There are four basic principles in medical ethics: autonomy, justice, beneficence and non-maleficence. Any procedure or treatment must adhere to all the four principles.
Autonomy entails the right of a competent adult patient to make informed decisions about their care. I have had an interesting encounter with a patient exercising his autonomy.
He was in his early seventies.
His arrival at the casualty caused chaos and pandemonium. He was brought bleeding from his backside. It had began when he went for a long call that morning. Clots of blood mixed with stool filled that toilet bowl, sparking anxiety and fear in the household.
Everyone fears blood, trust you me. Even health care workers. And the reflex reaction to that scare is almost always to call the surgeon. Unless the bleeding is from the private parts of an expectant mother when the gynaecologist takes over.
The phone call interrupted my ward round.
I could sense urgency from the voice of the experienced clinical officer on the other end of the line.
“ Is the patient in shock?” I enquired.
“Then get two large bore intravenous canulae and commence resuscitation with fluids as you organize for blood,” I answered after assessing the danger of the old man exsanguinating under our watch.
When I arrived at the casualty minutes later, there was a pool of dark blood in his pampers. He did not appear pale and his pulse was strong and reassuring.
A quick examination of his abdomen revealed a mobile fist-sized lump under his right rib cage.
Broke Bad News
“He has a ride sided colon tumour. Let us get him to intensive care unit (ICU) for close monitoring and look for some pints of blood,” I told the team. I reassured them that majority of bleeding from the bowel is self limiting within the first day. All we needed to do was replace the lost blood and keep a close eye for a new onset torrent.
I followed him in ICU and broke the bad news. I did not have confirmation but as the adage goes, ‘If it looks like a duck, swims like a duck and quacks like a duck, then it probably is a duck’.
He would hear none of my nonsense, he averred.
As predicted, the bleeding did stop and he was stable after a day in ICU. We discharged him and organised a colonoscopy (peeping into his large bowel using a camera introduced through the asshole).
He showed up with the results the following week.
You should have seen the ‘of course, I told you’ expression on my face as I perused the results that showed cancer of the colon. Scans of the abdomen and chest did not show any spread beyond the involved section of the intestines. I advised surgery as the cancer was curable at that moment.
He would hear none of my nonsense, again!
Being an adult of sound mind, I was obliged to respect his autonomy. No number of sessions with counsellors or family members would convince him otherwise.
Cancer Left Untreated
I apprised him that left unattended, the cancer would spread to other areas and grow to block his intestines. In another few months or so, he was likely to be brought back in extremis, unable to make a lucid decision.
I did not do that to scare him into consenting to surgery. I have learnt no to! I wanted him to give clear instructions on what needed to be done at the moment, which would surely come. Should I go with his stand of no treatment, or should I follow the family wishes which I know would include ‘do everything you can, doctor’?
The man was categorical, if he ever showed up with overwhelming infection from blocked intestines, I was to do nothing! Absolutely nothing irrespective of who gave orders to the contrary.
I noted that in his file and allowed him home, leaving my doors open for future discussions and looping the counselling team in.
Nearly a year passed, the old man kept defying the advice from his family. But he kept losing weight, growing sicker.
I eventually met him after he was brought with the tumour blocking his intestines, as predicted.
This time I was careful not to put on an ‘I told you so’ kind of face as I shook his hand.
Luckily the blockage was not complete. With bowel rest, the distended tummy eventually flattened, revealing the toll the disease had taken on him. I asked him what he wanted.
“ Do as you wish doctor,” he told me, matter of factly.
We were lucky that the cancer had not spread beyond the bowel wall. I resected the cancerous bowel and re-approximated the intestines to regain continuity. I was so worried that the joinery would break down and leak feaces into the rest of the abdominal cavity. Was this to happen, given his age and diseased body, it would have been a death sentence.
The converse, to temporarily fashion a stool outlet though an opening on his belly skin, would have been to kill him from shame and despair. I had learned this from his persona, and the advice of a senior colleague.
It so happens we got away with the risk we took. He walked out of hospital stronger than he had walked in. Final surgery: ‘right hemicolectomy with ileotransverse anastomosis for colon cancer’.
Would it have been different had he accepted surgery a year earlier? I do not know.
Such is the high octane drama that we call surgery. Sometimes I spend days explaining to patients how lifesaving surgery will be to them, then they succumb from surgical complications. Once in a while a patient defies advice for a life saving surgery, and walks home.
As we say in medicine, diseases do not read books.
Our work is to tell you what the science has unearthed. What is best practice as backed by evidence. It is your responsibility to decide to accept or reject the doctor’s orders. Your autonomy reigns supreme to whatever the doctor advises.
Only, your autonomy is not always in your best interest, viewed through the lenses of evidence and best practice.
Do be cognisant of that next time you are having a conversation with a surgeon.