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WHY A GOOD PRINCIPLE STILL NEEDS A WISE DOCTOR
[This, like all posts on this Practical Wisdom blog, is co-authored by Barry Schwartz and Ken Sharpe]
The principle of "patient autonomy" or "patient choice" sounds like a great principle. It is the principle that dominates the ethics of modern medical practice in America. As patients, we should be fully informed of our medical condition, and make what are sometimes life-determining choices ourselves. Choice resonates with the underlying values of freedom, individual rights, and self-determination that are so much a part of American culture. And no one wants to go back to the bad old days when doctors simply told their patients what to do, sometimes with no regard at all for the patient's own values and preferences. Yes, patient autonomy is a good principle. But sometimes, this good principle and good treatment conflict. And it takes a wise doctor to know how to manage the conflict.
Mr. Howe, a patient in his 30s, had been recovering for three days after the removal of a badly infected gall bladder. Suddenly his temperature shot up and he became short of breath. Dr. Atul Gawande, an intern at the time, remembers being paged. Mr. Howe was in trouble. He barely had any oxygen in his blood even with an oxygen mask on. It looked like Mr. Howe had become septic-that a bacterial infection had gotten into the bloodstream triggering a massive, system-wide response. Gawande called in the resident. She took one look and called for an intubation kit. She went over to Mr. Howe, put a gentle hand on his shoulder, and explained the situation. Antibiotics would fix the problem, but they would take time. He needed to sleep and he needed a tube inserted into his trachea him to help him breathe.
"No," gasped Mr. Howe, "Don't...put me...on a...machine."
The resident warned him: you'll die without this. She re-assured him: it won't be for long. We'll keep you sedated and comfortable. But Mr. Howe resolutely refused. They turned this his wife for help, but she was paralyzed with panic.
Gawande and the resident thought Mr. Howe was making a mistake. He was young, healthy (this episode aside) and had a young family. What to do? Continued efforts to get his consent got nowhere. Finally Mr. Howe tired out, closed his eyes, and lapsed into unconsciousness. The resident sprang into action. She quickly and efficiently performed the intubation. Mr. Howe was soon breathing comfortably. Over the next 24 hours, his lungs improved markedly. Sedation was reduced, and gradually, the machine was withdrawn. When Mr. Howe woke up, Gawande explained to him, with some trepidation, what had happened, and removed the breathing tube. "You had pneumonia, but you're doing just fine now." Gawande waited anxiously for Mr. Howe's response. In a hoarse but steady voice he said "thank you."
Did Gawande and the supervising resident do the right thing? Was proceeding in this way against the patient's express wishes a violation of medical ethics? Was Mr. Howe in a position to make a considered decision? Was his wife? Questions like these-the "who decides" questions-face doctors every day.
Dr. Jerome Lowenstein had been caring for his patient, a man in his 70's, for over a decade. But now antibiotics were not helping the persistent cough and fever the patient had had for several weeks. Lowenstein ordered at CT scan that revealed masses in the patient's lungs that turned out to be malignant. The condition was not curable. Lowenstein explained all this to the patient's wife, who immediately said "you cannot tell him he has cancer." Her husband had experienced bouts of depression throughout his life, and she was worried that "cancer" would just do him in. She assured Lowenstein that if he just told the man that the procedures Lowenstein had in mind were "necessary for further treatment" he would comply.
Lowenstein agonized. He consulted other physicians. He talked to his wife. He talked to the patient's daughter. He talked to a psychiatrist who had treated the patient for depression some years earlier. Finally, Lowenstein decided to honor the patient's wife's request. The patient accepted the diagnosis of "complicated pneumonia." He lived a decent life for most of the next eighteen months. Then he died quietly and comfortably. Did Lowenstein violate a doctor's ethical obligation to tell the truth?
What does the respect for patient choice demand? You might imagine that the ethical doctor will present the data about risks and benefits neutrally, along with her recommendation, and let the patient decide. But it turns out that this can almost never happen. Atul Gawande remembers his first week as an intern when he faced a patient who had had a major abdominal operation a few days before. She was recovering from surgery according to schedule, but she wouldn't get out of bed. Gawande gave her the information to encourage her to make the right choice: getting up would reduce the risks of pneumonia, clot formation, and other complications. She wouldn't budge. Later that day, the chief resident asked Gawande if the patient had gotten out of bed. Finding out she had refused, the resident said, "that's no excuse," and marched into her room. "Hi, how're you doing," he said, and after a little small talk, he took the patient by the hand and said, "it's time to get out of bed now." The patient got up without hesitation, shuffled over to a chair and said, "you know, that wasn't so bad after all." As handled by this experienced resident, the patient had no options. Doctors craft the patient's options all the time to nudge them in the "right" direction. Disrespectful? Manipulative? Madison Avenue in the clinic? Yes. Unless they have the wisdom to do it right, always with the patient's well being at the heart of what they do.
