Abusing patients by denying them choice

A useful tip for smart arse medical students. If asked: “What is the treatment for x?”Don't answer: “y.” Instead answer: “Whatever the patient chooses together with me after being fully informed of the pluses and minuses of all options.” Giving patients choice incomplex circumstances emerges as a theme in this issue—with the sombre overtone thatnot to give patients choice is to abuse them.

It first hit me that denying patients choice is a form of abuse when about six years ago I read a paper on patient choice in screening for colorectal cancer. One hundred Californian patients were given full information on five options: nothing, faecal occult bloodtesting, 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 with both positiveand 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 of the BMJ,wrote: “Suppose these same 100 patients had not received this information and were instead cared for by a physician who routinely performs flexible sigmoidoscopy because he considers it the best test. According to these data, fully 87% of the patients would undergo aprocedure other than the one they would prefer if properly informed” (J Fam Pract 1997;45: 205-8). Nine out of 10 patients have been abused.

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

Some 15-20 years ago an editorial in the BMJ suggested that every menopausal woman should have hormone replacement therapy. That now looks like bad advice not only because therapy increases the risk of breast cancer, heart disease, and thrombembolism but also because only women themselves can trade off how they value the benefits and risks. A group from Leicester present a detailed decision analysis of the harms and benefits of therapy in the light of the latest evidence and conclude that two important variables are perceived symptoms and baseline risk of breast cancer (p 371). Klim McPherson weighs up hormone replacement therapy and also draws lessons from the whole sorry story of the 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 are neither evidence based nor politically sustainable.