Inserting Government between Patient and Physician
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《新英格兰医药杂志》
In the patient–physician interaction, the physician applies his or her skills and then makes recommendations that he or she believes are in the patient's best interest. Sometimes the picture is crystal clear, and the medical pathway largely unambiguous. Often, however, the path to be followed depends largely on the patient's choice among reasonable medical options; at times, none of the choices are easy or pleasant ones. Today, the federal government is inserting itself into this highly personal setting, where outcomes are often filled with heartbreak no matter what course is chosen.
It is appropriate for the government to regulate the licensing of physicians and hospitals, the sale of drugs or devices, and the business of medicine. It is even appropriate for the government to intervene if a parent's views may deny a child a lifesaving treatment. But the legislative approach makes no sense when it comes to directing choices among procedures that are generally accepted in medical practice. Laws are blunt instruments that are of little value in helping a patient to select carefully the best path to follow in a particular crisis. Should my patient have to bow to a majority vote by Congress or a state legislature in making a decision about his or her own body?
As outlined by Greene and Ecker in a Sounding Board in this issue of the Journal,1 the Congress and President George W. Bush have intruded on a particularly contentious area of medicine — the decision to terminate a pregnancy. Greene and Ecker argue through compelling, real-world examples that the choices faced by a woman and her physician with respect to the termination of a pregnancy are not easy ones. Women who must make such choices may be the victims of forces beyond their control, and the failure to terminate a pregnancy can have devastating consequences for a woman's health, if not her life.
The recently passed law banning so-called partial-birth abortion does not proscribe abortion under the guidelines set forth in Roe v. Wade; rather, it sets limits on the ways in which this end may be accomplished. The law has two pernicious aspects. First, it is not clearly written, and it thus creates uncertainty in the minds of providers, making it harder for them to meet their patients' needs. As Greene and Ecker point out, few physicians want to risk a prison term over the details of what is or is not permitted. The law seems to be written in such a way as to strike fear into the hearts of providers, so as to limit what physicians will be willing to do for their patients. As a patient and her physician face difficult decisions together, they will now have to worry about the attorney general looking over their shoulders.
Second, and even more important, the law ventures into dangerous territory by specifying details of care delivery without knowledge of the specific circumstances in which the patient and physician find themselves trapped. Only a patient and his or her physician can make a meaningful and relevant health care decision at the time it needs to be made. They should be able to choose among all reasonable medical procedures, rather than among only those procedures that Congress or the President do not find gruesome. If, in the future, legislators decide that certain cancer operations are distasteful, will they enact requirements that these operations be abandoned in favor of other, more palatable treatments? Much of what is done in medicine is uncomfortable, unpleasant, or unsightly. But what is done to a given patient should be determined on the basis of data and, when there is no compelling "best way," by the patient's decision about what is in his or her best interest.
This current example illustrates what all of us who wear the physician's mantle know: many choices in medicine are not easy. Should patients be required to undergo a treatment that will maim them in order to gain a few more years of life? Should patients have to bear pain because physicians fear the side effects of pain relief? Should a woman be compelled to carry a pregnancy to term if doing so will vastly increase her risk of premature death? Should patients be forced to receive food and fluids to prolong their lives? Decisions about what is best should be made among reasonable alternatives by individual patients, in collaboration with their loved ones, as guided by their physicians. Experience has taught us that everyone makes these decisions on the basis of his or her own values, desires, and beliefs; legislation has no place in this process.
References
Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186.
Related Letters:
Abortion, Health, and the Law
Reardon D. C., Hoeldtke N. J., Marchetti P., Greene M. F., Ecker J. L.(Jeffrey M. Drazen, M.D.)
It is appropriate for the government to regulate the licensing of physicians and hospitals, the sale of drugs or devices, and the business of medicine. It is even appropriate for the government to intervene if a parent's views may deny a child a lifesaving treatment. But the legislative approach makes no sense when it comes to directing choices among procedures that are generally accepted in medical practice. Laws are blunt instruments that are of little value in helping a patient to select carefully the best path to follow in a particular crisis. Should my patient have to bow to a majority vote by Congress or a state legislature in making a decision about his or her own body?
As outlined by Greene and Ecker in a Sounding Board in this issue of the Journal,1 the Congress and President George W. Bush have intruded on a particularly contentious area of medicine — the decision to terminate a pregnancy. Greene and Ecker argue through compelling, real-world examples that the choices faced by a woman and her physician with respect to the termination of a pregnancy are not easy ones. Women who must make such choices may be the victims of forces beyond their control, and the failure to terminate a pregnancy can have devastating consequences for a woman's health, if not her life.
The recently passed law banning so-called partial-birth abortion does not proscribe abortion under the guidelines set forth in Roe v. Wade; rather, it sets limits on the ways in which this end may be accomplished. The law has two pernicious aspects. First, it is not clearly written, and it thus creates uncertainty in the minds of providers, making it harder for them to meet their patients' needs. As Greene and Ecker point out, few physicians want to risk a prison term over the details of what is or is not permitted. The law seems to be written in such a way as to strike fear into the hearts of providers, so as to limit what physicians will be willing to do for their patients. As a patient and her physician face difficult decisions together, they will now have to worry about the attorney general looking over their shoulders.
Second, and even more important, the law ventures into dangerous territory by specifying details of care delivery without knowledge of the specific circumstances in which the patient and physician find themselves trapped. Only a patient and his or her physician can make a meaningful and relevant health care decision at the time it needs to be made. They should be able to choose among all reasonable medical procedures, rather than among only those procedures that Congress or the President do not find gruesome. If, in the future, legislators decide that certain cancer operations are distasteful, will they enact requirements that these operations be abandoned in favor of other, more palatable treatments? Much of what is done in medicine is uncomfortable, unpleasant, or unsightly. But what is done to a given patient should be determined on the basis of data and, when there is no compelling "best way," by the patient's decision about what is in his or her best interest.
This current example illustrates what all of us who wear the physician's mantle know: many choices in medicine are not easy. Should patients be required to undergo a treatment that will maim them in order to gain a few more years of life? Should patients have to bear pain because physicians fear the side effects of pain relief? Should a woman be compelled to carry a pregnancy to term if doing so will vastly increase her risk of premature death? Should patients be forced to receive food and fluids to prolong their lives? Decisions about what is best should be made among reasonable alternatives by individual patients, in collaboration with their loved ones, as guided by their physicians. Experience has taught us that everyone makes these decisions on the basis of his or her own values, desires, and beliefs; legislation has no place in this process.
References
Greene MF, Ecker JL. Abortion, health, and the law. N Engl J Med 2004;350:184-186.
Related Letters:
Abortion, Health, and the Law
Reardon D. C., Hoeldtke N. J., Marchetti P., Greene M. F., Ecker J. L.(Jeffrey M. Drazen, M.D.)