APRIL 28 – Eighteen years out of training, and I still find myself struggling to understand the moral imperatives of medical practice.
Not long ago, as part of my hospital duties, I cared for a man who could no longer swallow. This dysphagia was his only medical complaint, one that had sneaked up on him over the course of a month. He simply couldn’t find the muscular strength to propel food and liquid down to his stomach.
After some investigation, the medical team discovered he had metastatic lung cancer. That explained the dysphagia: cancer had stimulated his immune system to attack his swallowing muscles.
While the cancer was incurable, we hoped we could slow its progression and give him a few extra months of life – small solace for a man in his mid-50s with a loving wife and several children ready to start new families, but it was the best we could offer.
On rounds the morning after he received a feeding tube, I stopped by to see how he was doing – checking his abdomen for signs of infection and, more important, assessing his fragile mood. I tried to keep things upbeat, making small talk while examining his belly. But something about his response, and the look he gave his wife, was troubling.
I looked up and asked him how he was feeling, keeping purposely vague about whether I was posing a medical or a social question.
It was his wife who replied – angrily. She lashed out at her husband for having sneaked off that morning for a cigarette. He glared back and told her to mind her own business.
She looked toward me for support – I was the physician, after all – and I found myself in a common medical quandary.
Was it my duty to tell this patient what to do or, instead, to give him the medical information he needed to make up his mind?
Medical decisions these days are increasingly recognised as being more than simply medical, with the right choice depending in part on the patient’s preferences.
Should a middle-age woman with mildly elevated cholesterol take a statin, for example? That depends on whether she thinks the pill’s benefits outweigh its burdens, burdens that only she can judge: costs, possible side effects and the inconvenience of taking medications.
Should an elderly man have knee-replacement surgery? That depends on how much he is suffering, how much he cares about the risk of surgical complications and how willing he is to undergo lengthy and painful rehabilitation.
According to this new paradigm of preference-sensitive decision-making, doctors like me shouldn’t tell patients what to do (Take your pills! Stop smoking!), but rather should educate our patients about the risks and benefits of their options.
So going by the book, I should have informed my patient about the pros and cons of tobacco.
But I couldn’t stand by, in the role of a dispassionate educator, and let this man hurt himself. Instead, I felt compelled to give him advice that would promote his best interests.
I advised him to smoke.
“You two obviously love each other very much,” I said. Then I turned to his wife.
“I know that you are trying to keep your husband from smoking because you love him and don’t want him to get sicker,” I continued, as I recall. “But those cigarettes aren’t going to hurt him now. If anything, they’ll help him relax. What matters is that you two stick together, because these next few months are going to be really difficult.”
I reminded them that the cancer wasn’t curable, that we were hoping to improve his quality of life, and that the best way to do that was to spend quality time with the people he loved.
Every situation is different, of course. But my duty as a physician is to improve my patients’ lives.
And if I can do that by sharing my perspective with them, however strange or uncomfortable it may sound, then that is what I must do.
Even if it means encouraging them to smoke. – NYT
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Obviously, I wasn't there, so we don't know the full story, but the idea, that this doctor would deliberately encourage the man & in doing so, polarise the man from his wife doesn't strike me as being "in his best interests." ESPECIALLY since it is NOT impossible to give his opinion regarding the pros & cons of tobacco, incl. in the context of this man's quality of life (QOL), in such a way that would have left the final decision up to the patient, who would then be able to take into account his own QOL, which also includes his relationship with his wife.
The reason we inform patients rather than tell them what to do is because we recognise that in the end it is their decision to make, and that any decisions they make has consequences for them. Therefore, it is unfair for us to make decisions for the patients when they, ie. the patients, are the ones who have to deal with the consequences.
And also, by doing so he has undermined the wife's role in caring for the patient by playing the "good guy" in this scenario. A needless exercise, which is plain dumb, as well, since as a doctor, you need their help & co-operation to deliver the best care for your patient, which isn't going to happen now he has alienated the wife.
Honestly, "but my duty is to improve patients' lives."
Isn't anyone else thoroughly annoyed by how convinced this physician is that he knows EXACTLY what is best for his patients, and how he, and he alone can dish it out??
Thanks to his unwanted & unwarranted interference, and completely inappropriate involvement in what clearly is a personal matter, he has possibly caused more damage to the patient's quality of life, all for what? A chance to say I encouraged a patient to smoke for his own good? How lame.