Abusing patients by denying them choice

doi:10.1136/bmj.328.7436.0-f

BMJ 2004;328 (14 February), doi:10.1136/bmj.328.7436.0-f

Editor's choice

Abusing patients by denying them choice

A useful tip for smart arse medical students. If asked: "Whatis the treatment for x?" Don't answer: "y." Instead answer:"Whatever the patient chooses together with me after being fullyinformed of the pluses and minuses of all options." Giving patientschoice in complex circumstances emerges as a theme in this issue—withthe sombre overtone that not to give patients choice is to abusethem.

It first hit me that denying patients choice is a form of abusewhen about six years ago I read a paper on patient choice inscreening for colorectal cancer. One hundred Californian patientswere given full information on five options: nothing, faecaloccult blood testing, barium enema examination, flexible sigmoidoscopy,or colonoscopy. Patients were told about the nature of the test,the preparation required, the need for sedation, the time required,how often the test would be repeated, the likely results withboth positive and negative outcomes in detail, and the cost.The result was that patients chose very different options.

Steve Woolf, a family physician and North American editor ofthe BMJ, wrote: "Suppose these same 100 patients had not receivedthis information and were instead cared for by a physician whoroutinely performs flexible sigmoidoscopy because he considersit the best test. According to these data, fully 87% of thepatients would undergo a procedure other than the one they wouldprefer if properly informed" ( J Fam Pract 1997;45: 205-8[Web of Science][Medline]).Nine out of 10 patients have been abused.

Mark Sculpher and others describe how they used something calleda discrete choice experiment to help men with non-metastaticprostate cancer to choose between different options for treatment(p 382). The main conclusions are that men are willing to engagein this complex process and will trade life expectancy in orderto avoid side effects. Mandy Ryan discusses how the techniquecan be used in other circumstances (p 358).

Some 15-20 years ago an editorial in the BMJ suggested thatevery menopausal woman should have hormone replacement therapy.That now looks like bad advice not only because therapy increasesthe risk of breast cancer, heart disease, and thrombembolismbut also because only women themselves can trade off how theyvalue the benefits and risks. A group from Leicester presenta detailed decision analysis of the harms and benefits of therapyin the light of the latest evidence and conclude that two importantvariables are perceived symptoms and baseline risk of breastcancer (p 371). Klim McPherson weighs up hormone replacementtherapy and also draws lessons from the whole sorry story ofthe mass drugging of women for largely non-existent benefits(p 357).

The main arguments against fully informing patients are that"It's too difficult, costly, and time consuming." But they areneither evidence based nor politically sustainable.

Richard Smith, editor

rsmith{at}bmj.com

To receive Editor's choice by email each week subscribe viaour website: bmj.com/cgi/customalert

Add to CiteULike CiteULike Add to Complore Complore Add to Connotea Connotea Add to Del.icio.us Del.icio.us Add to Digg Digg Add to Reddit Reddit Add to StumbleUpon StumbleUpon Add to Technorati Technorati What's this?

Relevant Articles

Where are we now with hormone replacement therapy?: Klim McPherson
BMJ 2004 328: 357-358. [Extract] [Full Text] [PDF]

Thalassaemia major: the murky story of deferiprone: Julian Savulescu
BMJ 2004 328: 358-359. [Extract] [Full Text] [PDF]

Benefits and harms associated with hormone replacement therapy: clinical decision analysis: Cosetta Minelli, Keith R Abrams, Alex J Sutton, and Nicola J Cooper
BMJ 2004 328: 371. [Abstract] [Full Text] [PDF]

Patients' preferences for the management of non-metastatic prostate cancer: discrete choice experiment: Mark Sculpher, Stirling Bryan, Pat Fry, Patricia de Winter, Heather Payne, and Mark Emberton
BMJ 2004 328: 382. [Abstract] [Full Text] [PDF]

Rapid Responses:

Read all Rapid Responses

Oncological Terrain, HRT prescription, and patient�s choice.: Sergio Stagnaro
bmj.com, 13 Feb 2004 [Full text]
how informed is consent?: Giovanni Codacci-Pisanelli
bmj.com, 13 Feb 2004 [Full text]
For goodness' sake...: John Hopkins
bmj.com, 13 Feb 2004 [Full text]
SUPERMARKET MEDICINE - is that the way forward: Radha Sundaram
bmj.com, 13 Feb 2004 [Full text]
Patient Choice and Government Targets: David Gill
bmj.com, 13 Feb 2004 [Full text]
Medicine as a science: Dr. Herbert H. Nehrlich
bmj.com, 13 Feb 2004 [Full text]
Abusing psychiatric patients by denying them choice.: AK. Al-Sheikhli.
bmj.com, 13 Feb 2004 [Full text]
Is this really abuse?: James D Atkinson
bmj.com, 13 Feb 2004 [Full text]
Missing reference: Richard Smith
bmj.com, 14 Feb 2004 [Full text]
Having a say in how my body is treated: Julia C Grier
bmj.com, 14 Feb 2004 [Full text]
Damage Limitation?....I don't think so!: Stephen J Beazer
bmj.com, 14 Feb 2004 [Full text]
Consumers Deserve Choice: Justine M Caines
bmj.com, 14 Feb 2004 [Full text]
"Rolls Royce or stay put" syndrome: Sethuraman K Raman
bmj.com, 15 Feb 2004 [Full text]
Understanding Responsibility, uncertainty and individuality in decision-making: Richard Fuller
bmj.com, 15 Feb 2004 [Full text]
Re: "Rolls Royce or stay put" syndrome: Sunil Ratilal Moreker
bmj.com, 16 Feb 2004 [Full text]
bad piece of advice?: Joseph C. Watine
bmj.com, 16 Feb 2004 [Full text]
Choosing best treatment: Roger A Fisken
bmj.com, 16 Feb 2004 [Full text]
Are we, the doctors, always prepared to choose?: M�nica Granja
bmj.com, 16 Feb 2004 [Full text]
Patient abuse: Deborah A. Kraut
bmj.com, 16 Feb 2004 [Full text]
Too simple an Editorial Comment: Bob Smith
bmj.com, 17 Feb 2004 [Full text]
Involving patients in decision making: Anthony Papagiannis
bmj.com, 17 Feb 2004 [Full text]
Empowering prostate cancer patients through education.: Donna L. Pogliano
bmj.com, 18 Feb 2004 [Full text]
The team of doctor and patient: Dr.Herbert H. Nehrlich
bmj.com, 18 Feb 2004 [Full text]
Are We Afraid of Making Choices?: Ruchir D Trivedi
bmj.com, 19 Feb 2004 [Full text]
good in theory, little in practice.: manan vasenwala
bmj.com, 19 Feb 2004 [Full text]
Abuse is the wrong line of argument: Aanand D Naik
bmj.com, 20 Feb 2004 [Full text]
Where is the real freedom of both patients and phisician ?: G Vetrugno, et al.
bmj.com, 20 Feb 2004 [Full text]
Re: good in theory, little in practice.: Julia C Grier
bmj.com, 20 Feb 2004 [Full text]
Re. Good in theory little in practice: Stephen J Beazer
bmj.com, 21 Feb 2004 [Full text]
Denial alternative treatments might even exist: Diana F. Pargeter
bmj.com, 23 Feb 2004 [Full text]
the FIRST patient choice: Barbara R. Parker
bmj.com, 23 Feb 2004 [Full text]
Re: Having a say in how my body is treated: John S Shackcloth
bmj.com, 20 Mar 2004 [Full text]
Let's reserve judgment for future, better research: Pepi Granat, MD
bmj.com, 20 Aug 2004 [Full text]