Thursday, February 24, 2005

Real Medicine Means Honoring Patient Choice

“Here’s a range of treatment options. What do you want to do?” That, according to Bruce Fuchs, the director of the Office of Science Education at the National Institute of Health, is what physicians today are likely to tell the patient. (Newsweek, Jan. 31 2005, p. 9). Presenting patients with a choice of treatment paths and letting the patient choose reflects the growing sense of responsibility that people have for participating in planning their own medical care. “Medicine is less paternalistic than it used to be,” said Dr. Fuchs in another recent interview. A lot of people “recognize they need to be more active participants in their health care.”

For the contemporary physician, giving the patient a choice is nothing less than an ethical obligation. The American Medical Association’s ethics advisor put it this way:

Each individual has the right to determine what medical treatment he or she will receive, including what life-sustaining treatment will be provided for a terminal condition. It is the physician’s responsibility to advocate for the patient’s right to choose any therapy, including alternative or nontraditional treatments, that reasonably may be expected to improve the patient’s quality of life. Source.

Breach of the doctor’s obligation to give the patient a choice of treatment options may constitute actionable negligence. One current text on the law of medical malpractice puts it this way:

In order to obtain the patient’s informed consent, the doctor must tell the patient not only about the alternatives that the doctor recommends, but also about all medically reasonable alternatives that the doctor does not recommend. A doctor does not comply with the duty of informed consent by disclosing only the treatment alternatives that the doctor recommends. Accordingly, the doctor must discuss all medically reasonable courses of treatment, including non-treatment, and the probable risks and outcomes of each alternative. By not discussing these alternatives, the doctor breaches the patient’s right to make an informed choice and effectively makes the choice for the patient. Source.

Giving the patient a range of alternatives and letting the patient choose is not merely a formal legal exercise. It’s good medicine. Behavioral scientists have long known that treatment which the patient chooses tends to work better than the same treatment when the patient does not choose it. The key is that choice enhances motivation. Source. “A fascinating study found that blood donors perceived significantly less discomfort when they were allowed to select the arm from which the blood would be drawn. The lesson is clear: people are happier and more comfortable when they believe they have some control over a process, particularly an uncomfortable one. Often the control handed over is largely symbolic (as in the choice of arm). In other cases, it’s very real: the medical profession has long recognized the value of allowing the patient to make an informed choice about alternative treatments for cancer and heart disease. These are extremely important, high-stakes decisions, and great value is gained by including the patient in the decision. He or she feels less helpless, less hopeless, and more committed to making the process work.” Source.

What does all this have to do with recovery from addiction? About ninety per cent of the current providers of treatment for addiction in the U.S. subscribe to the teaching that addiction is a disease, on a par with diabetes, heart disease, and cancer. But most of those same addiction treatment providers appear unaware of the basic ethical and motivational approach that real physicians today use in the treatment of patients with real diseases.

Real physicians give patients a choice of treatment options, including options that the physician doesn’t personally recommend. Rare is the addiction treatment program where this principle is observed. In most of them, “range of options” means only the choice between the “Big Books” of AA or of NA. Many treatment providers do not know that there are secular treatment and support group options, and when presented with this information, they do not want to hear it. Such counselors are incapable of conducting the kind of informed discussion of pros and cons of different alternatives that is required today in the real treatment of real diseases.

The real medical model of disease treatment requires obtaining the patient’s informed consent. Few and far between are the addiction treatment programs where informed consent is part of the professional vocabulary. Much more common in the addiction treatment business is the view that the addicted patient does not have the capacity to give informed consent, so that the treatment provider not only may, but must make the choice of treatments for the patient. Therefore, when the addiction patient asks about options or declines to follow the provider’s recommendations, the patient is “in denial” and the provider is justified in applying pressure until the patient “surrenders.”

In real medicine, the authoritarian, nonconsensual approach used in many addiction treatment programs today would be considered unethical, unprofessional, and liable to be prosecuted as malpractice. It’s high time that the addiction treatment field caught up with modern medicine and recognized that patients have rights, including the right to a choice of treatments. Giving patients a choice and involving them as participants in their own treatment yields substantially better results in the treatment of diabetes, heart disease, and cancer. Honoring the addicted patient’s choice among treatment alternatives will yield similar improvement in treating the disease of addiction.