Clint, a tough economist, juggler of charts and numbers, did not want to decide what to do with his heart. He wanted his cardiologist to tell him. But all the cardiologist did was present him with the options, recommend a stent, then drop the decision in Clint's lap, saying "it's up to you."
Well for crying out loud! When it comes to bashing the bailout or redesigning the stimulus bill, Clint is decisive. For one thing, the decision is not his to make, and for another - what's at stake? The US economy? Big deal. This is his heart they were talking about!
Clint followed the cardiologists' advice and a few days later found himself lying in the catheter room, a tube going from his groin to his heart spraying radioactive material, which indicates the degree to which blood flows through the arteries. The doctor used local anesthesia in the groin, so Cling was feeling no pain, lying there fully conscious and gazing at the screen showing his heart from the inside. Doc was looking too, and was getting in a pensive mode. "You know," he told Clint, "the artery we were going to put the stent in, I know it's half clogged, but it's also half open."
This may be right, but it was not the right thing to say, certainly not to a patient who, tough guy or not, has been mentally and physically prepared for a procedure. Clint, who thrives on a good pilpul, has had enough. He wanted something done to him, something which would unequivocally improve the blood flow to his heart. Something which his surgeon, handpicked and handsomely paid, would vouch for. And he wanted it now. If this was a Western, he would tell his doc "when you gotta shoot, shoot, don't talk."
"Ok," the doctor said, "but which stent should I use?"
Movement is restricted with a tube coming up your groin all the way to your blood pumping organ, but Clint managed a full head turn and gazed at his caretaker with disbelief. A tube was having a field day in his chest, which he was gazing at on a large scaled screen. Was he supposed to keep on making decisions on matters he knew nothing about and which may determine his health? Possibly his life?
Apparently yes. "There are two kinds," the doctor went on. "One that's just a stent, and one that is coated with slow release medication."
Making decisions is depleting. You made a few and your decision energy is wasted. All gone. This is why auto salespersons walk you through everything before getting to the sounds system. By the time you've decided on everything they are giving you, upholstery and the sort, you are depleted , like a balloon out of air, and you go for anything, anything at all, no scrutiny whatsoever, as long as you get the decision out of your way. Judging by Clint's scowl when he described the events, he was definitely depleted by the time he had to make up his mind between the two kinds of stents which he never knew existed.
Peter Ubel, in his book "Free Market Madness: Why human nature is at odds with economics - and why it matters" http://www.peterubel.com/free-market-madness/ describes the same choice, presented to an internalist having a heart attack. Ubel is as skeptic of the internalist's choice, as he is of the notion that free markets and choice contribute to health and well-being.
"How did you decide?" I probe Clint. "Did you watch an infomercial?" Because how does one, uneducated in the medical profession, decide between stents, mid-procedure?
Clint gestures with his hand to indicate something bordering on random helplessness. "Close," he says. The doctor told him the medication-coated stent reduces the risk of the artery from clogging again by 40%.
"That's reason enough for choosing it," I venture.
Clint‘s hand falls to his desk dramatically. Have I learned nothing yet? Did I really expect the decision merry-go-round to come to a pleasant halt? "This was the pro," he says. "And it's not that big a pro when you consider the chances of the artery re-clogging, which are not too big to begin with. Overall, research shows that I would be gaining a 5% increase in the probability that the stent would keep on working."
"So what's the con?"
"The con is that I would need to take a blood-thinning pill daily for a year, maybe forever."
Not the end of the world I suppose. But is it worth the 5% increase in the success rate? And how does one begin to gauge that in their fragile state, while their loved ones are biting their nails anxiously in the waiting room?
"There's more," Clint adds. "As long as I'm on this pill, I cannot undergo any surgery. So what if I do need to have bypass done?"
Clint's parents are long gone, and men, nay, cowboys his age, rarely admit they want their mommy. Naturally, Clint doesn't either. But for a moment you see a glimpse of the little boy he was once, wanting his mommy and daddy, or his doctor for that matter, some authority figure that has Clint's best interest in mind, to tell him that everything will be alright. Autonomy shmotonomy, I can see this little boy stamping his feet inside the big man occupying the chair at the economic research institute. And this little boy wants someone to put him out of his deliberative misery.
"Which stent did you choose then?"
"The simple one," Clint replies, almost disinterested. Because once the choice has been made, the last one in an agonizing series of choices, the agony of choosing, sometimes worse than a chest pain, was over.
So patients have gained autonomy, but the price may be higher than they expected. Because making choices requires knowledge, and is associated with an acute awareness of the uncertainty revolving medical procedures and their outcomes. Is a person lying on an operating room bed well equipped to make decisions? And if not, what are we maximizing by granting him the choice? Is the ultimate goal making better decisions, or using patient autonomy, potentially even abusing it, to diminish physician accountability? Because, for all of Clint's pains, what he stood to gain from the overdose of autonomy remains unclear.
Sometimes there just is a right answer, or at least one that is right for you. And if doctors now shun from saying what it is, they can at least point us in the right direction. And sometimes, even if there is no right answer, you cannot be bothered with figuring out what to do. If you too have experienced an incident where you felt choice between treatment options was thrown in your lap like a hot potato, please share by commenting below. And if you are a physician at odds with the current way of doing things, or fervently for it - make yourself heard.