The Amazon on the left here is Themis, also known as Lady Justice. It appears that, like me, she’s missing most or all of her right breast. She’s also fit and carries a weapon, like any good Amazon. She’s here because I am constantly astonished at how many of us do not know or understand the concept of informed consent. We submit to slashing, burning and poisoning to rid ourselves of cancer, often enduring permanent deterioration of our quality of life. Yet we don’t even comprehend this bedrock concept of medical legality and ethics, nor demand that it be consistently applied to us by our doctors.
Lady Justice was “blind” so she could weigh all options and evidence fairly. But we needn’t be. I work as a physical therapist, and believe me, we studied informed consent in great depth in grad school. It’s not always easy to get my patients to let me carry it out. Let’s face it. We all want someone to just fix us, to wave a magic wand and make us all better. When a doctor evaluates our respiratory symptoms and gives us a prescription for a drug that makes our cough and fever and sniffles go away, it may seem like she’s waved a magic wand. But whether we acknowledge it or not, we give our consent to our doctor’s treatment as soon as we agree to get the prescription filled and take the medication. There’s no magic involved.
With physical therapy, “audience participation” is de rigueur. I can’t prescribe magic pills and I can’t do my patients’ exercises for them. So it is essential that I get my patients to assume responsibility for their treatment, to set their own goals. The only way I can do that is to make sure I listen to them. I have to ask them to describe their symptoms very thoroughly. I have to find out what they want to change, what they want to accomplish. I have to understand their expectations and make sure they’re realistic. Above all, I usually have to give them homework, and if they don’t do it, they won’t get better. So, I also need to assess them well in order to explain what I think is wrong, and what I can and cannot do about it, as well as make sure they understand what they can and cannot do about it. It’s therefore crucial that I inform my patients as well as I can, and that they consent to work with me.
It’s been quite a revelation for me to be a patient, especially a breast cancer patient. In retrospect, it’s frankly appalling how inadequately the principle of informed consent was carried out by my cancer doctors. All three of my cancer docs — the surgeon, the radiation oncologist, and the medical oncologist — initially presented only one treatment option. After presenting this option, the first two did not invite discussion. Instead, I got “my way or the highway.” The surgeon talked about my having a lumpectomy, describing it as a minor excision, with the implication that I would hardly notice. Instead, I later discovered I’d had half of my breast removed. By the time I saw the radiation oncologist, I was more skeptical and researched other options beyond the six-to-seven weeks of daily radiation he initially recommended. During our second meeting, I asked to be evaluated for two other, much shorter, radiation protocols. Fortunately, I was able to qualify for one of them, but I wouldn’t have had I not found out about them on my own and asked. The medical oncologist, fortunately, was more open to discussion, and thus I felt much more that the decision about what kind of oral chemo I might take was mine. Like the other two, however, she provided little information about the collateral damage and possible long-term side effects of treatment. Those I had to discover — and endure — on my own.
Frequently, an insurance company ends up making our choices for us, in effect, because our plan may only cover certain options but not others, regardless of which option might be best for us. The system as a whole also financially rewards some doctors — particularly certain specialties — disproportionately, compared to other doctors, and certainly a great deal more than clinical specialties like mine, despite the fact that we are often in fact the key players in the successful administration and outcome of treatment.
The insurance reimbursement system certainly seems to reward physicians for spending less time, not more, with each patient. Too bad if you’ve just been told your cancer has metastasized and your prognosis stinks and you are crying your eyes out. If your doctor doesn’t see six patients an hour, he may not make enough money in reimbursements to pay his staff or his rent or his malpractice premiums. And it takes time to listen well and explain thoroughly. Insurance companies don’t care if you and your doctor are dealing with matters of life and death. Then again, maybe it’s the way physicians are educated. And not educated. To my knowledge, the average medical school curriculum is not necessarily required to include classes in social skills or listening skills or humility or compassion. Medical schools — and physical therapy schools, for that matter — are filled with academic nerds, because you have to get A’s in science to get into them. Scientific knowledge may provide the foundation for someone to become an adequate doctor. But it does not make someone a great doctor. Or physical therapist.
And yet, every newly minted doctor takes the Hippocratic Oath. And implicit in the Hippocratic Oath is the notion of compassion and the principle of informed consent.
From the Classical Version of the Hippocratic Oath:
- I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone.
- I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan….
- But I will preserve the purity of my life and my arts.
Hmmm. A magic wand might be helpful.
When I first wrote this post, here’s what I found on the American Medical Association site about informed consent:
Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention.
