Limning the Limits

Shortly after I submitted my last post “Limning Autonomy in Surgery” I was contacted by the blog editor letting me know that I had made a typo in my title and that he would go ahead and correct it for me. The problem is that I really do mean to use the word “limn.” When I was at Wheaton College a couple of my professors edited a book entitled Limning the Psyche, so I figured the verb “to limn,” which means to draw, delineate, or describe, was in common parlance. These entries are not an attempt to “limit” autonomy, but rather to draw out what it looks like in the surgical encounter. Indeed, it is as we reach the limits of autonomy in certain situations that we understand its outlines and contours.

The practice of surgery is inherently parentalistic. (Historically paternalistic is the term used, but my wife is also a surgeon. . .  ) For many reasons (which I plan to unpack in subsequent posts) the surgeon’s decision-making takes precedence to the patient’s. I am not arguing that it ought to take precedence; I am merely reporting that it does (c.f. Hume’s fork.) The prime example is the decision that someone is “not a surgical candidate.” This could be due to a tumor being “unresectable” or to the physiologically deconditioned state of the patient, or the narrow margin of improvement a patient could make with an operation. The point is that this is a function of the praxis of the surgeon, which hopefully has been developed in the crucible of residency and through years of experience. Charles Bosk, in his classic text Forgive & Remember: Managing Medical Failure, notes that it is this development of sound surgical judgment that is the most important part of a surgical residency. Surgeons are intimately linked with the outcomes of their patients, and every day is the Catch-22 of cutting someone (for their own good) and the Hippocratic dictum primum non nocere. So we are cautious and, in making a decision who will benefit from an intervention, parentalistic.

But society has rejected paternalism and the abuses that went along with it. Parentalistic actions must be expunged from practice, so all decisions made by the surgeon are open to question. Barron Lerner explored and contrasted the paternalistic / non-paternalistic approach in his recent book The Good Doctor.  One of the results of this is the necessity to define certain interventions as “futile.” Then the hospital can have a futility policy that states that physicians do not have to perform futile procedures. For example, let’s say a family demands that an aortic root replacement be performed on their grandmother who has been deemed “not a surgical candidate” by the cardiac surgeon. The contemporary “way out” of a situation like this is to state the procedure itself is futile, and then invoke the futility policy. The problem that I have with this is that it reifies the idea of a “futile treatment” and pretends to be more objective than it is. There is a tremendous amount of subjectivity involved in decisions like these. The uncertainties surrounding the many variables in play belie precise objective quantification.

A particular surgeon operates on a specific patient on any given day and that event is a performance. We predict outcomes by conglomerating large numbers of these performances and statistically analyzing these data, but I contend that the decision of whether or not a patient “is a surgical candidate” is one that relies on the kind of tacit knowledge that Polanyi described. I am not trying to disparage endeavors to minimize variations in performance nor attempts to capture these statistics in a way to hopefully better understand what exactly our surgical interventions do, I am merely saying that there is much more to it than that.  No matter how well-informed  about an operation a patient is, there is something incommunicable that the surgeon knows that requires him or her to make definitive judgments on behalf of the patient. This is where autonomy hits the wall.

Drawing the line between coercion and persuasion

Is it ever right for a doctor to try to persuade a patient to choose one course of action over another? Some would argue that this is an example of blatant paternalism, even coercion, unethical because it violates a patient’s autonomy. To such people, the doctor’s job is to present unvarnished, unbiased facts: just present the options and let the patients choose. (I would argue that such a position is a repudiation of the whole idea of medicine as a profession, that autonomy viewed in such a fashion makes the doctor not a professional but a shopkeeper, just presenting his wares to whoever will buy. The ethical imperative that is an essential component of a profession is obliterated by such a view of autonomy. But that’s a subject for another post.)

The April 24th JAMA carries a potentially provocative Viewpoint entitled “Evidence-Based Persuasion: An Ethical Imperative” (you can view the abstract and a little over half the article here). The authors classify persuasion under three headings. The first is removal of bias, the correcting of mistaken beliefs or cognitive biases, such as the mistaken belief that the MMR vaccination causes autism; the authors see this as mandatory. The second is recommending options, that is, assessing patients’ values and counseling them regarding which treatment option is most in line with their values; the authors see this as “usually permissible but sometimes inappropriate.” The third is creating new biases, the creating of new mistaken beliefs or cognitive biases in order to persuade a patient to follow a recommended course of action; the authors see this as “normally impermissible but sometimes acceptable in rare cases.” The authors conclude with a discussion of the importance of context, and the statement that “persuasion is an essential component of modern medical practice, and it may be impossible to respect patients’ autonomy without engaging in persuasion.” (!!)

The removal of bias is perhaps the most problematic, because sometimes (often) we find out in medicine that what we thought we knew, was wrong (The short history of medicine: “Ignorance replaced with fallacy”). But I think the authors strike a good balance between ethical and unethical persuasion. The physician-patient relationship is inherently asymmetrical; the patient is exposed (metaphorically and/or literally) and vulnerable, and the physician has great power over the patient by virtue of the trust the patient places in her, power that potentially could be misused for coercion. Absolute dictums regarding where to place the boundary between autonomy-respecting persuasion and outright coercion are impossible; every person, every relationship is too different and complex to make blanket statements that apply to every situation. But the currently accepted absolute dictum that sees the doctor as shopkeeper and the patient as consumer is as destructive to the patient-physician relationship as the coercion it attempts to eschew; and while it may be easier to take a universal, “just-let-the-patient-decide” approach than to make nuanced, thoughtful, difficult, shared, context-driven decisions, it is also contrary to the fundamental nature of medicine as a helping profession.