When is the right time to question a medical decision?
The British Medical Journal and the Academy of Medical Royal Colleges have announced a major initiative “Choosing Wisely” aimed at stopping unnecessary tests and treatments. This is to counter a perceived pressure on the medical profession to “do something” at each consultation. There have been calls for medicines for mild raised blood pressure, anti-depressants for mild depression and unnecessary blood tests to be looked at carefully. The Academy is also urging patients to ask their doctors whether there are simpler and safer options. Professor Dame Sue Bailey is the Chair of the Academy of Royal Colleges and is leading this call to arms.
It is good to see the medical profession encouraging patients to empower themselves by asking questions rather than simply expecting to be administered to. It is also important to acknowledge the pressure on doctors to prescribe and be proactive when often their advice could be more pragmatic and less interventionist. Deborah Orr’s writing in the Guardian acknowledged the pressures on doctors stating:
“It’s important to recognise that doctors can and do feel pressurised into an attitude – caring and empathetic as it may be – that is similar to the market’s “customer is always right” ethos.”
From a medico-legal perspective advising a course of no treatment might seem to be a high risk option but the reality is that if a treatment has no positive benefits and, in some instances, is potentially harmful the no treatment option will be a more appropriate course.
Court decisions such as Chester v. Ashfar and the Supreme Court case of Montgomery v. Lanarkshire this year point to a sea change in the relationship between patients and their doctors. The Courts consistently endorse concepts of patient autonomy. Their Lordships in Montgomery make some compelling statements, for example:
“it would…be a mistake to view patients as uninformed, incapable of understanding medical matters, or wholly dependent upon a flow of information from doctors. The idea that patients were medically uninformed and incapable of understanding medical matters was always a questionable generalisation…to make it the default assumption on which the law is to be based is now manifestly untenable”.
“The social and legal developments which we have mentioned point away from a model of the relationship between the doctor and the patient based upon medical paternalism…what they point towards is an approach to the law which, instead of treating patients as placing themselves in the hands of their doctors (and then being prone to sue the doctors in the event of a disappointing outcome), treats them…as adults who are capable of understanding medical treatment is uncertain of success and may involve risks, accepting responsibility for the taking of risks affecting their own lives, and living with the consequences of their choices.”
With an ever stretched budget and ever increasing demand relying on the patient taking responsibility for healthcare decisions, provided they are properly informed in the decisions they are making, has got to be a sensible and pragmatic way to ensure scarce resources can be better used. By sharing responsibility and encouraging patients to actively take control of their treatment the relationship shifts in a way that is beneficial to all.
To return to the “choosing wisely” campaign: Doctors have nothing to fear from a decision not to treat provided there is a note recording a sound and rational reason for the course adopted. Given the emphasis from the Courts on the role of the patient in deciding their own healthcare the clear note that records that the patient understands the decision will help protect patients and doctors.
The cultural shift that both the campaign and the cases reflect is positive.
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