Autonomy, Paternalism and Colleagues Gone Wild

crossposted at Two Women Blogging

Angie asked me to write about that strange story from New Jersey – the one where a surgeon placed a temporary tattoo on the abdomen of a young woman, without her knowledge or consent, while she was anesthetized for back surgery. I’d read other blog posts on the topic but I just read the story itself for the first time, and was kind of stunned to realize that the surgeon admits he did it.

Kirshner does not deny placing the tattoo – and has left washable marks on patients before to improve their spirits, his lawyer, Robert Agre of Haddonfield, said last night. He said none has complained.

To improve their spirits? He actually said that? The article goes on to say that the surgeon is offended by being sued because of the implication that his actions were “prurient”. He’s offended? Wow. Just, wow.

I agree with everything Brown Shoes said: this is troubling because it is sexist, and also because it raises a deep concern about the actions of doctors who can’t distinguish between their own desires and their professional obligations. And I also agree with PhysioProf about the culture of arrogance that still pervades medical training, especially surgical training.

Everyone I’ve read on the subject, even the ones that don’t think this sicko’s action is “all that bad”, have taken for granted that patients have autonomy, both bodily autonomy and autonomy of action. It’s a given, a fundamental tenet of medicine, right?

Maybe. The three pillars of American medical ethics* are patient autonomy, benificence and non-malificence. We accept that patients have the right to accept and refuse medical procedures and (as long as they retain the capacity to make decisions) they have complete autonomy over their treatment. We also act in their interests only (benificence) and do not ever act against their interests (non-malificence). (I believe that participating in drug company marketing violates the non-malificence tenet, but that’s a rant for another day.) I learned those three terms in the first week of medical school. Everything I’ve done since then, every conversation I’ve had about withholding or withdrawing care, every DNR order I’ve signed, every time I’ve talked with patients about surgery or screening tests, has been informed by those standards. But if you look at the sweep of history, they are almost brand-new.

Current thinking about medical ethics developed in the 1960s and 1970s in response to the explosion of medical technology and the demand for increased patient involvement in care. For a profession that claims Hippocrates as an ancestor, forty years is the blink of eye. My grandfather practiced medicine from 1927 to 1980. He started compounding arsenicals for the treatment of syphilis, and using creosote for coughs, and retired in the era of ICUs, CT scans, MRIs and pacemakers. But the real revolution in his professional lifetime was the acceptance of patient autonomy. That not-so-simple idea has changed medical practice more than all the technology put together.

Despite the widespread acceptance of patient autonomy, paternalism is not dead. I do believe this particular loon is a one-off, a deeply troubled man who deserves censure and probably also needs help. But PalMD is wrong when he writes

The days of systematic pathologic paternalism on the part of doctors is long gone. It may linger in places, but it’s just not part of the culture anymore. Doctors are authorities. We know things that others do not, and use that knowledge to help people. We have an unequal part in the doctor-patient relationship which is potentially (but rarely) abused. To level this relationship senselessly, to claim that doctors have no different skills or knowledge than others, is to abandon our responsibility to our patients. (emphasis mine)

In the first sentence he announces the death of paternalism and in the third he brings it back to life. I am not an authority, and neither is he. I may know more about the pathophysiology of insulin resistance than the patient I saw at 11:00 AM today, but she is the authority on her diabetes. She knows how it affects her life, how her sugars react to what she eats, how her body responds to the medications I’ve prescribed. We are in an unequal relationship, but I have to work to overcome that in order to help her. It’s not enough to sit on my stool and be confident that I’m not abusing my position. I have to recognize the ways in which that power imbalance interferes with my patient’s health, and figure out a way around it.

The asshole who placed a tattoo on a young woman’s body may be an anomaly, but our colleagues who still place themselves above their patients are legion. We need to recognize all the ways in which we deny our patients their true agency. I am grateful to those who went before me – including a bunch of second-wave feminists – who started this conversation, and I will continue to honor them in my work and my daily life.


*By “American medical ethics”, I really mean “mainstream-English-speaking-mostly-white-American”. Other cultures, including many with a substantial presence in the US, hold very different beliefs about the role of the patient and the physician, and about the role of the family and community in decision-making. My obligation to autonomy also obliges me to figure out what that means to each patient and how to honor each person’s values without compromising my own. Other countries, even Western European countries, strike a different balance among individual autonomy, social stability and resource utilization. The ethical structure I describe here cannot be assumed to apply elsewhere – or even everywhere in the US.


One Response

  1. Excellent and thoughtful post!

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