Interdisciplinary Ethics Day

Last Saturday, I had the pleasure of attending an interdisciplinary conference between first year law, medical, social work and physician assistant students.  They examined and discussed this case:

http://www.npr.org/sections/health-shots/2015/01/08/375659085/can-connecticut-force-a-teenage-girl-to-undergo-chemotherapy


As it is every year, the discussion was very interesting.  I was struck again about how quickly you can differentiate the law from the medical students - you can do it within a few seconds of hearing them speak.  These are students in the first few weeks of their professional studies - and they already wear distinctive mantles.  This conference (usually held on the first truly beautiful Saturday morning of fall - a tragic thing for all of us) always gives me a lot to think about.  I try not to say too much during the goings on, but here's what I sent off to the students today on the subject of consent, capacity, and doing the right thing. 



1.       Objective Criteria for Determining Maturity – several people made mention of using some objective criteria to decide whether a patient was mature enough to make medical decisions.  Something like that would be useful, but nothing like that exists.  It’s hard to define what we mean by “maturity.”  Any attempt to objectify it becomes arbitrary.  Part of the issue is that the ability to make a decision for one’s self depends not on age or maturity so much as what the decision at hand actually is.  I may not trust a 5 year old to make a decision about chemo, but I would let them decide what to eat for dessert, for instance.  But I wouldn’t let a baby decide what to eat, because they might literally eat poison if it was brightly colored.  And so on. 

Close to the maturity issue, I think is the issue of Informed Consent.  FYI, you can break this down into a few specific questions.  Does the patient have the ability to understand the information they need to make the decision?  (So they need to be able to listen/look/think and also to communicate back by some method their understanding).  Second, can they tell me the consequences of their action?  (for instance, “You (the doctor) are worried that I will die of infection or sepsis in less than a week if I do not take this antibiotic.”)  If the answers to these questions are yes, and you don’t think the patient is being coerced by outside forces (a controlling family member, etc) – then the patient has decisional capacity.  As you can see, if you are very young, you may not meet the first criteria, and if you are delusional you might not be able to fit the second.  However, it’s decision specific.  A patient may have the ability to make some decisions but not others. 

If a patient has decisional capacity, they get to make the decision, even if you think it’s a terrible decision.  That’s our right as autonomous humans.  BTW, law states that if decisional capacity is in question, two doctors need to weigh in and come to consensus on it.  It doesn’t state that it has to be two psychiatrists – although they are often asked to assess capacity/competence (“capacity” is the more PC term) because it comes up not infrequently in patients with significant mental illness.  Any licensed physician can assess decisional capacity. 



2.       Protecting Patients from their own Regrettable Decisions.  I saw a trend for the law and medical students to come down on different sides on this.  Apart from the question of letting patients make bad decisions is the issue of how hard we should try to convince them to decide otherwise.  This process is part of that mysterious “art of medicine” that you hear doctors talk about.  You’ll never read about how to do it or where the line is in doing it in a book.  You will deal with the impulse to do this with almost every patient.  So, here are my two cents. 

Your ideas on this will change as you practice.  When I was a student/resident/new practitioner I tried very, very hard to get people to make what I thought was the best decision.  I think just about everyone who saw me doing this would have given me an A for effort.  The problem was that even though my effort was massive, the results were anemic.  The truth is, as a doctor, you can lean and lean and lean on someone until you force them to say “ok, I’ll do it your way.”  And they may actually do it your way for a while.  But then they’ll get out from under your thumb at some point, and guess what happens then?  They do what they want.  AND they no longer will come back to see you – because you and they, they have correctly surmised, do not see eye to eye. 

People need time to figure things out for themselves.  Sometimes they have to see things for themselves.  Educating someone about their problem sometimes takes many visits over long periods of time. Sometimes they need time to talk to other people and let things sink in, etc. etc.  There are very few times in medicine where people must follow your advice immediately.  So when people choose a course that I think is a mistake, I let them know that they should keep checking in with me to see how they are doing and then, if I think they have decisional capacity, I let them do what they want.  I have learned a lot about medicine this way, because many times something I thought was a terrible decision turned out to be a good one for the patient in the end. 



3.      No fighting.  If I can tell you nothing else, it’s that if you are fighting and arguing with a patient, you are doing it wrong.  I think if you really can’t disengage and in good faith live with a decision your patient is making, you should recuse yourself from the care of that patient.  I would tell you though, that when patients realize you’re still on their side even though you don’t love what they are doing, they really appreciate it.  Knowing that you support them without judging the way they are running their life often opens the door to them listening to you and trusting you more.  It’s through this kindness that patients will sometimes change their minds and consider doing something much better for themselves!