Shoutout to lil to motivate me to post this one, It's been a busy few weeks for me. Remember to include why you like your quote!

'In order to maintain coherent debate on the topic of patient autonomy, and to keep this book out of the realms of metaphysics, we must ask the reader to operate under the assumption that human beings do in fact have free will.'

-Taking Sides: Clashing Views on Biomedical Ethics, Fifteenth Edition

I like this quote because in the context of my Bioethics class, it helps us structure debate and immediately sussed out the single Determinist Christian (God already has a plan, nothing we do can change it) in the class. In the context of patient autonomy it provides a fundamental assumption that allows for the creation of an operational framework to discuss how much control a patient should have over their own care. Personally, I believe that every patient should be an informed, and well informed patient, and for any kind of chronic disease that patient should know their illness well and stay abreast of their own care and research in the area of their illness. However we've got a pretty heated debate running in my class which is arguing for a return to a more paternalistic approach to medicine, where you just do exactly what the doctor says and don't expect to understand the issue. Also within my own paradigm I struggle to understand people who don't want to understand their disease, but they do exist apparently.

Shout out time!

blackbootz, xenophon, betta90210, nowaypablo, AnSionnachRua, flagamuffin, JamesTiberiusKirk, b_b, NikolaiFyodorov, ghostoffuffle, humanodon, rob05c, Herestolife, c_hawkthorne, tehstone, beezneez, notbillgates, insomniasexx, briandmyers, AFaucetConk, thenewgreen, rezzeJ, josselinco, mk, blackfox026, mhr, blackfox026, Roycliffe, nishant625, wilkeywoman, delta, ericblank, eightbitsamurai, havires, TheGreatAbider16, water, minimum_wage, pseydtonne, Kaius,

Edit to say that these are AWESOME! I love these threads, the conversation is always really interesting.

JamesTiberiusKirk:

Just curious, are you a medical student?

In a perfect world, I think your perspective is ideal. Unfortunately we live in a far-from-perfect world. Your view requires the following:

-Patients must be able to understand and digest complex medical information, the majority of which simply isn't that clear or even accessible to the average layman. The study that clearly demonstrates superiority of one therapy over another is rare; most are simply various shades of gray that requires a calculus of sorts to come at a decision. The fact is that a not-insignificant number of physicians fail to read research articles critically. These people (we) are, theoretically, smart. How can you expect a layman to do what many physicians fail to do?

-Not every patient wants to know or cares about their disease process. Based on how you're talking about it, you sound like a pre-clinical student (assuming you're in medical school). It will be interesting to see how your perspective changes once you start seeing patients. Many patients want little more than to show up, be told what to do, and feel better. It is the exception rather than the rule for patients to want to know how or why their disease occurs, how our interventions work, etc. etc.. Many young medical students - and I used to be in this category - think that if they can simply distill their medical knowledge to easily understandable terms and make clear the importance of treatment, then patients will "care" about their disease and be more motivated to adhere to therapy. This has not borne out in my experience, unfortunately.

-Tangent about the above note: being in the medical profession - and this is going to sound elitist, I know, but hopefully I can successfully get the point across - you have likely been among a group of peers that is intellectually at the right side of the bell curve. Statistically, you are more than likely from a solidly middle class family; if you're in medical school, it is more likely than not that you have at least one parent as a physician and came from a household in the top quintile of income. I say all this to point out that your perspective of "average" is likely very, very skewed. The people you think of as whatever pejorative you can think of are, more than likely, still above average when viewed in the context of our entire society. Your note about people that "apparently exist" that do not care about their own health not only don't exist but are exceedingly common. I will let you come to these realizations yourself and not beat you over the head with this point, but this is something that you perhaps might consider.

-In my view, people see a physician because they want the physician to exercise their judgment, which they have gained from years and years of training and practice. Let's pretend for a second that 100% of the information on WebMD is accurate and that patients can 100% understand everything presented there or at an even higher quality source (e.g., UpToDate). That is all knowledge that a second year medical student has largely been exposed to. They may not know everything from memory, but they will understand that information. And yet a second year medical student is hardly a competent clinician. More than likely, they'll look like a complete fool once they start their third year. The difference between WebMD and JamesTiberiusKirk, MD is that I have seen tens or hundreds or thousands of patients with the disease you have, and I have treated those patients with a variety of medications using a variety of modalities. I have the ability to pick up on subtle differences that might result in different treatments between Ann and Bob even though to the layman they seem identical. I am more familiar with what various treatments mean and can more likely translate what a patient wants from a treatment into an appropriate medical intervention (I'm thinking of more chronic diseases here where therapy can be a burden). These are not things you can gleam from WebMD. And again - that's putting aside the fact that the average layman can accurately digest medical information (hint: they can't - at least not to the degree necessary to diagnose and treat disease).

In my own view, we have swung too far on the opposite side of the pendulum in pursuit of the "patient-centered decision-making" model. Like you, I agree that patients should be - MUST be - informed about their disease and their various options for treatment. It is the clinician's job to provide that information in such a way such that they are able to make a truly informed decision. We do a terrible job of this in medicine. There is need for improvement. But that said, I also think it's unfair to put this burden at the foot of the patient and say, "you decide." This is doubly true for clinical situations where many different treatment options exist and there is no real winner. Yes, patients should be informed, but I think it's the whole job of the physician to say, "...but this is what we should do." They should listen to and heed patient concerns or reservations about a therapy, and no patient should be forced to do anything against his/her will, but I think it is critically important to understand that patients do not understand - and should not be expected to understand - the myriad of subtleties you learn throughout your clinical training. Expecting them to puts an unfair burden on those folks and could very well lead them to make a definitively bad decision (for a prime example, see how end-of-life care happens in the U.S.).

Hopefully you aren't offended with what I've said, but your view strikes me as hopelessly naive and working under the expectation that your average patient is going to be like you. They will not be. Some will, but they will undoubtedly be the minority. A surprising number of people still don't know what the difference between a virus and a bacterium is, yet you expect to be able to inform them enough to do the calculus required to decide on things like cancer therapies, whether an elective procedure with significant risk (but potentially significant reward) is a good idea, and other clinical quagmires?

Contrary to helping the patient and giving them agency, I think that approach leaves them to drown in what they don't know.

But perhaps I'm just an elitist curmudgeon.

Edit: Having seen the other comments here, it seems I didn't understand the purpose of this post. Regardless, I hope this is some food for thought for the OP and anyone else with an interest in medical ethics.


posted 3566 days ago