question mark doctorA patient has rheumatoid arthritis for which she should be taking drugs to control the disease and prevent further joint damage. However she tells the doctor that she has stopped because she does not like the look of the side effects listed on the leaflet in the packet and would like a treatment she found on the internet. The doctor disagrees with her preferred treatment. What issues does this raise? How should the doctor handle this scenario?


Patients point of view

It seems that the patient has researched her condition and made her mind up. Autonomy – the right of people to decide what happens to themselves is an important principle in medical ethics. However there are possible problems with this;

Was what she read about this new treatment of good scientific quality? Has it been peer appraised and published in a reputable journal? Has she, the patient the ability to decide if it is the best for her? It is oftendangerous to self diagnose. She may have little knowledge when compared to the doctor or she may be an ‘expert patient’. Such patients may know more than the doctor because they research their illness in depth and may be in correspondence with others with the same illness.

Autonomy gives competent patients the right to refuse treatment but not the right to have treatment. For example if a patient requests antibiotics for a cold autonomy does not mean they have the right to antibiotics.

The Doctor’s Point of View

The doctor has a duty to act in the best interest of a patient[beneficence] and not harm the patient [non maleficence].  He will be held responsible and possibly negligent if he does not prescribe appropriate treatment for her or prescribes treatment that may harm her.  He must not feel pressurised to prescribe something he does not agree with. There are protocols for the treatment of most conditions, if doctors deviate from what is considered best practice they will face criticism unless they have a good reason.

However the patient has the right to have their concerns taken seriously. The doctor and patient should form a therapeutic relationship. In this the patient needs to feel understood by her doctor and trust her doctor. Doctors nowadays should encourage patients to understand and jointly manage their condition and treatment [as in the saying ‘No decision about me without me.‘]. This takes time and patience, and is often hard to do properly in the restricted time available in appointments. Beneficence means acting in the best overall way for the patient. If the patient does not agree with the doctor’s first choice of treatment it may be better to have another treatment rather than nothing at all. It is known that about 50% of all prescriptions written by doctors are never even collected and of those that are only about 50% are taken properly as prescribed. This presents a huge challenge as a clever diagnosis is of little value if a patient does not take the treatment.

If the doctor does not know much about the new treatment he must be honest and find out about it or offer to refer her to someone who does.He must realise the limits of his capability.

He might have concerns relating to the cost of this new treatment and how it might affect his prescribing budget but a doctor’s first concern should be the patient and the GMC is clear that any budgetary concerns should be secondary to this.

Society’s point of view

If the treatment is more expensive than the standard treatment and is no better than the standard treatment it can be said to be unreasonable to expect a publicly funded body such as the NHS to fund such treatment.[ie not fair – ethical pillar of JusticeNICE [the National Institute of Clinical Excellence] recommends, after looking at the efficacy of treatments, which treatments are to be prescribed and sets limits on how much it considers reasonable to spend even if a treatment is more efficacious [better]. It uses QALYs [quality added life years]. This is currently set at about £20,000 for each extra year of good quality life a treatment provides.

In summary there is a possible conflict between the ethical principles of autonomy on one side and beneficence/non maleficence/justice on the other. If the doctor feels that what the patient is suggesting is not in her best interest or is not justified he will need to try and persuade her to come round to his point of view or at least a compromise which will be in her overall best interest.To what extent patient power – it is hard to judge and as more and more information becomes available  from both good and bad sources conversations like this are becoming much more common.