- 26 November, 2012
By Mehrnaz Hadian, MD, 1L Southwestern Law School
Dr. Conrad Murray, who was convicted of involuntary manslaughter, became the poster child for doctors who blindly follow patients’ leads and pay a price. Even Michael Jackson’s death has not deterred some doctors from similar practices. Recently, another physician, Dr. Lisa Tseng, has been charged with murder for overprescribing drugs resulting in death of her patients. So why do physicians agree to provide medically inappropriate treatments upon patients’ requests?
Remember the public outrage over the Octomom, Nadya Suleman, a single mother of four and on welfare, who underwent in-vitro fertilization (IVF) and gave birth to her octuplets, all at taxpayers’ expense? Unlike other cases, money couldn’t have been her doctor’s primary motivation. After all, she had no money. According to Suleman, she didn’t want any of her embryos to be “destroyed.” Therefore, she “insisted” her doctor implant them all (twelve embryos) at once, resulting in a very high-risk pregnancy. The California Medical Board found the doctor in an “extreme” departure from the standard of care and revoked his license. IVF requires large doses of hormone therapy that can be detrimental to a woman’s health. The general consensus is that the procedure should not be done when a woman already has four children. According to Lawlor and Nelson in their article Effect of Age on Decisions About the Number of Embryos to Transfer in Assisted Conception: A Prospective Study, the maximum number of embryos implanted at once should not exceed two or three, due to the high risk imposed on mothers’ and babies’ lives associated with multi-fetus pregnancies.
Suleman’s doctor’s conduct is no different than Dr. Murray’s or Dr. Tseng’s. In fact, had Nadya Suleman died as a result of her high-risk pregnancy, her doctor could have easily ended up behind bars. Interestingly, the public outrage in Suleman’s case was mainly about the cost imposed on taxpayers. It seemed like nothing would have been wrong if she was able to afford it all. Of course, that could not be further from the truth.
The real issue in such cases—and many others that do not make it into the news—is a health care system that reduces the sacred patient-physician relationship to a customer-business model, where the primary goal often becomes making customers happy. The reason for such practices may be to avoid having to go through frivolous lawsuits, negative publicity, or complaints to regulatory bodies by “dissatisfied” patients. However, it is often justified by the patient’s right to autonomy in medical decision-making, a Patient’s Bill of Rights adopted by the American Hospital Association in 1973, available at http://www.patienttalk.info/AHA-Patient_Bill_of_Rights.htm.
The Patient’s Bill of Rights protects patients from doctors’ unilateral decision-making authority. It gives patients the autonomy to choose or refuse a treatment, once it is presented as a medically appropriate option. It does not give a patient the right to demand a treatment that is not indicated. Regrettably, the public’s misunderstanding of the law, and doctors’ willingness to comply has taken us down a dangerous path. The definition of patient autonomy, in the eye of the public and many health care providers, has changed from the patient’s right to choose between (or refuse all) medically appropriate treatments to the patient’s “right” to demand and receive whatever treatment he or she “wants,” no matter how ineffective, non-beneficial, or harmful it may be.
For example, a patient’s family may insist to keep a patient on “life-support,” after doctors determined such invasive measures would no longer be effective. Knowing that the goal of treatment is no longer achievable, the patient’s family may still insist doctors to “do everything” under the name of patient autonomy. However, the true reason in many cases is that the family is not ready to let go of a loved one. Therefore, it is willing to put the patient through unnecessary pain and suffering at the end of his or her life. In such cases, it would be easy for a doctor to comply with the family’s request, but it would not be the right thing to do for the patient. Doctors must educate patients (and their families) on the meaning of patient autonomy, and the principle of “do no harm” in medicine. According to the Uniform Health-Care Decisions Act section 7(f), A physician is not obligated to provide ineffective, non-beneficial, or harmful treatments simply because a patient has asked (Unif. Health-Care Decisions Act § 7(f) was adopted by California as Cal. Prob. Code § 4735). A physician should convey this clearly and compassionately to patients and their families. This approach was adopted by the American Medical Association in Opinion 2.037, which discusses its “policy on medical futility in end-of-life care,” available at http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion2037.page.
As physicians, when we agree to deviate from appropriate practice just because patients ask or insist, we have started going down the path of least resistance. It is often much easier to give patients or their families what “they want” to “make them happy” as some physicians say. However, that is not a responsible way of practicing medicine. That path of least resistance can take us easily to the point of no return. It can destroy a professional career, and sometimes put us behind bars. But more importantly, it will hurt our patients, whom we have a fiduciary responsibility to protect, and never knowingly to harm.