I’ve got a good one for you.
Who is the better doctor?
Is it the caregiver who–by whatever means–gets her patient on the best treatment, or, is it the doc who communicates the options most clearly?
I ask because the Institute of Medicine has made shared-decision making (or patient-centered care) a major focus of quality healthcare. That sounds good on paper, right? Medical intervention can be burdensome so it’s important to align it with the patient’s goals for care. And, clearly, patient-centric care exemplifies the first tenet of medical ethics–namely autonomy. Though it’s smart to cycle with a helmet or drive with a seat-belt, not everyone shares the same risk aversion.
Enter the second tier of medical ethics, beneficence, which is defined as doing good. There is scientific evidence that certain medical treatments reduce the risk of death. That’s a good thing. Like riding with a helmet or driving with a seatbelt.
As a heart rhythm doctor who implants internal cardiac defibrillators (ICD), the intersection between patient choice and medical benefit comes up often. Clinical trial data tells us that implanting an ICD in “eligible” patients decreases the risk of death. Medical guidelines have set out these benefits. Quality healthcare is that which provides the most benefit. We even have catchy phrases that proclaim such: Get with the guidelines.
Alas, neither the guideline writers, nor the referring doctor, nor the implanting doctor has to have the device implanted in their chest. We don’t have to live with the risk of infection or shocks. This is why I have always felt (even before the Institute of Medicine proclaimed the virtues of patient-centric care) that patients need to understand the trade-offs of an ICD. These shockers come with plenty of trade-offs.
The conflict that comes up in my mind is that presenting the benefits and burdens of an ICD (or any fateful medical treatment) candidly and honestly may lead some eligible patients to decline an evidence-based therapy. In other words, maximizing autonomy–by aligning care with one’s goals–might compromise beneficence. In the case of an ICD, it might mean a patient dies prematurely. That’s huge.
In preparation for my ICD talk at the Heart Rhythm Society meeting I jotted about 1300 words on the matter. The topic was complex enough for me to have asked for help. The essay includes quotes from five thoughtful medical leaders. The quotes are great.
I hope you want to read more. It’s over at theHeart.org. The title and link are:
P.S. Worry not afibbers, there is a nugget there for you.