Who Is Responsible for Patient Health Decisions?

Kevin Sack's New York Times article, p.A14, June 10, 2008, portrays and seems to endorse a philosophy of U.S. medical care which appropriately died in the late 1950s. Under that patriarchal philosophy, physicians assumed full responsibility for patients, including all treatment and connected lifestyle decisions. It was the "don't worry your little head about your diagnosis, disease or treatment, I'll take care of everything since I'm the doctor-expert on your your illness, your treatment and what's best for you" school of medical practice.

According to Sack, The Archives of Internal Medicine Article, authored by Dr. Thomas Sequest of Harvard Medical School, made the point that physicians "do not discriminate in the way they counsel patients." Sequest was quoted as saying "Our one-size-fits-all approach may leave minority patients with needs that aren't being met." Sack cited standardized dietary advice as not realistic for the cultures being advised, including black or Latino patients, apparently under the uncritical acceptance of Sequest's inference that doctors should be conversant with the dietary, lifestyle and health habits of every culture, subculture, ethnic group, religious denomination, race and individual in America.

By the mid-1960s, physicians had changed their traditional patriarchal behavior to recognize not only that patients needed to be told about their conditions, treatments available, and prognosis, but that patients had a right to make decisions about their care which could be inconsistent with advice given by physicians, nurses or health care system. Any adequate review of modern literature on medical ethics, including legal texts reviewing U.S. Supreme Court cases, recognizes the importance of patient autonomy. Patient autonomy, a common issue in biomedical ethics consultations, invokes respect for a patient's understanding of salient facts about an illness, diagnosis, treatment course, alternatives, side effects and downside risks and respect for his or her informed decisions even if those decisions may cause illness and death.

When a patient chooses to eat rice and beans notwithstanding physician advice to eat fruits and vegetables, that does not mean that the physician has not given proper advice. It may mean that the physician lacks time for discussion because he is overscheduled, or that the patient does not have sufficient income, or a safely accessed well-provisioned neighborhood store, to allow the purchase of fruit and vegetables. If a black person chooses foods, practices, activities or medications (or not to take medications), which are not optimal for health, it is the height of condescension to assume that the person did not understand the doctor's recommendation and has made a dumb uninformed choice. And if a Jewish matron (who has been clearly told by her physician about the effect of salt intake on her health)chooses to eat a bagel, salty lox and creamcheese and provokes congestive heart failure, she is expressing her autonomy.

A condescending physician, or one who evokes guilt in patient for failure to follow advice, will find that the that patient will not return.

The physician's job is to apply science to patient communication, care and advice. The patient's responsibility is to listen to and consider that information and advice, and to act consistent with his or her autonomous decision.