Is Patient Autonomy For or Against Us? - Drug Week


By Zach Schepis

Image courtesy of Wikimedia Commons.

Imagine that you are a doctor treating a patient with severe clinical depression. This very same patient has also been diagnosed with lung cancer. Despite your best medical advice, the individual refuses all potential treatments and wishes to be left alone.

What do you do? Should you honor your patient’s decision, or override it with the intention of doing what might be “best” for them?

We have entered the all-too-relevant arena of bioethics and must tread carefully. There is a very fine line between complete patient autonomy and the paternal instincts of a well-informed practitioner.

Betsy Binkowski, M.D., is Board Certified in Internal Medicine. She has 20 years of primary experience treating adults from 18 to death with acute and chronic medical illnesses and conditions. Patient autonomy is a progressive choice that she believes has the potential to foster a necessary responsibility and self-awareness on the behalf of the patient.

“I think the first implication is that the patient is competent to make a medical decision,” Binkowski tells BTR. “It has to be implied that this person can understand the reasoning behind a health care recommendation and formulate a choice after given that information. But the patient has to feel comfortable making the decision, and finally, the patient has to understand there are risks after making a decision.”

The question then becomes not whether autonomy is the answer, but whether the risks outweigh the benefits of personal freedom.

“For example,” Binkowski continues, “if I choose not to have a mammogram every year and I develop breast cancer that is found by the mammogram, could I have changed my outcome by having the test sooner? If an autonomous decision is made, the patient and physician will both have to ‘live’ with the consequences.”

To further examine the issue, it becomes imperative to briefly survey the history of the physician-patient relationship all the way up until the current model that we know today. While we have been practicing medicine as a species for close to 2,500 years, the majority of change in the field has occurred only during the past 100. The birth of our contemporary medical ethics stems from the Nixon era, in which bioethics became legitimated by Congressional mandate. Additionally, new developments occurred in federal sponsored research, made possible by the Kennedy hearings of 1973.

Alongside these advancements followed subsequent triumphs in the name of civil rights, and the political identities of homosexuality and feminism. Furthermore, newly introduced abortion rights granted more legal power for moral choice. The newfound freedom carried well on into the 1980s and ’90s, however, a rise of malpractice suits cornered the medical establishment into an eventual defensive posture.

What we’ve been left with is a drastic shift from physician discretion to increased patient involvement. Where benevolent deception was once encouraged to withhold “detrimental” information from a patient, we now place an inherent value in bolstering patient self-determination.

Kirsten McCaffery, Associate Professor and Principal Research Fellow at the University of Sydney, discovered with her colleagues that complete patient autonomy could prove to be problematic. She tells BTR about her findings recorded in “Supporting Patient Autonomy”, which was published in the Journal of General Interest Medicine.

“If care is entirely guided by patient preferences and choice it may undermine autonomy rather than enhance it,” McCaffery says. “This perspective could suggest an autonomy-supportive professional intervention–for example, a physician challenging a patient preference, [like] a patient being encouraged to face their needle phobia, may increase patient autonomy rather than undermine it. But there are also situations where patients do not have the capacity to make autonomous decisions.”

According to McCaffery these vulnerable patients, often with low health literacy, must be encouraged to grow with the proper support.

“Autonomy supportive physician behavior can be thought of akin to a close friendship,” she explains. “Views are sometimes challenged and preferences influenced in order to help an individual make a supported decision.”

Of course, the inverse can arise in which a patient who defies a doctor’s prognosis does so at the expense of his/her own well-being.

“What if the diagnosis is not what the patient desires?” Binkowski asks. “Many times a patient will ask for an antibiotic –which treats a bacterial infection–when they have a viral illness. I don’t think the ‘wrong’ treatment should be given based solely on a patient’s request.”

Another potential risk stems from eager pharmaceutical companies looking to push their new drugs on an ever-expanding consumer base. As of 2012, Americans spent over $271 billion on prescription medications annually. Total spending on drug therapy amounts to a whopping $300 billion, which is estimated to grow by 5.2 percent in 2014.

Clearly the demand is higher than ever before, but are we really just self-medicating and overindulging ourselves, swayed by the power of multi-million dollar marketing ads for drugs that we don’t need? “In countries where there is direct to consumer advertising such as the US, there is potential for individuals to be manipulated by industry,” says McCaffery.

She posits that such a relational perspective could motivate practitioners to challenge pharmaceutical advertising and thus teach their patients how to spot an apparent bias. Through acknowledging this conflict of interest, patients steadily build a better health literacy.

Ultimately, however, both McCaffery and Binkowski agree that patients hold the opinions of their doctors in a far higher esteem than they do the pharmaceutical industry. So long as the practitioner presents all sides of a treatment option, the patient will never feel misguided.

“I do agree that strong advertising can affect both the physician and the patient,” Binkowski explains. “The physician must be knowledgeable and open to explain to the patient why and how a product works and whether or not it would be beneficial for that patient. The physician needs to be open to suggestions and the patient has to be open and able to understand the medical reasoning for or against a product.”

Regardless of the risk, patient autonomy spurs men and women to realize the importance of self-actualization. With the power rooted in our hands we must choose wisely and continue to turn inward for the answers to our personal health.

“I think the biggest reason for this increase in autonomy is a more educated society,” says Binkowski. “In any decision, the more informed you are the more capable you are of making a decision.”