Sunday, December 3, 2017

Does Patient Autonomy Improve Health?

It used to be that doctors knew best.  We told you what to do and you obediently complied.  The world has changed and the paternalistic system of yore has given way to the shared decision model where patient autonomy is respected.  

The Old Way:  “Well, I’ll be setting you up for surgery soon.”

The New & Improved Way: “Let’s discuss all of the reasonable options with their respective advantages and drawbacks.  Then, you make the call.”

To paraphrase the mantra of Fox News:  Doctors Report – You decide!

Has our current fidelity to patient autonomy improved medical outcomes?  I have no idea.  It has certainly changed patient’s (and our) experience, but I do not know if it has improved patients’ health.   I wonder if doctors and patients who have experienced both systems believe that the current system have improved medical outcomes.

Has anyone measured if the new system is better?

Not every patient wants this level of authority.  I cannot count how often patients have asked me over the years to make the medical decision for them – which I do.  There is an argument that the professional is better equipped to make the right medical choice; but the question is who has the right to make that choice. 

My point is not for us to return to our prior paternalistic pattern, but only to pause and consider if patients have benefited under current norms as much as many believe.

I am certain that attorneys and various consultants can relate to this issue very well.  Lawyers today, for example, generally don’t dictate an edict, but present clients with a range of options depending upon cost, risk and tolerance of legal exposure and the facts.

Why not extrapolate to the next level?   Let the patient make any medical choice he desires despite our medical misgivings.  If a patient, for example, wants a colonoscopy, antibiotics, a heart catheterization or removal of the gallbladder – and they are fully informed of the risks and benefits – why should medical professionals obstruct them?  Doesn’t the patient come first?   

Isn't this how the marketplace works?  Customers buy what they want, not necessarily what they need.   Should I be prevented from buying a premium vacuum cleaner if my current one is adequate?  If I want a contractor to do some remodeling which makes no aesthetic or functional sense, should he turn the job down?  

Yes, you might argue that medical care is different than buying an appliance.   But, if we doctors can refuse an informed patient's request, then aren't we returning to the Era of Paternalism that we claim to have abandoned?

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