This weekend’s reading has included this book. In fact, I haven’t read anything else. The last two chapters in particular explore the relationship between doctors, their patients, between patient autonomy and taking clinical responsibility.
Atul Gawande is a surgeon and writer based in Boston, Massachusetts. He has written several very popular books about the praactice of medicine, as well as delivering four Reith lectures for the BBC in 2014.
This is his first book, published in the UK in 2002. There are fourteen essays, grouped into three sections. The first deals with fallibility and error, and the second looks at the mystery of medicine.
The final four essays discuss how we manage uncertainty in medicine, the interface between clinical evidence and human decisions. The penultimate essay is entitled ‘Whose body is it anyway’. In this essay, he discusses some of the core issues of realistic medicine, fourteen years before Catherine Calderwood coined the phrase. In truth, consent and patient autonomy are not new, but having a banner under which to explore these themes has been powerful.
He discusses the gap between what patients want and what they hope for. His writing is straightforward, and his arguments are illustrated by cases, the stories that hook clinicians into the debate. He describes how honest clinical discussions allow patients to understand what is happening, and take their share in the decisions.
In his own words: ‘Just as there is an art to being a doctor, there is an art to being a patient. You must choose wisely when to submit and when to assert yourself. Even when patients decide not to decide they should still question their physicians and insist on explanations… You do the best you can, taking the measure of your doctors and nurses and your own situation, trying to be neither too passive nor too pushy for your own good.’
‘Where many ethicists go wrong it is in promoting patient autonomy as a kind of ultimate value in medicines rather than recognising it as one value amongst others. Schneider (The Practice of Autonomy) found that what patients want most from doctors isn’t autonomy per se; it’s competence and kindness. Now kindness will often involve respecting patient autonomy, assuring that they have control over vital decisions. But it may also mean taking on burdensome decisions when patients don’t want to make them, or guiding patients when they do.’
‘Even when patients do want to make their own decisions there are times when the compassionate thing to do is to press hard: to steer them to accept an operation or treatment that they fear or forgo one that they pinned their hopes on. Many ethicists find this line of reasoning disturbing, and medicine will continue to struggle with how patients and doctors ought to make decisions. But, as the field grows ever more complex and technological the real task isn’t to banish paternalism; the real task is to preserve kindness.’
The eternal balance between clinical evidence, being clear about outcomes and chance, giving patients the chance to influence the chances that they have and the treatments that they receive.