By Stephen T. Sinatra, M.D., F.A.C.C., F.A.C.N., C.N.S., C.B.T.
“The secret of the care of the patient is caring for the patient.” – Dr. Francis Peabody (1927).
How much say should patients have in medical decisions? Who should ultimately choose what course of medical treatment a patient will undergo – the patient or the doctor? According to a recent study (Chung, et al.), virtually all patients want to be offered treatment options and consider their doctors’ medical opinions; however two thirds want their doctors to actually make the treatment decisions. Such a “deference preference” reflects a crossroads we’ve been reaching in medicine over the past few decades: where exactly, does responsibility for patient health lie – within the patient or physician?
Evolution of Patient-Centered Care
Let’s say you go to the emergency room with chest pain and the doctor suggests a CT-scan after finding a suspicious spot on your chest X-ray. The doctor is not sure whether it is a benign mass associated with the pneumonia you’ve recently had or a blood clot which could cause a fatal heart attack. Since the CT scan can provide a much more detailed image of your lungs through the use of rotational x-rays, the doctor wants to use it to help figure out, what exactly is that spot on your lungs? However, CT scans deliver much higher doses of ionizing radiation than X-rays and increase your risk of developing cancer.
Based on your physical exam and medical history, is your risk of having a heart attack or stroke (from leaving a possible blood clot undetected) greater than your risk of developing cancer (from undergoing the CT scan)? Are there any other, better treatment options?
Rather than decide this for you, as would have been the case until the late 1960s, a doctor is supposed to explain your choices and the risks and benefits associated with each one. S/he needs to do so in a way you can understand and ultimately make sure you “consent” to the procedure.
Commenting on the Chung study through her NYTimes.com blog, Pauline Chen, M.D. explains that, until about 50 years ago, when ethical treatment of patients became a greater social concern, medical care was essentially paternalistic, i.e. doctors simply made all medical decisions. As themes of patient empowerment and respect for patient autonomy began to gain momentum, the clinical ideal, “patient-centered care,” was born. Patient-centered care eventually led totoday’s requirement that patients give “informed consent” for whatever courses of treatment are pursued. While controversy exists as to the boundaries of informed consent, it involves three basic elements: information, comprehension and voluntariness.
In theory, informed consent seems a simple and reasonable concept, yet in practice, the line between patient autonomy and medical expertise is often blurred. “Consent” can mean different things to different doctors: while one doctor may very persuasively explain an option, another doctor might more objectively compare various options to allow the patient more personal choice in the matter. As Dr. Chen explains, in reference to the majority “deference preference” shown in the Chung study, giving patients too much leeway may not be in their best interests, and may actually approach unethical territory.
With the line between “consent” and “choice” still unclear, Dr. Chen writes that situations of uncertainty, where the best courses of action are not obvious, pose the greatest challenges to both doctors and patients. “In these situations, when doctors pass the burden of decision-making to a patient or family, it can exacerbate an already stressful situation,” writes Chen, citing that doctors also grapple with “their own set of worries.” Should they presume to know what their patients really need? Should they present information persuasively to get patients to go along with what they think is best, or be more objective with less attachment to their medical opinions? Will their presentation style send mixed messages to patients and confuse them, if not erode their trust?
“Autonomy,” a Subjective Concept?
Respect for a person’s autonomy, i.e. his or her ability to “self govern,” underlies the informed consent standard. In actual medical decision-making, though, how much autonomy a patient has may depend on a variety of factors. The Chung researchers identified some demographic factors may influence a patient’s preference toward medical decision making: patients who are male, of older age, more religious, and/or healthier tend to want doctors to make medical decisions for them, while patients who are younger, female, university educated and/or in poorer health prefer to decide for themselves about particular medical treatments.
But there are other factors, particular to each individual, which may also shape the exercise of informed consent. These may include the patient’s level of medical /health knowledge, the physician’s awareness of the risks and benefits of alternative treatments, the physician’s clinical experiences, and, unfortunately, the amount of available time and energy the physician has for the patient.
Let’s say a patient has read up on alternative medicine information and wants to explore alternative practices in addition to, or instead of, pharmacologic therapies. If s/he’s seeing a very convention physician who has little to no experience with alternative medicine, his or her informed consent will be of limited nature because the doctor cannot adequately advise him or her. Patients who disagree with a doctor’s suggestion can benefit from seeking second and third medical opinions, possibly from naturopathic or other holistic-minded physicians who, collectively, can help patients make better informed medical decisions.
Also, while patient-centered care and patient empowerment are wonderful medical ideals, they can be difficult to practice when time is of the essence. Often patients need much more time than what the doctor actually has to become truly “informed”; the reality is that too many other patients may be waiting for the same thing.
Patient Empowerment is a Learning Curve
So what to do? There certainly aren’t any easy answers when it comes to the issue of informed consent. While many patients want the ability to choose what medical treatments they undergo, the Chung study demonstrates that many also simply prefer to leave health care decisions to medical professionals. This reflects the potential need for the informed consent standard to remain as loosely applied as it is. As modern medicine continues to move in an integrative direction, doctors can feel out the decision-making process with patients on a case-by-case basis.
But this is not about the evolution of integrative medicine… or is it? As we learn more about how lifestyle choices shape our states of health, the more patients may be expected to take greater responsibility for their health. In time, they should not continue to expect doctors to “fix” them. Our health care system is crumbing under this mentality. However, the widespread need for lifestyle modification has been part of the learning curve which has steered us toward integrative practices, which will take time to reach mainstream acceptance. Fortunately, in this age of information technology, doctors and patients alike can more easily access cutting edge health information to better understand the many aspects of health.
Patient Empowerment is a Shared Responsibility
When both patients and doctors take the initiative to better educate themselves about health, modern medicine stands a much better chance of successfully evolving from the practice of “crisis and disease” to “preventative” care.
References and Resources:
- Chen, Pauline. “Letting Doctors Make the Tough Decisions.” NYTimes.com, Aug. 11, 2011.
- Chung GS, Lawrence RE, et al. Predictors of hospitalized patients’ preferences for physician-directed medical decision-making. J Med Ethics doi:10.1136/jme.2010.040618, published online June 2011.