In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:
- The patient’s diagnosis, if known;
- The nature and purpose of a proposed treatment or procedure;
- The risks and benefits of a proposed treatment or procedure;
- Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
- The risks and benefits of the alternative treatment or procedure; and
- The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states. Providing the patient relevant information has long been a physician’s ethical obligation, but the legal concept of informed consent itself is recent.
Sounds good, doesn’t it? The link to the above description is no longer active on the AMA’s site, but when I searched for a replacement, I found this summary instead under AMA Code of Medical Ethics – Informed Consent:
The patient’s right of self-decision can be effectively exercised only if the patient possesses enough information to enable an informed choice. The patient should make his or her own determination about treatment. The physician’s obligation is to present the medical facts accurately to the patient or to the individual responsible for the patient’s care and to make recommendations for management in accordance with good medical practice. The physician has an ethical obligation to help the patient make choices from among the therapeutic alternatives consistent with good medical practice. Informed consent is a basic policy in both ethics and law that physicians must honor, unless the patient is unconscious or otherwise incapable of consenting and harm from failure to treat is imminent. In special circumstances, it may be appropriate to postpone disclosure of information, (see Opinion E-8.122, “Withholding Information from Patients”).
Physicians should sensitively and respectfully disclose all relevant medical information to patients. The quantity and specificity of this information should be tailored to meet the preferences and needs of individual patients. Physicians need not communicate all information at one time, but should assess the amount of information that patients are capable of receiving at a given time and present the remainder when appropriate.
It all sounds reasonable, but it’s not what I got from my cancer docs. The American Cancer Society says this:
Informed consent is a process that includes all of these steps:
- you are told (or get information in some other way) about the possible risks and benefits of the treatment
- you are informed of the risks and benefits of other options, including not getting treatment
- you have the chance to ask questions and get them answered to your satisfaction
- you have had time (if needed) to discuss the plan with family or advisors
- you are able to use the information to help make a decision that you think is in your own best interest
- you share your decision with your doctor or treatment team
Ah, yes. That’s more like what usually happens, with a subtle shift of emphasis. The ACS shifts more of the responsibility for being able to give your informed consent to you.
If you ever have to be brought to the Emergency Room, barely conscious and profusely bleeding, you are in no position to grapple with informed consent, and no reasonable, ethical doctor would withhold life-saving treatment in such a situation. But when you are told you have cancer, it’s difficult not to feel a similar sense of urgency. In fact, it’s appropriate to feel a sense of urgency. This is no head cold here. Your life is being threatened. All you want to do is get rid of the threat, as quickly and efficaciously as possible. Which is not a bad thing.
However, it’s not that simple. When you first hear the word cancer applied to you, you’re too numb to assimilate information and weigh options and discuss anything sensibly. You look at your doctor and yearn for that magic wand. But cancer and cancer treatment are complicated. And there’s nothing like being told you have cancer to force you into learning about all the flaws in the behemoth that is health care, not to mention the informal crash course in oncology you end up taking. I have no great words of wisdom to impart here. But I will say that the most useful, pertinent information I’ve acquired about the consequences of cancer and cancer treatment has come from other cancer patients, as well as from good, reliable Internet sources that present evidence-based treatment options. I discovered those further options for radiation therapy first by hearing from other breast cancer patients, and second, by verifying them by reading published research studies. But not everyone is able or willing to read research. However, the best advice I can impart is this: however you make it happen, the most important part of informed consent is you, babe.
If I think about it for more than two minutes, I still feel frustrated and not a little angry that my doctors did not prepare me more thoroughly for what I would experience both during and years after cancer treatment. But in the end, it doesn’t matter how I was informed or by whom. It matters that I realized that it was my privilege and responsibility to get informed. Ultimately, informed consent means you — no one else — are the one who has the final say in how you live your life and what treatment you get. Cancer is a hugely dis-empowering diagnosis, but you can and you must make your own choices. And that means that sometimes you might not agree with your doctor. And you might not find your girlfriend’s unsolicited opinion very useful. Or care to explain to your impatient spouse that, no, you aren’t “all done with cancer yet.” Sometimes nobody will understand you and what you are going through. Sometimes you might just piss everyone off. And that’s okay. Because they don’t have cancer. You do. And it’s not their life. It’s yours. And you don’t get through cancer by being nice and agreeable and trying to please anybody. You get through cancer yourself, as best you can.
Knowledge is power. So go get some. And tell everyone to get the heck outta the way. You got some major cancer ass to kick.
Hippocratic Oath, Medicine.Net
“Hippocratic Oath,” definition, Wikipedia
Informed Consent, American Cancer Society
Informed Consent, American Medical Association
“Informed Consent,” definition, Wikipedia
Institutional Review Board of Samford University
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