01(23): The over-emphasis of patient autonomy under the guise of patient-centred care

One of my modules this semester is titled “Communication for Improved Patient Care”. Yesterday, we had a lecture from 1-2pm, followed by a workshop from 2-4pm. The theme for this week was “Creating the right therapeutic environment”.

When delving into the realm of medical ethics and the nature of the relationship between doctor and patient, it behooves us not to neglect the work of Beauchamp and Childress. I quote from reference [1]. They are American philosophers best known for their work in medical ethics. Their book Principles of Biomedical Ethics was first published in 1985, where it quickly became a must read for medical students, researchers, and academics. The book was written in the wake of some highly unethical biomedical experiments – most notably the Tuskegee Syphilis Study, where hundreds of rural black men, their partners, and subsequent children were infected or died from treatable syphilis. Beauchamp and Childress aimed to identify healthcare’s “common morality”.

The four principles that they established were: 1) Respect for autonomy; 2) Beneficence; 3) Non-maleficence; 4) Justice. With these principles, it is not difficult to see why the Tuskegee Syphilis study was deemed outrageously unethical. Some will claim that morality is subjective and that the weighing of these different ethical principles, which are often in tension with one another, is subjective. What I will talk about in this post is not about whether these principles are valid. Debating the innate fundamental validity of these principles, or even whether morality is subjective, is something probably best left to the devices of philosophers and theologians. In this post, I instead make the assumption that these four principles are all valid principles to be considered in the context of modern evidence-based medical practice.

During the tutorial, we were told to get into pairs or trios, as part of one of the initial activities, to discuss the question: “What is meant by patient-centred care?” I started by first sharing with my group partner how the term is somewhat self-explanatory. Patient-centred care would just mean placing the patient’s needs and welfare above all else to ensure optimal patient outcome. It’s so simple. What could possibly go wrong?

Reality is not so straightforward. The tutor voiced her disagreement regarding one of the points I made (I shall elaborate on this soon) in front of the entire tutorial group during the tutorial. The disagreement probably stemmed from misunderstanding as there wasn’t enough time for me to fully explain my views. Hence, I have written this post.

The impression I got from her was that she views patient autonomy as being the most important thing to consider in the context of “communication for improved patient care”. Understandably, she might feel this way due to the nature of the topic and perhaps, even some past experience where she feels that her autonomy should have been emphasised. I am not her and I cannot say with certainty what she thought, and so I’m merely speculating.

In the context of patient communication, we cannot directly control the minds of patients and influence their responses and behaviours. What we can change, however, is what we can do on our part (eg our diction, our tone, our body language, our holistic response). For example, you may encounter an unreasonable patient who raises his voice and shouts at you during the consultation. In such a scenario, it would be inappropriate to respond likewise. Raising your voice at the patient as a way to vent your frustration will likely land you in trouble. It will likely provoke an even more emotional response from the response, and this will not help in de-escalating the situation at all. The last thing you want is a letter of complaint from the patient which ultimately gets you berated from your superior, which might in turn cost you your job. What you can do, however, is to insist on behaving in a professional manner and adhere to a standard of decorum which is expected of a medical practitioner.

While optimal patient care requires both the patient and doctor to play their part, the sole focus tends to be on what the doctor can do, at least for this particular module I’m currently taking. After all, the patient tends to be passive while the doctor tends to be active. Some people talked about the power differential between the doctor and patient; some talked about the state of vulnerability of the patient.

I talked to my group partner about a hypothetical scenario where there are two treatment options for a patient’s condition. Let us suppose first that hypothetically, all options work equally well given the patient’s condition, and that treatment A and B cost $50 and $100 respectively. Patient-centered care in this context would mean explaining to the patient that both options work equally well and that treatment A costs less than B. The rational patient would likely choose the former option since it is more affordable and it works just as well as the more expensive option. Everyone lives happily ever after. Simple, right?

Let me now introduce you to something slightly more realistic. What if Treatment B works better, and that it improves the patient’s quality of life more than A? You explain how both treatments to the patient and the patient gives informed consent to proceed with a particular treatment. The patient’s autonomy is respected. Even if the patient rejects either treatment, the doctor accepts it and the patient’s autonomy is respected, and everyone still lives happily ever after. Still simple, right?

I talked about this issue with my group partner. Specifically, I talked about how certain medications can be administered to lower peripheral vascular resistance, so as to treat hypertension by lowering blood pressure. Blood pressure in our bodies is governed by the equation BP (Blood Pressure) = CO (Cardiac Output) * PVR (Peripheral Vascular Resistance), which can be further broken down to BP = SV (Stroke Volume) * HR (Heart Rate) * PVR. There are so many things you can do to influence blood pressure in the body. Let’s talk specifically about PVR (Peripheral Vascular Resistance).

With the equations above, you can lower BP by lowering the vascular resistance. There are at least three ways you can lower the PVR.

According to a doctor who knows well how hospitals in Singapore operate, treatment 1 is relatively affordable. Treatment 2 is moderately priced. Treatment 3 is relatively expensive. In Singapore, at least, Treatment 1 tends to be given more in public hospitals whereas Treatment 3 tends to be given more in the private hospitals. These treatments have different levels of effectiveness in people with different conditions. Do you see the different principles at play here? As much healthcare providers would like to provide quality patient care, there are other considerations, particularly so for public hospitals which have more red tape and standard operating procedures. Resources are scarce and subsidies are limited. Who gets to decide what constitutes an equitable distribution of resources? How much subsidy should a patient receive? Means-testing? How then is the criteria decided? There are endless questions one can ask. Many stakeholders are involved, and the ever-changing laws and advancements in medical technology just further complicate matters. These issues cannot be analysed as though they constitute a static cross-section in the moving tubular fabric of time.

