I have written a bit in the past about medical ethics. The previous case we discussed involved a Jehovah’s Witness, blood transfusion, and patient autonomy. There is a false dichotomy often drawn between the ethical principals of autonomy and paternalism, with the extremes of both being invoked. On the one had, evil paternalistic doctors want to make all your decisions for you, on the other, patients are given a list of medical options and left on their own to choose what they wish to do.
Both of these are ridiculous. A good physician is flexible and must make rapid judgments about how to approach a particular patient at a particular time.
Mrs. Norman is a lovely 90 year-old woman, caring for an ill husband… She dutifully shows up at my office every three or four months for a check up, and is in remarkable health. She looks no older than 75. Her husband is somewhat bed-bound and rarely comes to the office. So it was unusual when she and her husband were brought in by one of their children. Mr. Norman had a little cough but was otherwise alright. Mrs. Norman had a cough, a fever of 102 F, and a heart rate in the 130s. Despite that, she didn’t look too bad, and minimized her symptoms. I checked her oxygen levels, which were about 95%—not bad, but not entirely normal. An X-ray, to which she assented, showed a very questionable area of pneumonia on the left.
She insisted she felt fine, and wanted to return home to care for her husband. I sat for a few minutes, looked at her and at the data I had, then looked at her age again.
“Mrs. Norman,” I said, “you may have a small pneumonia, or maybe influenza. I know you don’t feel all that bad, but looking at the whole picture, things could go south pretty quickly. I’m going to call the hospital and have you admitted overnight for observation.”
This was a very paternalistic approach, and I’m sure there are those out there who would be horrified. I used my most authoritative voice, and essentially removed the option of her going home. She went to the hospital, was admitted overnight, and I visited her the next morning.
“How are you feeling?” I asked.
“Dr. Pal, I feel so much better, just being here. I…I cannot tell you how happy I am you made me come in.” (At this point she is holding my hand with a ferocity belying her age.) “I never would have come in if you hadn’t made me, and I didn’t realize how sick I really was, especially with Mr. Norman sitting next to me.”
Paternalism isn’t dead. It isn’t even in the ICU—it is a necessary tool that should be found in every doctor’s bag. This elderly woman would never have overcome her guilt of leaving her husband to take care of her own illness. She needed more than permission—she needed the decision taken away from her completely. Is this always the right approach? Of course not. I have many patients with whom a more collaborative model is appropriate. In fact, the same patient may need a different approach at different times.
And the worst part of it all is that sometimes as a physician you take the wrong approach. You make the wrong choice of styles to use with a patient, and the patient ends up making a poor decision. It happens to me all the time. Herein lies the art of medicine, the humanity. Evidence-based medicine is a tool that has revolutionized the science of medicine, but it must still be wielded by a person.
A great post. So many times our patients need “permission” to pull back and take the time to get well.
I see it in the ER all the time. Our doctors write “rest” as a discharge instruction and I am adamant that the patient understand how important that is and spend time telling them why.
Paternalistic (or maternalistic : ) )? Maybe, but people just will not put aside what they perceive as obligations unless told to do so (and often it’s important this is done in front of family members so pressure isn’t put on the patient to do more than they should!)
Working in home care, I saw this sort of thing a lot. A spouse most often, but occasionally a child, who will drive themselves ragged caring for an ill or dementiated loved one. Injuries, illnesses, sheer burnout, all minimized until they themselves either face intervention or cease to function themselves. It’s a common theme.
It’s hard to switch gears from “I’m doing all right” to “I need help”, especially when the change is gradual.
Medicine is a science, practicing medicine is sometimes an art. The same dilemma occurs when confronted by some facts about a patient’s disease. When to tell them and what.
Regards Dr Shock
Nice post and I will take it into consideration.
You might want to double check the spelling of “paternalism” in your title (with all due respect).
oops
What I am tired of is the physicians acting cowardly for fear of lawsuits or harassment charges (or something else along those lines) for being too “paternalistic” or for “not giving the right medical advice”. That’s why it is called MEDICAL PRACTICE. Doctors need to stand up and take a stand and be the model citizens that used to be.
I am also so sick and tired of patients who hear the physician’s advice but it falls on deaf ears because (usually) the patient feels all too often that they know “better” or “more” than the doctor. Hey, who spent the decade’s worth of college in med school? This is why I think doctors need to act like parents sometimes with self-absorbed patients and put their foot down and not take anymore b.s.
Medical ethics normally involves four principles: justice, autonomy, beneficence and non-maleficence. If you correctly judged the difference between beneficence and non-maleficence (do good and first do no harm) in this case you are to be applauded for your skills. The real-life cases are often a trade-off between these principles and autonomy does not always have to rule!
I like it when my commenters have read their Beauchamp and Childress.