Competency?

If a patient has a fixed belief that a treatment outcome includes something not regularly reported for it or commonly experienced by the treating physician, yet this is the primary reason the patient seeks the treatment, should the physician administer it? You’re considering a question of competency – not competency in the legal sense but in the ethical sense of informed choice. Is the patient’s choice for the treatment really competent? What moral responsibility does a physician have toward ensuring a patient understands what they are getting into? There is a fine line between a physician abusing the unequal power across the physician-patient relationship and paternalism.

I don’t have easy answers to this question. Fundamentally why do we have the sense that maybe a physician to act in such a situation might be doing something wrong? Why do we have the sense to not act affronts a patient’s choice?

Does the risk or cost of a treatment matter in such a question? Should how the physician is paid matter? In surgery both the costs and risks can be significant and for years medicine has operated in a fee-for-service model that compels physicians to do more because they get paid more. It is this physician-first, patient-second sense that studies citing the Dartmouth Atlas sometimes intimate and when acknowledged spawn alarming headlines.

The rates of hysterectomy across different parts of the United States are not uniform. Women are far more likely to have a hysterectomy in the South or Midwest than in the Northeast. If, for the sake of argument, women in the South are having hysterectomies without being fully competent of that treatment choice (note an article appeared in Obstetrics and Gynecology in 2000 citing 70% of hysterectomies are without sufficient medical indication – I’m guessing that % has improved over 14 years) are the physicians violating the categorical imperative; using persons as a means to an end and not as ends? Alternatively, to not do these hysterectomies will “hysterectomy eligible” southern women view their physicians negatively, as not delivering good care? Ironically, given today’s emphasis on “patient experience” in physician evaluations, such a view among these women could eventually favor physicians who are less evidence-based. This sort of reason has been proposed for why the surgical robot is misused in gynecologic surgery.

As I said I don’t have any easy answers but perhaps what can be appreciated is the sense that these questions have moral roots. The systems at work in driving better care are rooted in tough moral questions that in a pluralistic society may never have a stable response. It should also be appreciated that there is a balance at work here that can easily tilt in favor of endpoints that are both negative. Respecting a patient’s autonomy (in my example maybe the patient really does know something the physician doesn’t) is balanced against a physician’s duty to not harm the patient and to equitably administer limited health resources (among others). Such appreciation would I hope inspire humility among us all.

 

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