Still manageable? Well, let me now bring you to murkier waters. I want to discuss informed consent, which is a sacred cow in healthcare. There is information asymmetry between a doctor and his patient, and this was the point of disagreement and contention between my tutor and me. I said that a doctor is likely to have a far better understanding of the patient’s condition than the patient, and objectively speaking, it is the doctor who has a much better chance of making the informed decision. After I raised this, she immediately said that she disagreed. She talked about how the patient also considers the non-medical aspects of his situation. For example, in deciding which treatment to get, or whether to even get treatment, a patient would also consider whether he would be able to cope with his work/daily activities as he would have to deal with the side effects of the treatment. Finances are involved too. Medicines can be quite expensive and insurance plays a huge part. Insurance policies are notorious for their fine print and it doesn’t help that there are so many types of insurance policies. The patient’s policy might not cover a particular treatment. In this aspect, I agree with the tutor regarding how the patient is and should able to make an informed decision because of two reasons:

1) There should be respect for patients’ autonomy.
2) The patient knows and understands the non-medical aspects of his life more than the doctor. In this sense, the patient can take into account the medical and non-medical aspects of his life when making a decision whereas the doctor will only have a superficial understanding of the patient’s non-medical aspects. Regarding the non-medical aspects, the doctor is limited by what the patient tells the doctor. However, the caveat is that the patient’s understanding of the medical aspect of his condition is limited by how much his doctor tells him about the condition and how much the patient understands what the doctor is telling him.

However, there is one factor that we cannot neglect in the above scenario:

Externalities.

If my tutor insists on the notion of giving utmost precedence to patient autonomy without carefully weighing the impact of these externalities, I would have to respectfully disagree with her stance. There are externalities associated with different treatment options or rejection thereof. These externalities can be positive or negative, and externalities bring us directly to the heart of the tension between the four principles. If patient autonomy were given utmost precedence under every circumstance, the issues of anti-vaccine groups, abortion, euthanasia would not even be controversial. In Singapore, it is compulsory for a child to be vaccinated against measles and diphtheria. If patient autonomy (in this case, the parent decides on behalf of the child) were to always take precedence, why is it then legally mandatory for children to be vaccinated against measles and diphtheria? After all, shouldn’t they have the right to reject the treatment? Haha.

These are highly contentious issues, and we need to remember that patients’ decisions regarding medical treatment often do not just affect themselves but also the people around them, the general public, and even another powerless entity whose life depends on the patient (in the case of abortion).

In addition to the issue of externalities, another thing for us to consider is the power differential between doctors and patients. When you go beyond the clinical setting and consider the big picture, saying that doctors are always in a position of power and authority over their patients is an oversimplification. Patients have ways of getting back at their healthcare providers in the form of complaints, litigation, etc. Allow me to quote from an article entitled “Things are looking up for the medical profession. Really.” written by Salma Khalik, Senior Health Correspondent, published on 21 March 2019 by The Straits Times (reference [4]), regarding the case involving a $100,000 fine:

In January, a doctor was fined $100,000 for not telling his patient about the side effects of a steroid jab, which is fairly common injection. The disciplinary tribunal said it was the correct treatment, but took exception to his not telling the patient about the possible side effects, which she suffered from. An expert witness during the hearing said that while it is good practice to do so, not all doctors do, since the side effects are both rare and transient.

The judgment and the size of the penalty upset doctors in both the public and private sectors. Some wrote in to the Forum pages, others signed a petition to the MOH, and the subject was also raised in Parliament.

In the light of the two recent cases in Singapore, we see that doctors don’t take that high-and-mighty role all the time. Even when they act reasonably in good faith, they can be subject to disciplinary tribunals, litigation, and can be meted out with unreasonably harsh penalties. Do we really want to see defensive medicine in Singapore, where doctors order excessive tests, create more paperwork and forms to sign, spell out the comprehensive list of side effects for even ubiquitous drugs such as paracetamol to avoid getting sued and avoid having to pay exorbitant sums of money? This will only bloat the healthcare sector, particularly the public sector, with more inefficiency, smother everyone with red tape, and ultimately cause healthcare costs to skyrocket.

In conclusion, while I do believe that patient-centered care is a noble objective that doctors must strive for, it is quixotic to take this to the extreme by insisting that the patient’s desires and views must be at the forefront at the expense of other factors that need to be considered. Respect for the patient’s autonomy is one thing, but what about beneficence, non-maleficence, and justice? The needs and limitations of other people, in addition to his patient, need to be considered carefully as well. These principles are often in tension with one another and drawing the line is not easy. Patients should acknowledge that the doctor does not have an easy time as the doctor needs to carefully weigh all these factors because he is not just accountable to his patient alone; he is also part of a network of healthcare providers which is responsible for the healthcare of an entire population.

Yours faithfully,
Nicholas Loh
22 March 2019

P.S. (2019-03-22, 2:16pm, ACDT) One of the readers of this post, a medical student, has given valuable feedback. He talked about how in the context of Singapore’s healthcare, some older patients are more accustomed to medical paternalism, and I think it is good for medical students to be aware of this. Hence, they can be somewhat shocked when they are confronted with “choices”. They have grown used to having the physician as the authority figure who knows what is best for them. Hence, they can be taken by surprise. What is the physician then to do? Can there truly said to be “informed consent” in this scenario? I contemplated discussing in this post the Bolam and Montgomery tests. However, I decided against it as to do the issue justice would require a separate blog post!

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