Sunday, August 14, 2005

Respect for autonomy, or patient abandonment?

Today's New York Times has a featured piece on patients' role in treatment decisions. In the old days, the doc was the expert: he (they were pretty much all guys back then) might tell you what was wrong with you, and he would definitely tell you what he was going to do about it. You, the patient, were simply to do as you were told. Then came the revolution, powered by the rise of public distrust in the professions, the patient empowerment movement (especially around women's health), the increasing availability of health information from other sources (including drug companies and websites of various provenance), patient distrust of managed care's bottom-line focus, and reports of medical error coverups and conflicts of interest.

Patients demanded more control in decisions about their care. Studies showed that what the physician thought the patient wants, or should want, and what the patient actually wants aren't always the same: patients value outcomes differently. For example, while prophylactic mastectomy indubitably reduces a woman's risk of breast cancer, most women who have tested positive for a predisposing genetic mutation for breast cancer don't choose surgery.

Today, physicians are trained to consider the patient's preferences and values in decisions about treatment. They are taught that patients have the right, and perhaps the responsibility, to take an active role in health decision making. But where's the line between providing the opportunity to decide--if the patient wants it, she can take it--and dumping the decision in the patient's lap? Should the physician lay out the options and make the patient choose? Or should she describe the range of options and recommend the one she thinks makes most sense for the patient, together with a rationale for that choice?

The impact of this question for women goes beyond their own medical care. Studies show that women tend to be the healthcare decisionmakers for their families: spouses, children, and, increasingly, elderly parents.

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