Bioethics, healthcare policy, and related issues.
I haven’t blogged on the developing furor over the New Hampshire physician now being sued by a former patient for telling her – rather brusquely, it seems – to lose weight. But the longer this goes on, the more it seems to me the real problem is being missed.
The facts of this particular case aren’t clear, but apparently the doctor told the patient that if she didn’t lose weight she would suffer consequences to her health and her social life. The New Hampshire Union Leader explains:
Dr. Terry Bennett, who practices in Rochester, said he has “an obesity lecture for women” that is a stark litany designed to get the attention of obese female patients.
He said he tells obese women they most likely will outlive an obese spouse and will have a difficult time establishing a new relationship because studies show most males are completely negative to obese women.
Bennett said he tells them their obesity will lead to high blood pressure, diabetes, heart disease, gastroesophageal reflux and stroke.
My reaction has always been that this is rather out of line, and a patient is not amiss in taking offense. If the doctor actually is making hard-and-fast predictions of this kind, he is going beyond the facts to simply scare his patients into losing weight – not giving them information to make decisions, but deliberately pushing emotional buttons to get them to make the decision he wants, and doing so on the basis of predictions of future consequences he cannot know will be true for each patient. That’s not good doctoring, and it may certainly be offensive – lapses for which the doctor should be held accountable. But this is not what catches my attention about this case.
What is interesting is that the case has been discussed in the media almost entirely as a dilemma pitting the doctor’s responsibility against the patient’s negative reactions, or against the doctor’s liability for offending the patient. The harshest comments have taken the familiar “frivolous lawsuit” tack, while others have asked “how can doctors do their jobs?” if they cannot speak their minds to patients. (The “fat acceptance” community has had a different perspective, but one that has – predictably – been treated as freakish in its own right by the many commentators.)
This response assumes that bugging patients about their health is a doctor’s job. And, isn’t it? I’m not sure that’s so.
The move to the “shared decisionmaking” model of the provider-patient relationship, along with the decisive authority granted to the patient by the law and the autonomy movement, makes “the doctor’s job description” a much more malleable thing than in the past. Patients may simply choose not to address certain issues that are, arguably, unhealthy by some sort of “normal species functioning” physiological standard, but which the patient does not regard as incompatible with their own sense of health, or the curing of which is incompatible with the patient’s other goals. A doctor who insists on harping on some issue the doctor thinks should be an important part of the patient’s healthcare, but which the patient does not want to address, is overriding the patient’s goals for treatment and the treatment relationship – which under the current model of that relationship, the doctor may not do. What doctors are entitled to do is what patients authorize them to do, either explicitly or implicitly. Absent some contrary request, it is probably appropriate for doctors to raise “normal functioning”-type questions with patients when they meet those patients for the first time; there is a presumption in the “standard” treatment relationship, that is, that physiological issues are fair game for doctors, whom patients seek out, after all, because they are trained on precisely those issues. But when the patient has clearly indicated their goals and preferences for treatment – either at first meeting or over the course of an ongoing relationship – the “high autonomy” model requires that the doctor accept the patient’s goals for treatment and focus their efforts accordingly.
The question to be asked is not whether nagging (or insulting) patients is within the bounds of a doctor’s appropriate efforts to get the patient to act in a healthy manner – the question is whether “getting the patient to act in a healthy manner” is appropriately the doctor’s goal or responsibility. That is, the question is whether the treatment relationship and its content are defined by the doctor’s understanding of the health needs of the patient, or by the patient’s own preferences and goals regarding their own health – whether we endorse the “doctor knows best” model or the “high autonomy” model of healthcare goal-setting.
To that question, my answer is an unequivocal endorsement of autonomy. My argument for this position will have to wait (hopefully, for my dissertation, and, hopefully, in the foreseeable future), but the general argument for autonomy is well-known by now. And from this perspective, doctors not only may not attempt to force or cajole the patient into health goals the patient does not value, but doctors also should not attempt to scare, manipulate, or trick patients into health goals – even, arguably, physiologically beneficial ones – that the patient has not endorsed, on the assumption that the patient would endorse them if asked.
All it would have taken for this doctor in New Hampshire to have avoided the whole problem was to have asked the patient “You know your body weight is above average – is that something you want to work on?” Instead, he worked up an entire (almost literal) song and dance predicated upon his patient’s presumed resistance to an issue that he also presumed they would want to address – if only they could make themselves act on the values he assumed they shared with him. All he had to do was ask.
3 Responses to “Unwanted Medical Advice”
September 7th, 2005 at 1:55 PM
Based on what you have written, the doctor was acting like a boorish moron. He may have had excellent intentions, but I think he went too far.
