Some Thoughts about Medical Advice: Patient/Family vs Physicians

Here are some ruminations on this subject by a member of the President’s Bioethics Committee. It comes from the transcript of
Session 6: Bioethical Issues of Aging II: The Wisdom of Advance Directives Friday, April 2, 2004 and was spoken by Member Daniel Foster, M.D., John Denis McGarry, Ph.D. Distinguished Chair in Diabetes and Metabolic Research, University of Texas Southwestern Medical School.


Let me just say one other thing very quickly, and I don't want to sound self-serving about a profession and so forth, but the courts have clearly held that families and patients cannot require a physician to do or not to do any things. These are advice. I mean, we're not obligated for an 85 year old person to do chemotherapy. The courts have made that clear.

There is a second issue of judgment that the physician may have. The late Franz Ingelfinger, who was the long time editor of the New England Journal of Medicine, himself a gastroenterologist who worked on the esophagus developed esophageal cancer. And he wrote an article in the New England Journal of Medicine called "Arrogance." This was a time of the peak of autonomy for patients. Women would be squatting over mirrors to try to see if they could do their own pelvic examinations and see if they could just see — because they had the autonomy for their own health.

Because he was probably the most famous physician in the world, the editor of the New England Journal of Medicine usually is in terms of name, he received advice from all over the world telling him radiation first, surgery this, that and the other. And finally someone told him, he says "Franz, what you need is a doctor." And so he chose an internist and said, "I put myself in your care." And afterwards he said it was like a huge burden off of his life. He got back to editing the New England Journal of Medicine. And, by the way, his two children were doctors and so forth and so on. And he wanted somebody who was competent who cared for him to make the decisions should we do this or should we not do that.

Now, one could say that's a very arrogant position to say that maybe the physician would be the best person to make a choice as to whether this was good or helpful or not. And I'm not defending that at all. But I think that most physicians — I don't have statistics. But I think that many physicians will always want to do what they would do for their own family. That's a question that's asked us all the time; if this was your wife or this was your mother, what would you do. And when one answers under those circumstances, almost always in my experience the family will go with the judgment of the physician which is there. Because you try to explain what the downsides are, what the upsides are, what a treatment that might add two months, you know, but makes one sick is usually not — there might be circumstances where you would do that if somebody didn't have time to make a will or something. I mean, I've done that. Do a treatment that might be give me two or three months because of some critical issue in the family.

So I do think that there's been an arrogance about doctors who think they're gods, you know. But on the other hand, we probably do have a better sense of what should be done than the family does.

When my own father died of lung cancer—he wasn't a smoker, he just had an endocarcinoma — he had not wanted anything. He just had an IV glucose, just a glucose to keep open so they could give, you know, if he needed anything to do. And his granddaughter came in there and began screaming that when that was taken out of the arm. It was just giving fluids. She began to scream, "They're killing grandpa." It was not killing grandpa, I mean it was just glucose and water going in there. He had no need for it. And we just took it out.

So, anyway, I think that there is sense where the physician should have, you know, at least advice in these things and maybe more than that. I don't know.

It’s all about who should be giving the advice to whom and which advice should trump the other. Any suggestions? ..Maurice.