Wednesday, September 09, 2009

Autonomy

We have talked a lot about autonomy in the past four weeks of medical school. The basic concept is that the patient is the sole source on what is best for the patient and that the parentalistic days of "doctor knows best" ought to be over.

In the 1950's only 30% of doctors told their patients the full truth about their diagnoses and treatment plans. At that time, it was assumed that it was the doctor's job, with all his knowledge and expertise, to sort out the story and tell the patients what they "needed to know." The doctor was expected to act altruistically, "in the patient's best interest" which he often did, but a lot of assumptions went into deciding what the patient's best interest was.

Now, the patient is king (or queen). The patient's definition of success in a given situation is the working definition.

For example, let's say a Jehovah's Witness patient needs a major surgery that may require a blood transfusion. It is considered a serious offense (to some, not all) Jehovah's Witnesses to ingest blood, including in a transfusion. Potentially risking eternal punishment. In the past, a surgeon who was afraid of losing the patient would transfuse the blood as necessary to save the patient's life. Now, if the patient says that sustaining temporal life at the expense of potential eternal death is unacceptable, it's unacceptable, no blood is given and that is that.

This is relevant to the latest political debate (of which I've only heard fragments, I spend most of my time reading textbooks) about the health care reform encouraging the euthanizing of seniors. According to my professor, this actually all ties together.

Historically, doctors worked to sustain life, period. Up until recent technological advances (50 years or so), that was pretty clear. Now, there are questions being raised about what is the right thing to do? If a patient is terminal, going to die in a few days and wants to leave the hospital, refuse food and tubes and die at home with their family, autonomy says they should have the right to do that.

Apparently, when given the choice, most people say they'd like to die at home. In the 1950's about 50% of patients died in a health care facility. Now, that number is more like 90%. So, why the disparity? Is it "doing harm" to use every last tool in the toolbox to try and sustain the life of someone who is invariably dying? Is that heroic? Is that tortuous? Who gets to decide?

It's complicated. At some level, I'd rather the expert did the deciding. But, as a patient I might have real opinions about how the tradeoff between quality of life and quantity of life works.

Hmmm.


This plays out in a whole bunch of ways. For instance,

1 comment:

Christie said...

I have yet to read anything in the health care reform bill that "encourages the euthanizing" of seniors, but it is true that there are (or were, they might have been removed) sections that dealt with having consultations with seniors regarding end of life care, such as the creation of wills, DNRs, etc.

You and Ron will be able to have an interesting discussion when your two areas of study collide. In the example you gave with the transfusion, if you (the doctor) ignore the patient's wishes regarding transfusions and transfuse anyway, you could be charged with battery. All the elements are there. Thank you very much, tort law!