Allan S. Brett

The problem with futility.

Futility is one of the newest additions to the lexicon of bioethics. Physicians, ethicists, and members of the media are increasingly concerned about patients and families who insist on receiving...

When Patients Request Specific Interventions

The issue of rights to health care has generated considerable controversy in recent years.1 Most discussions of such rights center on broad social issues (e.g., the access of certain socioeconomic ...

Addressing Requests by Patients for Nonbeneficial Interventions

PATIENTS FREQUENTLY EXPRESS STRONG PREFERENCES FOR medical tests or treatments of their own choosing, even when physicians believe that those interventions are not beneficial. Physicians grant such requests for various reasons. One compelling reason is to avoid confrontation: patient-physician relationships flourish in an atmosphere of trust and goodwill, and physicians rightly worry that disagreement will threaten those relationships. Moreover, explaining why an intervention is not beneficial takes time. For patients with the common cold, granting requests for antibiotics is far less time-consuming than discussing viral microbiology and harms of antibiotic overuse. Although patients’ preferences are key factors in clinical decision making, a patient’s preference for a diagnostic or therapeutic intervention is not decisive unless a modicum of potential benefit, viewed from a conventional medical perspective, is present. When diagnostic or therapeutic choices are consistent with such a modicum of benefit, patients’ preferences should drive decisions. In contrast, physicians should not provide interventions that do not meet this criterion. Patients are increasinglywilling tochallengephysicians’ intellectual authority. Patients request interventions based on media publicity about new research findings, sometimes before physicians learn about them. Internet sources of clinical information empower patients to make medical judgments independent of consultations with physicians. Directto-consumer advertising prompts patients to diagnose themselveswithconditions tied toadvertiseddrugs. Inone respect, physiciansshouldwelcomethesechanges: clinical encounters involving informedpatientsbecomegratifyingwhenbothparties collaborate to advance patients’ best interests. However, patients who misinterpret self-acquired medical information may request unnecessary or even harmful interventions. Physicians may respond to requests for nonbeneficial interventions not only through individualized clinical reasoning but also by applying practice guidelines. When guidelines recommend against a requested intervention, physicians can appeal to them as external sources of authority and depersonalize potential conflict with the patient. However, guidelines also can be problematic: those who create guidelines may have conflicts of interest, guidelines from different sources may conflict, and applicable guidelines are unavailable for many clinical problems. Patient Autonomy and Professional Integrity Patient autonomy is often invoked to support patients’ requests for specific interventions. According to this perspective, patients’ preferences are always decisive because medical decisions reflect value judgments, and patients are always better suited to choose interventions consistent with their personal values than are physicians. However, this rationale is flawed. Distorting biases may influence a patient’s clinical judgment, and autonomous patients sometimes make decisions that confer no benefit or put their health at risk. Using patient autonomy to justify acquiescence to patients’ requests for nonbeneficial services violates professional integrity. Professional integrityrequiresphysicianstoadheretostandards of intellectual and moral excellence. Physicians achieve intellectual excellence by submitting clinical judgment to disciplined, evidence-based reasoning. Physicians achieve moral excellence by protecting patients’ health-related interests as a primaryconcern,keepingself-interests systematically secondary. Commitment to professional integrity requires that physicianschallenge requests fornonbeneficial interventions.For example, patients may derive subjective value from taking antibiotics for viral infections; however, such value is not decisive intheabsenceofbenefit fromthemedicalperspective.Over time,allowingpatients’demandsforunnecessary interventions to trumpcarefulclinical reasoningresults inanondeliberative, rote practice style that undermines clinical excellence. Patient autonomy is not an unqualified right to choose. A broader view of autonomy includes the ability to understand and apply relevant information in making clinical judgments. Correspondingly, the physician’s obligation is to promote coherent deliberation and not simply to dispense whatever the patient wants. The interpersonal nature of patient-physician encounters is better captured by the idea of respect for autonomy than by an abstract principle of autonomy. This idea underscores the physician’s obligation to consider seriously patients’ values and preferences while protecting their health-related interests.

Managed Competition and the Patient-Physician Relationship

Managed competition has stormed into Washington. It has been widely endorsed by the lay press and powerful groups, and it forms the core of President Clintons health reform proposal1–6. Managed competition was designed to address the problems of cost and access, with a strong emphasis on creating efficient systems of health care delivery. Consequently, recent critiques of managed competition have focused on whether it will control costs and whether it can be implemented in nonmetropolitan regions of the United States7–10. There has been little discussion of how managed competition might affect the patient-physician relationship. However, the .xa0.xa0.

Hidden Ethical Issues in Clinical Decision Analysis

In recent years, decision analysis has been increasingly advocated as a means of solving complicated clinical problems. These problems tend to involve numerous variables that must be carefully weighed before a solution can be proposed. For example, an article demonstrating the application of decision analysis to renal vasculitis and stomach ulcerations recently appeared in the Journal. 1 The rationale for using this method is that intuitive answers to clinical problems may not always be the most accurate. Instead, a decision tree is constructed that incorporates known values about disease frequency, disease mortality and morbidity, treatment toxicity, and accuracy and ill .xa0.xa0.

Prostate-Cancer Screening — What the U.S. Preventive Services Task Force Left Out

A preventive-services task force omitted three key issues in recommending against PSA screening: the impossibility of addressing the probabilities and uncertainties coherently during routine visits, variable management of PSA levels, and a lack of cost-effectiveness.

NEW GUIDELINES FOR CODING PHYSICIANS' SERVICES : A STEP BACKWARD

In July 1998, the Health Care Financing Administration (HCFA) intended to implement a revised and more complex set of guidelines specifying how physicians should code and document “evaluation and management” services billed to Medicare. These services include office visits and hospital visits and are distinguished from surgery and other invasive procedures. In 1996, Medicare payments for evaluation and management services totaled about

Gabapentin and Pregabalin for Pain — Is Increased Prescribing a Cause for Concern?

16 billion, or 40 percent of payments to physicians under the program.1 Before the proposed date of implementation, the new guidelines created considerable turmoil among practicing physicians and were a subject of spirited and sometimes angry commentary in .xa0.xa0.

Psychologic effects of the diagnosis and treatment of hypercholesterolemia: Lessons from case studies

Recent guidelines from the CDC recommend gabapentinoids as first-line agents for neuropathic pain. But some clinicians may be prescribing these medications excessively for various types of acute, subacute, and chronic noncancer pain in an attempt to avoid opioids.

The Case against Persuasive Advertising by Health Maintenance Organizations

Some patients exhibit adverse psychologic responses to the diagnosis and treatment of hypercholesterolemia. These responses are, in part, a function of the patients perception of the distinction between disease and illness and the patients understanding of the probabilistic relationship between risk factors and associated diseases. Moreover, failure to acknowledge some of the specific complexities of hypercholesterolemia (e.g., natural fluctuations in serum cholesterol levels, variability of response to diet, etc.) may result in considerable anxiety. Clinicians should recognize and address these potential sources of dysfunctional psychologic reactions when they counsel hypercholesterolemic patients.