Octavio has prostate cancer. His prostate growth is large but localized.
“What do your doctors suggest?” I asked him.
“They sent me to two specialists at the medical center,” he said. “One does robotic surgery, the other does radiation. Each one told me why they recommend their technique.”
“How will you decide?”
“I’ll do some reading,” he said.
“What about the doctor who sent you to them?”
“He hasn’t discussed the choice with me, just sent me to get opinions. I have to make up own mind.”
Out of training for some time, I gather from students and family medical interactions that patient autonomy is now a reigning principle. Here is one definition:
. Patient autonomy does allow for health care providers to educate the patient but does not allow the health care provider to make the decision for the patient.
This sounds sensible, even admirable: no more paternalistic physicians talking down to patients and ordering them around. Yet a closer look shows a contradiction:
1. The second sentence says that patient autonomy “does not allow the health care provider to make the decision for the patient.”
2. But the first one says that patients should decide, “without their health care provider trying to influence the decision.”
Is “trying to influence” the same as making the decision for the patient?
Some would argue that it is: The power discrepancy between the parties makes a doctor’s attempt to influence amount to coercion.
Do you agree, esteemed colleagues, those of you who, like me, treat patients all day? If the choice is between freezing an actinic keratosis, burning it, or using topical chemotherapy, do you just lay all three options out there and ask the patient to pick one? What if your patient works in public and doesn’t have 2 weeks to wait while the reaction to topical 5-fluorouracil that makes his skin look like raw lobster subsides? Can you point that out? Or would that be “trying to influence” and thus not allowed?
You and I can think of many other examples, about medical choices large and small, where we could pose similar questions. This is not abstract philosophy; it is what we do all day.
Look up robot-assisted surgery and radiation for prostate cancer. You will find proponents of both, each making claims concerning survival, recurrence, discomfort, complications. Which is more important – a 15% greater chance of living 2 years longer or a 22% lower risk of incontinence? Will reading such statistics make your choice easier? What if other studies show different numbers?
Octavio chose surgery. I asked him how he decided.
“I talked with an internist I know socially,” he said. “He shared his experience with patients he’s referred for my problem and advised surgery as the better choice. I also saw a story online about a lawyer who chose one method, then 5 years later had to do the other.”
Octavio is sophisticated and well read. He lives near Boston, the self-described hub of medical expertise and academic excellence. Yet he makes up his mind the way everybody does: by asking a trusted adviser, by hearing an arresting anecdote. It’s not science. It’s how people think.
You don’t have to be a behavioral psychologist to know how hard it is for patients, especially frightened ones, to interpret statistical variances or compare disparate categories. Which is better – shorter life with less pain or longer life with more? How much less? How much more? There are ways to address such questions, but having an expert, trusted, and sympathetic adviser is a pretty good way to start. Only an abstract ethicist with no practical exposure to (or sympathy with) actual existing patients and their actual existing providers could possibly think otherwise.
“Let’s freeze those actinics off,” I suggest to a patient. “That won’t scar, you won’t need a dozen shots of lidocaine, and you won’t have to hide for 3 weeks.”
Did I influence her health care decision? Sure. Guilty as charged, with no apologies. When I am a patient, I want nothing less for myself: sympathetic, experienced guidance, shared by someone who knows me and appears to care one way or the other how I do.
Lord preserve us, doctors and patients both, from dogmatists who would demand otherwise.
Dr. Rockoff practices dermatology in Brookline, Mass., and is a longtime contributor to Dermatology News. He serves on the clinical faculty at Tufts University, Boston, and has taught senior medical students and other trainees for 30 years. His second book, “Act Like a Doctor, Think Like a Patient,” is available at amazon.com and barnesandnoble.com. Write to him at [email protected].