After a breast biopsy, my 36-year-old patient was diagnosed with cancer. When her surgeon recommended a total mastectomy to be followed by reconstructive surgery, she became anxious. Every time we talked about the surgery, she seemed ambivalent. So I was shocked when I heard the surgeon telling her what she, the surgeon, would do under these circumstances. Afterward, my patient signed the consent form. Now she seems completely comfortable with her decision and even told me, “I feel so much better now that I've decided to do what Dr. Johnson wants.” Do you think this surgeon's approach was a subtle form of coercion?—J.F., N.C.
The surgeon is ethically obligated to tell the patient what she needs to know to make an informed decision. That includes discussing the diagnosis, prognosis, treatment options, probable and possible risks (including the risk of doing nothing) and expected benefits. Your patient must receive and understand this information to make an informed decision about her health care. She also needs to hear clearly that the choice is hers.
Perhaps the surgeon informed the patient of prognosis, options, risks, and benefits when she explained the biopsy results. Your patient's anxiety and ambivalence are exactly what you'd expect from someone who's received a life-threatening diagnosis.
When you heard the patient and surgeon again discussing treatment options, the patient was probably ready to seek guidance. It's entirely appropriate for a patient to ask those she trusts for their opinion while she reviews her options. It's also appropriate for an experienced surgeon to tell a patient what she'd do for herself under the same circumstances.
What a surgeon can't do, however, is tell a patient that she must do exactly the same thing; that would be coercion. A patient must know that she has choices, including the option to go against her physician's advice or seek another opinion.
When you talked with your patient, did you confirm that her surgeon told her about her options and her right to choose? If you're not sure about this, talk with her again to reassess. But don't undermine her choice. You're right to want to protect her autonomy, but remember that a good surgeon has the same obligation to your patient, who's her patient too.
Susan A. Salladay is an independent consultant in bioethics based in Spokane, Wash. Address your questions to: Ethical Problems, Nursing2005, 323 Norristown Rd., Suite 200, Ambler, PA 19002.