The life-and-death decision is difficult for both doctors and patients, and medical ethics are still imperfect from theory to practice, and when there are differences in cultural backgrounds between doctors and patients, more contradictions and conflicts will arise. In the face of this problem, pre-planning and continuous communication may be the best strategy to reduce and resolve conflicts.
Written by | Li Changqing
Recently, there was a widely circulated article about a man living abroad documenting his wife's journey from the time she was diagnosed with terminal lung cancer to her death. The article is full of emotion, and once rushed to the hot search on social platforms, and it is believed that it has caused a wide range of discussions among the public and doctors.
This article does not want to comment on the rights and wrongs of both the doctors and patients involved in this article, because it is inappropriate to evaluate any specific clinical case based on only one side of the argument when there is a possible cognitive bias between the doctor and the patient. However, the scenarios described in the article involve some important principles in medical ethics, which are worth exploring in specific clinical practice that people from different cultural and social backgrounds have very different perceptions.
Who makes decisions about health care options?
The country in which the case took place is Canada, while the author is more familiar with the clinical environment in the United States, and the comments are based on the similarity of medical cultures between the United States and Canada.
One of the focal points is the issue of health-related decision-making, that is, who has the final say when it comes to the choice of diagnosis and treatment. In the United States, the first priority must be the patient himself. If the patient is currently found to be capable of making decisions, such as being conscious, mentally normal, able to communicate normally, and able to understand and repeat the doctor's opinion, then any decisions about the patient's own diagnosis and treatment should be made by the patient. Unless the patient voluntarily relinquishes decision-making power to others, including family members, friends, guardians, lawyers, etc.
The more difficult situation is when the patient is considered to be incapable of making decisions, or does not have full decision-making capacity. For example, the patient is in a coma, delirious, and has obvious mental abnormalities, such as schizophrenia. In this case, it is necessary to find out whether the patient has left instructions before, and give in advance the measures that can be selected when he loses the ability to make decisions, and various health conditions appear. Only in cases where there is neither decision-making capacity nor advance directives will the opinions of the patient's family be taken as a reference. In such cases, in addition to the decision-maker appointed by the patient in advance, advice is generally sought in accordance with the family relationship prescribed by law, and the priority is: spouse, children, parents, siblings.
Such decision-making priorities are not a cultural practice, but are protected by law. In addition to the regular rights bills, there are also the Patient Self-Determinant Act (PSDA) and the Health Insurance Portability and Accountability Act (HIPAA). Medical practices that do not respect this right will be immediately warned, and doctors may even be imprisoned in a lawsuit.
As can be seen from the article "The Death of My Wife", the author does not understand this principle very well. People who are accustomed to the domestic medical culture may not understand it very well. Traditionally, a person's life, old age, sickness and death are never a personal matter, and doctors rarely refer to the patient's opinion when considering the implementation of diagnosis and treatment measures for the patient, especially some major medical decisions, such as surgery, hospice treatment, etc. There are even some very common situations where doctors will go beyond the patient and consult directly with the family to make a decision.
The reason for this kind of behavior that does not conform to the principles of modern medical ethics is not entirely the influence of cultural traditions, but also some very practical reasons, such as economic aspects. Whether it is the patient or the patient's family, the impact on other family members should be considered when it comes to medical expenses. In terms of law, there are currently no laws and regulations on the priority of medical decision-making in China. If the patient's personal wishes are contrary to those of the family, or if the personal wishes cannot be expressed independently, there are no laws and regulations that can safeguard the patient's autonomy, and the doctor has no obligation to defend the patient's decision-making priority. Even basic rights to information can be denied, such as the problem of concealing the illness from patients with malignant tumors, which is still widespread today, although this is understandable based on the country's view of life and death.
Doctors' tendencies, choices, and attitudes
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The second focus is on hospice or palliative care decisions. There are many specific clinical issues involved, such as whether to choose endotracheal intubation and cardiopulmonary resuscitation for patients with heart or respiratory failure, and whether patients with advanced malignant tumors should prolong their lives or maintain their quality of life.
It is a well-known common sense that although such a decision is made by the patient on the basis of full communication between the doctor and the patient, the attitude of the doctor is extremely crucial. The public needs to learn to "understand" what the doctor is saying: in most cases, when doctors ask patients whether to intubate and do CPR, they are already inclined not to do intubation or CPR, and when doctors ask the option of prolonging life or maintaining quality of life, they are actually inclined to maintain quality of life. Such advice is contraindicated within the profession as a waiver of treatment, but to a large extent, this is how the patient understands it.
Conversely, when doctors believe that active treatment is still valuable for the patient's life and health, and that it is possible to win the war against the disease, they often do not take the initiative to propose the above options to the patient. In such a situation, if the patient voluntarily "gives up", the doctor will even go to great lengths to try to change the mind of the patient and the family.
Such tendencies exist both in China and abroad. For advanced tumors like the one in "The Death of My Wife", which progresses rapidly, I believe that most doctors believe that there is not much chance of cure under the current medical technology. Even if the family finds many life-saving straws, it is common sense that straw does not save lives when drowning.
Doctors have a tendency to do this, mainly based on their professional knowledge and experience, and this tendency is for the sake of the patient's quality of life and dignity, which has a positive meaning. However, it is undeniable that in specific institutions and individual cases, doctors will also tend to make patients "give up" in order to rationally use medical resources and reduce costs.
There is also a concern in the medical community about the deterioration in the quality of care for patients due to certain choices. Some studies have found that patients who sign the informed consent form of "no resuscitation (DNR" (that is, no cardiac compressions when the heart stops) will have less time and frequency of ward rounds, and the in-hospital mortality rate will be significantly increased. The reason is that doctors acquiesce that such patients are less of therapeutic value and do not want to prolong their lives.
It can be seen that there are still many imperfections in medical ethics from theory to practice, even in countries and regions where ethics has developed earlier and its practical application is more standardized. When there are differences in cultural backgrounds between doctors and patients, more conflicts and conflicts arise. In the face of this problem, pre-planning and continuous communication may be the best strategy to reduce and resolve conflicts.
This article is reprinted with permission from the WeChat public account "Science China".
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