriate with regard to standards of practice, therapeutically ineffective, primarily harmful to the patient or
even against the moral values of the physician. If the request is rejected by the doctor, the doctor must make an earnest attempt to aid the patient in finding another physician who will follow the patient's request otherwise without that attempt, patient abandonment may be construed. ..Maurice.
If my family trust teh doctor and intend to remain with him, we have gotten into teh habit of asking... what does the doctor think or how would he respond if it was member of his family.. This does not give up our right to making a decision, but it gives the doctor a chance to put his experience to use...
My orthopedic surgeon just outright says what he would do if it were him... and I believe him.. my mom's eye surgeon told her all of th eoptions and added what he thought was best.. what he would do.
A patient does not have to take a Dr.'s advice, but a doctor whould not be too leary of giving what he would do as part of his advice.. as long as it truly represents his feelings..
leemac
Dr. Bernstein,
You posed the question "Regarding any decision, should the doctor insist that the patient explain to the physician’s satisfaction, the patient’s basis for the decision? If the physician is dissatisfied with the explanation, then what? Or should the physician, in keeping with patient autonomy, accept and follow any decision made by the patient? Where does patient autonomy end and to maintain physician professional integrity degrees of physician guidance extending to decision rejection begin?"
I've done some research on this, and from a legal standpoint, the physician doesn't really have a choice in the matter. The patient's absolute right of autonomy in making decisions regarding their health care evolves from common law and is well supported in case law by numerous court decisions dating back to the early 1900's.
Again, it comes down to the well established and legally recognized principle of informed consent. The physicians' duty is to provide the patient with information on the possible treatment options (including doing nothing), along with the potential risks and benefits of each option. They also may recommend a specific course of action to the patient, especially if the patient requests it. Once they have done this, the final decision on which course of action to take belongs solely to the patient.
Whether the physician agrees with the patient's decision or thinks they made the wrong decision simply isn't relevant. They have no legal standing to reject a patient's decision. Neither do they have any right to browbeat the patient to provide an explanation for their decision. As long as the patient can demonstrate they understand the information they were provided and understand the risks and possible consequences associated with their decision, nothing further is legally required of them.
Of course, if a physician has a personal moral or ethical objection to the specific treatment option chosen by the patient, they have the option to withdraw themselves from the case, but they must refer the patient to another provider in order to avoid the potential issue of patient abandonment.
In response to the previous blogger, it is my contention that it is the legalistic interpretation of autonomy and informed consent that has produced the erosion of trust in the therapeutic relationship. If autonomy is conceived as moral autonomy, along the lines of Kant, the the physician's autonomy provides the duty of the doctor to not only respect, but to promote the autonomy of the patient. Informed consent turns out to be informed refusal which then turns out to be virtually meaningless (here's the form sign here). The opportunity lies in the inter-subjective relational nature of autonomy such that, properly executed, results in a dialogical process of problem-solving jointly. This creates a bond of trust and establishes the relationship as a covenant. This approach is far more conducive to patients getting the care they need and the information they need to choose wisely.
PMC
I would agree with PMC. The conflict between physicians and patients has been set in recent times between paternalism on the part of the physician and autonomy on the part of the patient. What the public may ignore is that the physician also bears an autonomous responsibility to maintain his or her professional requirements of beneficence and safety (non-maleficence) to the patient. These requirements cannot be taken away by any patient autonomy argument. Final decisions of therapy is never one solely based on the patient's autonomous decision. There must be, as PMC, states a joint problem-solving between patient and physician. Without the physician protecting his or her professional ethical requirements of doing a good and avoiding harm and simply succumbing to a view that the patient is the sole keeper and user of autonomy in the relationship will only destroy any benefit to the patient from the essential joint problem-solving. ..Maurice.
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