Opinion : Patient Autonomy and Physician Paternalism

Submitted as a position paper for my Med. and Society ethics class:

When a major disease or condition is diagnosed, there are often several treatment options, each with their own strengths and weaknesses. The important question that arises is who gets to chose the ultimate course of treatment, the patient, or the physician. This question is complicated by two other issues in medical care, knowledge and responsibility.

It is usually safe to assume that the physician knows more about the treatment than the patients, and is in a better position to make a logical and rational choice, yet there are pertinent life circumstances affecting the choice that are only known to the patient. While it is always optimal to reconcile these differences with communication, this process can never be perfect. The question now becomes how should the physician explain the choices to the patient (objective vs. subjective) and how to evaluate patient comprehension.

As far as responsibility, a physician can certainly be held legally liable for their decisions, yet it is the patient who ultimately has to live with the consequences of any treatment decision. It is hard to argue that a patient could be responsible for a decision when they don't completely understand the facts however. Physicians also have trouble accepting responsibility after getting overruled by a patient and carrying out a treatment option that they know is not optimal.

This brings us back to the question of what role a physician should play in choosing the treatment options for their patients. I believe that a physician should make every attempt to educate the patient on the condition and the treatment options. They should not withhold any possibilities or outcomes and should explain when the literature is ambiguous or contradictory. Physicians should say what they think is the proper course of action only if they thoroughly explain their choice. They should also give other opinions if requested by the patient. If a patient makes an irrational choice, the physician should explain why this is the case, but should not resist implementing that treatment or putting the patient in any type of duress. If the patient chooses says at the beginning that the physician should just do whatever he feels is best, the physician should still explain what this is and what the risks are, as well as why he would choose that treatment over others.

If the physician is an effective communicator, than the patient will be making an informed decision about their health. If the patient chooses to disagree with the physician, hopefully they will be able to communicate the reasons that decision. Once a consensus has been reached, the physician will take responsibility for the effective delivery of services, and the patient will have to live with the outcome. If the patient chooses to go against the physician's advice, than they are mitigating the physician's responsibility for the outcome of the treatment, although not the treatment itself. These guidelines allow for a patients rights while making the physician's responsibilities clear.