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http://www.nytimes.com/2002/07/02/health/policy/02CASE.html

Advice Rejoins Consent

By SANDEEP JAUHAR, M.D.

y patient had just had an angiogram. He was still lying on the operating table, catheters in his groin. A cardiologist called me over to review the film.

When I got to the cardiac catheterization lab, two attending physicians and a senior fellow were studying the angiogram on a computer monitor. The coronary arteries looked like sausage links, sectioned off by five narrow blockages.

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What was to be done? The senior physician favored angioplasty, where tiny balloons and coils of wire called stents are used to open blocked vessels. Two blockages could be opened today, he said, and three at a later date. The others thought bypass surgery was the better option. Someone asked my opinion.

I thought about it for a few minutes. Surgery was probably the more durable solution. Bypass grafts could last a decade or more, longer than most stents.

Plus, surgery for my patient meant one procedure, not two.

Still, there were risks. Because of his advanced disease, my patient probably had about a 10 percent chance of dying in surgery. If he survived, he could be left with memory deficits or chronic chest-wall pain. Plus, it would take longer for him to recover from surgery.

Since we couldn't reach a consensus, and it wasn't an emergency, the senior attending physician made what seemed like a reasonable proposition: give the patient the options and let him decide. After all, he was the one who was going to have to live with the consequences.

He was lying on a long, narrow table, a middle-aged man covered from neck to toe by a sterile drape. His face had a strangely disconnected look, which I attributed to anxiety and sedation. He smiled as I approached. "The angiogram is done," I started off saying.

I told him he had five blockages in three arteries and two options. Angioplasty could open the arteries without surgery, but he would need two procedures, one of which could be started right away. Open-heart surgery, on the other hand, probably offered him the best chance of not having to undergo another procedure in the future. "But it's a big surgery," I added.

I didn't want to bias him one way or the other. A few months ago I had convinced a patient to have heart-valve replacement surgery, which had resulted in serious complications. I didn't want another bad outcome on my conscience.

He listened intently but did not say much. I repeated his options. He nodded. So what did he want to do? He looked puzzled. "What is best?" he replied.

That I was having this conversation at all is testament to how much medicine has changed in the last two or three decades. In hospitals today, "patient autonomy" is the ruling ethical mantra, even superseding beneficence. But it can be a problem.

Patient autonomy often seems to be more important to doctors than patients. As a first-year cardiology fellow, a big part of my job is to obtain "informed consent" for procedures. I tell patients the risks — bleeding, infection, heart attack, death — but rarely does this prompt a meaningful discussion. Instead, I am invariably told, "You're the doctor, I'll go along with whatever you say."

Most of my patients seem to think "informed consent" is a sham, either asking them to ratify decisions that have already been made or to make decisions they are not equipped to make. Informed consent, as it is practiced today, is very different from the way ethicists envisioned it. It was supposed to protect patients from doctors. Instead, it is used to protect doctors from patients or, rather, from the hard decisions that patient care demands. Doctors today sometimes use informed consent as a crutch to abdicate responsibility, as I probably did that afternoon.

I do not advocate a return to the paternalistic ways of the past, but patients need doctors to guide them through the tough decisions and, sometimes, tell them what to do. The father of a friend of mine died two years ago from lung cancer. My friend told me that when he asked the doctors about chemotherapy, they gave him numbers and statistics but assiduously avoided giving advice, which was what he really needed.

It had been 20 minutes. "What is best?" my patient asked me again. "I can't tell you what to do," I repeated. He stared blankly at me. Then I decided to start acting like a doctor.

"What are you afraid of?" I asked. It turns out his uncle had had open-heart surgery a few years back. Judging by his tone, he wanted no part of it. "It sounds like you're scared of surgery," I said. He nodded. "So we should do the other thing," I said. The patient agreed; we did an angioplasty, and it went well.

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