Patient Choice and Narrative Ethics
Patient Choice and Narrative Ethics
Most doctors subscribe to the idea of offering patients a choice about their medical management: for example, choosing whether to start preventive treatment for a risk factor like hypertension, or deciding which hospital to go to for an operation. Of course, such choices may not be as straightforward as they seem. Doctors may give a steer by what they mention in terms of risks and benefits, and some patients prefer their doctors to make decisions for them anyway. In spite of this, engaging in dialogue about choice has become one of the hallmarks of good medical practice. The right to choose has become a central feature of medical consumerism. There are also whole areas of medical discourse and training – like patient-centred medicine and shared decision-making – that focus on the idea.
As well as being able to help patients make decisions, doctors also need to offer choices of a different kind during the consultation: inviting people to choose what they want to talk about at any moment. Although the skills for doing this receive far less attention than those concerned with decision making, they may be even more important. Consider, for example, these two alternative versions of the same consultation:
Version A:
Patient: I've come about the spots on my face.
Doctor A: How long have they been there?
Patient: I've had them since I was a teenager. But they've really broken out badly in the last few months.
Doctor A: Have you tried anything for them?
Patient: I've bought a few things at the pharmacist but nothing seems to work.
Doctor A: Well, let's have a look then …
Version B:
Patient: I've come about the spots on my face.
Doctor B: How long have they been there?
Patient: I've had them since I was a teenager. But they've really broken out badly in the last few months.
Doctor B: Do you have any idea why?
Patient: I'm not sure. Could it be stress?
Doctor B: Why do you ask?
Patient: Well I lost my job about six months ago, and then my boyfriend left me in the summer and I've been pretty low generally and … (starts to cry).
Although the opening of the consultation is the same in both versions, the two doctors take it in entirely different directions. Doctor A fails to hear the patient explain that the spots have broken out badly 'in the last few months', or at least decides not to follow this cue. Doctor B not only hears the phrase, but offers the patient a chance to expand on why this may have happened. By the end of the consultation, the patient may still reach the same 'choice'– in the technical sense of which medication she uses for her spots. However, Doctor B's curiosity opens up an additional set of possibilities for her. This includes the option of forgetting about the spots, and exploring a better way of addressing her recent life events. There will then be no prescription. What is commonly meant by 'patient choice' will have turned out to be quite irrelevant.
Introduction
Most doctors subscribe to the idea of offering patients a choice about their medical management: for example, choosing whether to start preventive treatment for a risk factor like hypertension, or deciding which hospital to go to for an operation. Of course, such choices may not be as straightforward as they seem. Doctors may give a steer by what they mention in terms of risks and benefits, and some patients prefer their doctors to make decisions for them anyway. In spite of this, engaging in dialogue about choice has become one of the hallmarks of good medical practice. The right to choose has become a central feature of medical consumerism. There are also whole areas of medical discourse and training – like patient-centred medicine and shared decision-making – that focus on the idea.
As well as being able to help patients make decisions, doctors also need to offer choices of a different kind during the consultation: inviting people to choose what they want to talk about at any moment. Although the skills for doing this receive far less attention than those concerned with decision making, they may be even more important. Consider, for example, these two alternative versions of the same consultation:
Version A:
Patient: I've come about the spots on my face.
Doctor A: How long have they been there?
Patient: I've had them since I was a teenager. But they've really broken out badly in the last few months.
Doctor A: Have you tried anything for them?
Patient: I've bought a few things at the pharmacist but nothing seems to work.
Doctor A: Well, let's have a look then …
Version B:
Patient: I've come about the spots on my face.
Doctor B: How long have they been there?
Patient: I've had them since I was a teenager. But they've really broken out badly in the last few months.
Doctor B: Do you have any idea why?
Patient: I'm not sure. Could it be stress?
Doctor B: Why do you ask?
Patient: Well I lost my job about six months ago, and then my boyfriend left me in the summer and I've been pretty low generally and … (starts to cry).
Although the opening of the consultation is the same in both versions, the two doctors take it in entirely different directions. Doctor A fails to hear the patient explain that the spots have broken out badly 'in the last few months', or at least decides not to follow this cue. Doctor B not only hears the phrase, but offers the patient a chance to expand on why this may have happened. By the end of the consultation, the patient may still reach the same 'choice'– in the technical sense of which medication she uses for her spots. However, Doctor B's curiosity opens up an additional set of possibilities for her. This includes the option of forgetting about the spots, and exploring a better way of addressing her recent life events. There will then be no prescription. What is commonly meant by 'patient choice' will have turned out to be quite irrelevant.
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