The Mustard Isle of Medicine

Today's Boston Globe has an article about what I have jokingly referred to as the mustard isle problem in medicine. If, as Paul Root Wolpe suggests,

medicine has become a good to be consumed, and where patients are customers to be wooed, informed consent becomes the disclosure of the contents on the back of the box. Informed consent involves discussion of the nature of a procedure, its risks and benefits, and alternative treatments, and is enacted through the modern ritual of free assent, the signing of a contract (1)

then we have the mustard isle problem.

Where at one time the grocery shelf gave us two options, yellow or brown mustard (or, to take the physicians advice or not), we now have multiple rows of choices that must be compared and contrasted. Within these notions of full disclosure and informed consent is the idea that the physician is now merely the grocer pointing you to the shelf of mustard; while they might have a preference, that is their informed decision, and not your own autonomous choice. The physician is now a servitor, called upon by the patient’s need. Increasingly, doctors are seen as being quite literally on-call, and patients have shifted from being patients to becoming clients. (2)

Marcia Angell takes it further, and perhaps less tongue in cheek, than I did. She very clearly highlights one of the bigger problems the extreme focus on autonomy has left us with: doctors bend backwards in an effort to be as neutral as possible, thrusting the entire decision onto the patient, under the pretense that this is what autonomy and informed consent requires of a person. The patient is expected to evaluate all options placed before her, do the necessary research on her own (and doesn't this make you fear Wikipedia even more than ever?), and make a decision that best suits her desires and needs.

While on the surface this sounds like a better option than the overt paternalism of times past, it is simply another form of bad. Amusingly enough, Angell also runs with the grocery store analogy, saying that

deciding how to treat prostate cancer is not the same thing as shopping for groceries. When patients have to take responsibility for important medical decisions, they often feel abandoned and anxious. If the choice turns out badly, they may face self-recrimination as well as worsened disease. Sick people need to be able to rely on their doctors not just for an expert recital of choices, but also for advice about what to do, and doctors should accept responsibility for the outcome.

The expert has become extraneous in our idealized version of society, where information is free and accessible for all. Instead of seeing the doctor as expert who can take their numerous years of education and knowledge to guide us towards the treatment that best meets up with our own goals, we have tossed the doctor-as-expert out with the paternalism-bathwater. 

Like Angell, I have no desire to return to those days of blindly following every order the doctor gives. But I agree that doctor-as-vendor, provider of services, is a problematic model that places too great a burden of responsibility on the patient. We need a return of the expert who will guide us in our choices, understand our wants, needs and desires, and help us realize the treatments and options that will allow us to most maximize our individual life-goals.

(1) Wolpe, Paul Root. Quoted in O’Neill, Onara. Autonomy and Trust in Bioethics. Cambridge University Press, Cambridge; 2002. pp 47

(2) Hills, Kelly. "Towards Affect-Centered Ethics." Unpublished.