Indexing Title:

C LEYSON’S Medical Anecdotal Report [05- 02] 

 MAR Title:  Patient autonomy

 Date of Medical Observation:  February 2005

 Narration:

             This is a case of an 18-year-old male who sustained a degloving injury of his right hand middle finger. A distant abdominal flap was done, and after discharge he was lost to follow-up. A month later, I saw him and scheduled him for an operation to release the flap, but he didn’t come back on the agreed date of admission. When he came back, he was with his mother, telling me that she planned to bring him to the province and let the doctors there release the flap. I explained to her his condition and the plan of operation. I tried to convince her to let me be the one to release the flap but she insisted on bringing him to the province. So, I provided her with a clinical abstract. After about three weeks, they sought consult with us and the mother said that she wanted her son to be operated on as soon as possible. So we scheduled the patient on a Friday the following week and explained to her and to the patient what we are going to do. They agreed and everything went smoothly until after the operation when I got to talk to her again. She said, “Doktora, tanggal na po ba?” At first I thought I heard wrong, so I asked her what she meant, and she said, “Yung daliri ng anak ko.” That’s the only time the thought sank into my brain and I asked myself if this woman was in her right mind. I told her, that was not the plan for her son; it’s not the operation we explained to her. So I told her that the superior flap was released and we will schedule him again for the inferior flap. She answered, “Ano? Eh di nakadikit pa yung daliri ng anak ko? Dapat tinanggal mo na lang yung daliri nya. Pano yan, di pa sya makakatrabaho nyan.”   I told her, two more weeks and it will be released totally. “Wala na kong panggastos,” was her reply. When I told her that we could ask for help, she answered that she has no time for that. “Dapat tinanggal mo na lang, gusto na rin nya yun. Dapat tinanggal mo na!!!” I was nearing the edge of my patience, thinking, how could this lady, who was supposed to be a mother, ask a surgeon to mutilate her son?  But still, she insisted that we should remove the finger. Things were running through my mind at that moment, so I asked a colleague to talk to her for I might do what I was thinking.

 Insights (Physical, Psychosocial, Ethical) (Discovery, Stimulus, Reinforcements)

                        We were taught in patient management to always consider, in any surgical decision-making, what is ultimately best for the patient by considering the benefit, risk, cost and availability. But what if a relative of the patient would want a perspective too radical or not even indicated for the patient just because he/she feels that it’s a waste of time and money to go back for follow-ups and consults, would you comply with his/her wishes? Eventhough it is against your values?

Autonomy vs Doctors values

     Patient autonomy is  the idea that patients should be allowed to make decisions about their medical care and physical health unconstrained by the values of medical professionals. Certainly, doctors and nurses are sought out for the technical expertise which they have worked and studied to achieve; however, that doesn't give them the authority to impose their personal, non-technical values upon their patients,.

            In reality, patient autonomy is not unlimited. There are a number of ways in which it is and should be restricted. For one thing, patients cannot demand to be treated by non-medical means. Second, patients cannot demand treatment that is scientifically valueless. Finally, patients cannot demand treatment that is inconsistent with the purpose of medicine and the medical profession.

            But the question is… is that procedure (voluntary amputation) is within the boundaries of accepted medical practice?

            If patients are unable to find a single doctor willing to perform the amputation, despite the variations in ethics and values those doctors have, then that serves as evidence that the procedure is, indeed, outside the boundaries of acceptable medical practice. Thus, even though the patient's autonomy is being limited by the values of the doctors, it is not occurring in an unacceptable or unethical manner.