Addressing Requests by Patients for Nonbeneficial Interventions
Authors: Allan S. Brett, Laurence B. McCullough
Journal: JAMA (2012)

PATIENTS FREQUENTLY EXPRESS STRONG PREFERENCES FOR medical tests or treatments of their own choosing, even when physicians believe that those interventions are not beneficial. Physicians grant such requests for various reasons. One compelling reason is to avoid confrontation: patient-physician relationships flourish in an atmosphere of trust and goodwill, and physicians rightly worry that disagreement will threaten those relationships. Moreover, explaining why an intervention is not beneficial takes time. For patients with the common cold, granting requests for antibiotics is far less time-consuming than discussing viral microbiology and harms of antibiotic overuse. Although patients’ preferences are key factors in clinical decision making, a patient’s preference for a diagnostic or therapeutic intervention is not decisive unless a modicum of potential benefit, viewed from a conventional medical perspective, is present. When diagnostic or therapeutic choices are consistent with such a modicum of benefit, patients’ preferences should drive decisions. In contrast, physicians should not provide interventions that do not meet this criterion. Patients are increasinglywilling tochallengephysicians’ intellectual authority. Patients request interventions based on media publicity about new research findings, sometimes before physicians learn about them. Internet sources of clinical information empower patients to make medical judgments independent of consultations with physicians. Directto-consumer advertising prompts patients to diagnose themselveswithconditions tied toadvertiseddrugs. Inone respect, physiciansshouldwelcomethesechanges: clinical encounters involving informedpatientsbecomegratifyingwhenbothparties collaborate to advance patients’ best interests. However, patients who misinterpret self-acquired medical information may request unnecessary or even harmful interventions. Physicians may respond to requests for nonbeneficial interventions not only through individualized clinical reasoning but also by applying practice guidelines. When guidelines recommend against a requested intervention, physicians can appeal to them as external sources of authority and depersonalize potential conflict with the patient. However, guidelines also can be problematic: those who create guidelines may have conflicts of interest, guidelines from different sources may conflict, and applicable guidelines are unavailable for many clinical problems. Patient Autonomy and Professional Integrity Patient autonomy is often invoked to support patients’ requests for specific interventions. According to this perspective, patients’ preferences are always decisive because medical decisions reflect value judgments, and patients are always better suited to choose interventions consistent with their personal values than are physicians. However, this rationale is flawed. Distorting biases may influence a patient’s clinical judgment, and autonomous patients sometimes make decisions that confer no benefit or put their health at risk. Using patient autonomy to justify acquiescence to patients’ requests for nonbeneficial services violates professional integrity. Professional integrityrequiresphysicianstoadheretostandards of intellectual and moral excellence. Physicians achieve intellectual excellence by submitting clinical judgment to disciplined, evidence-based reasoning. Physicians achieve moral excellence by protecting patients’ health-related interests as a primaryconcern,keepingself-interests systematically secondary. Commitment to professional integrity requires that physicianschallenge requests fornonbeneficial interventions.For example, patients may derive subjective value from taking antibiotics for viral infections; however, such value is not decisive intheabsenceofbenefit fromthemedicalperspective.Over time,allowingpatients’demandsforunnecessary interventions to trumpcarefulclinical reasoningresults inanondeliberative, rote practice style that undermines clinical excellence. Patient autonomy is not an unqualified right to choose. A broader view of autonomy includes the ability to understand and apply relevant information in making clinical judgments. Correspondingly, the physician’s obligation is to promote coherent deliberation and not simply to dispense whatever the patient wants. The interpersonal nature of patient-physician encounters is better captured by the idea of respect for autonomy than by an abstract principle of autonomy. This idea underscores the physician’s obligation to consider seriously patients’ values and preferences while protecting their health-related interests.