GPVILLANUEVA’S MAR [15-03]: Autonomy versus Paternalism

MEDICAL ANECDOTAL REPORT
Indexing Title: GPVILLANUEVA’S MAR [15-03]
MAR Title: Autonomy versus Paternalism
Date of Medical Observation: April 2015
Tag: Learning from experience the principles between autonomy and paternalism
Category: Professional/ Ethical – Reinforcement
 
NARRATION:

I was then busy talking to a patient in the Out-Patient Department when my senior, already a graduate and the one that I highly regard, called up. He was endorsing a patient, his distant relative, a 74-year-old female with a mass on her left breast. He already knew that the mass was malignant and so he requested that the patient be scheduled immediately for Modified Radical Mastectomy. I assured my senior that I will take care of her relative’s preoperative preparation. The following day however, I was surprised when I met the patient. By further history taking I have learned that she already had a previous surgery of excision of the mass which revealed a malignant lesion upon histopathologic analysis. She has now an approximately 6cm by 6cm lesion with scar on the upper outer quadrant area involving the skin.
A patient on her age with the same lesion should still undergo neoadjuvant chemotherapy (meaning chemotherapy be given to the patient prior to operation) based on the Breast Cancer Guidelines. I then showed the patient to our consultant and the details of the treatment were further discussed, options were laid down to her. The patient was then told of a five to ten year disease free survival. On this part of the conversation patient caught us off guard when she told us that she is already grateful that she has reached her ripe old age and would no longer want anything more in her life. She understood the ideal treatment but for her, she is already contented with what Modified Radical Mastectomy would give to her. It was only at that time when I realized again that the patient is already on the late stages of her life and that five to ten years from now, her age would cause her demise and not the actual disease of cancer.
 
INSIGHT:
(Physical, Psychosocial, Professional/ Ethical)
(Discovery, Stimulus, Reinforcement)
 
During our days learning the Ethics of Medicine, we were taught of the 5 principles essential in our practice – Respect for Autonomy, Beneficence, Non-maleficence, Justice, and Paternalism. These are the principles that help us doctors to make decisions when reflecting on moral issues that arise at work. These five principles do not have any hierarchy and thus ideally we have to uphold all of them. However, in the actual world, we must determine which carries more weight.  My experience with the patient made me to once again review each of the five principles. Based on the Principle of Beneficence, I as the patient’s doctor have the duty to take positive steps to prevent and remove the patient from harm meaning I have the duty to make sure that the patient receives a beneficial treatment procedure. While based on the Principle of Paternalism, I as her doctor also have to guide her to take the ideal route of management. However this  Principle of Paternalism comes into conflict with the Principle of Respect for Autonomy. Despite adequate and repeated explanation of the benefits of undergoing neoadjuvant chemotherapy, the patient in her right mind and along with discussion with her inner circle of relatives have decided to forgo with such procedure. The patient has the utmost right for her own body and so her decision in this case should take precedence. There lies the clincher, the patient should be properly and compassionately informed of her options and let her ultimately make the final decision. Thru the guidance of the principles and our consultants, we now learn from the actual experience of how decision making process should be done.
ROJoson’s Notes (17feb18):
Inform and guide patients in their decision-making  but in the long run, respect whatever decision they make. Balance all the known ethical principles in advising patients.
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