And I agree with you that doctors should respect a patient’s autonomy.
But it seems to me you are leaving something out of the equation here: the patient’s role in this whole autonomy model of the doctor/patient relationship.
Pretend you are a doctor.
You not only have a duty to respond to a particular complaint that a patient volunteers. You also have a duty to take a thorough history and, with the consent of the patient, to conduct a thorough physical exam whenever such an exam is indicated.
If you uncover a condition, such as diabetes, high blood pressure, or chronic obesity, that is health-impairing or life-threatening, you have a duty to inform and educate your patient about the condition and about what can be done.
If it has been your experience that being assertive and aggressive is often a good way of prodding certain patients to examine their priorities and come to terms with their health, then you might feel a duty to be assertive and aggressive. While you know it is easy to go a little bit too far if you choose to be assertive, you decide that the benefits to such an approach far outweigh the costs, such as hurting a patient’s feelings.
Let’s assume, however, that you are wrong. Let’s assume that you have misinterpreted your experience, and your approach, on balance, has in fact been counterproductive.
And let’s say an obese patient comes in and gets the obnoxious lecture treatment from you. What should the patient do?
Should she ignore your advice, and pretty much continue to not address her obesity? Should she sue you, despite the fact that patients are autonomous and are free to ignore any particular doctor and get another opinion? Should she resent you and your advice, despite the fact that you are just a fallible person doing the best you can, as you see it, to perform your duty?
I think if we take the autonomous patient model seriously, then along with the rights you describe there are also certain responsibilities. A patient should expect that a trip to the doctor’s office might entail some unpleasant surprises. A patient should deal with a poor bedside manner not by playing the victim, but by engaging in constructive feedback (unless, of course, the doctor is guilty of serious abuse). And ideally, a patient should be grateful for unpleasant information that is helpful, even if the doctor delivers it in a somewhat incompetent fashion.
In other words, autonomy is a two-way street. If patients are free to make mistakes regarding their health, then doctors should be free to make well-meaning errors in trying to educate their patients.
September 10th, 2005 at 9:44 PM
I think if we take the autonomous patient model seriously, then along with the rights you describe there are also certain responsibilities. A patient should expect that a trip to the doctor’s office might entail some unpleasant surprises. A patient should deal with a poor bedside manner not by playing the victim, but by engaging in constructive feedback
I think you’re right in all this.
Autonomy does put a great deal of responsibility on the patients. If patients control the treatment encounter because they know their own values and goals best, and treatment providers are required to act in keeping with those values, then the patients must communicate those values and goals to the providers to get the right kind of treatment – there’s no other way for the providers to proceed. And patients must also accept that there will inevitably be miscommunications and providers will not be able to give them what they, the patients, want – as opposed to the “doctor knows best” model in which we can hold providers completely accountable for all missteps because the providers define the appropriate treatment and completely control the patient encounter.
However:
If it has been your experience that being assertive and aggressive is often a good way of prodding certain patients to examine their priorities and come to terms with their health, then you might feel a duty to be assertive and aggressive.
This seems to me to be a move back toward the ommipotent-provider model. The goal of the provider is not necessarily to “prod patients to examine their priorities”. The patient may be perfectly happy with their priorities, and have already come to terms with the state of their health (this is what the “fat acceptance” movement is all about). The provider’s role under the autonomy model is to provide the patient with the information and treatment alternatives that are relevant given the patient’s priorities and state of health, and assist the patient in making reasonable choices by the patient’s own lights, and then providing the chosen treatment. It’s almost never necessary to be overly aggressive to convince patients to accept and live by their own values, so getting heavy-handed with patients while playing this kind of provider role seems strange. (And that seems clearly not to be the way this doctor visualizes his role.)
Good points, though. Thanks for your comments.
September 11th, 2005 at 3:16 AM
“[...]despite the fact that you are just a fallible person doing the best you can, as you see it, to perform your duty?”
Just elaborating (nitpicking?) on this point a little bit. One of the key points about being a fallible person and doing your best is that you admit the fallibility and strive to improve yourself.
In a case like this – that means reading the complaint for comprehension, admitting you were wrong, and apologising for real (not a sulky “oh gee, I’m sorry you were offended” faux-apology, which appears to be what occurred, filling in the gaps in the media reports).
If you refuse to do these things when the initial complaint occurs, and insist on pushing your own barrow of hubris to the point of external involvement – then you suck it up and go along to the prescribed medical ethics class, or whatever other action is appropriate to reduce the chances of the error happening again. You don’t bluster around clumsily defending your actions and lambasting ethics education as “touchy-feely school” – these aren’t the actions of someone who believes in the autonomous model.
Great blog, Kevin. Thanks.