Physician neutrality and patient autonomy in advance directive decisions.

• Author: Peppin, John F.

The concept of neutrality is clearly characterized by Gianfranco Cecchin, M.D.: "Accepting our inability to act in neutral or nonpolitical ways, the term 'neutrality' was originally used to express the idea of actively avoiding the acceptance of any one position as more correct than another."(1) The concept as used in medical ethics literature, however, is much more robust than Cecchin's characterization suggests. Physicians are somehow to remove their personal values from patient-physician interactions. Further, they are to present all information and make all treatment decisions in an objective "value neutral" atmosphere. These admonitions are legion.(2) For example, David Orentlicher, M.D., J.D., the Ethics and Health Policy Counsel for the American Medical Association, encouraged physicians to "examine their practices [in order] to ensure that they are not imposing their values, wittingly or unwittingly, on their patients' end-of-life decisions."(3) Before "value neutrality" can be assumed to be the proper posture for a physician, two questions need to be asked. First, why be value neutral? What possible benefits could this approach entail?(4) Second, clearly if I ought to be value neutral, then I can be value neutral, but can I be value neutral? The answer to this question is without doubt a resounding no (vide infra). Therefore, the answer to the first question becomes moot. If value neutrality is unattainable, then the proper approach for physicians is an honest divulgence of their values.(5) In this way patients can choose those physicians with like-minded values and be more assured that their own values will be respected. The suggestion that physicians work from a morally neutral position is naive.(6) The lack of neutrality is painfully evident in instances where older patients are manipulated into refusing treatment through advance directives;(7) the Patient Self-Determination Act (PSDA) can serve as a tool in this regard.

The PSDA, part of the Omnibus Budget Reconciliation Act of 1990,(8) was specifically designed to reduce Medicare disbursements.(9) Because of a perceived invasion of patient autonomy, the PSDA requires Medicare providers to inform patients (in writing) of their rights concerning advance directives and refusal of treatment.(10) Although some see this act as an extension of the principle of autonomy to all patients,(11) the contemporary medical ethics literature predominantly refers to the PSDA in terms of older persons and not other age groups.(12) Moreover, the PSDA is designed specifically for patients to refuse treatment, rather than to choose to be resuscitated.(13) The initial intent was for patients to have the right to refuse expensive "end of life" treatment.(14)

It is unclear whether autonomy in the normative sense assumed by patients is exercised by older persons in the process of specifying advance directives. Definitions of autonomy such as that by Bruce Miller cannot fulfill the implied level of autonomy in the PSDA.(15) Clearly, autonomy can exist with limitations; for example, we do not allow patients the right to have one leg removed because it is longer than another simply at a patient's request. However, the notions implied to patients are quite a different matter. Patients are given a robust normative notion of autonomy through terms and concepts such as the PSDA. A pamphlet recently prepared by a consortium of professional organizations states, "An Advance Directive is a document stating your health care choices or naming someone to make the choices for you if you become unable to do so."(16) Notice that the pamphlet gives no limitations on the patient's "health care choices." Regardless of what philosophical definition of autonomy a professional may embrace, it is possible, if not actual, that patients are given and subscribe to notions of autonomy that are much more robust.

Physicians favor certain types of treatment depending to a large extent on the biases developed in medical training and experience.(17) Many feel strongly about certain approaches to therapy and often will do their best to persuade patients to accept that treatment through "manipulation of the consent process."(18) These forms of manipulation occur daily in medical practice and in themselves are not inherently wrong. In fact, they are oftentimes used in the patient's best interest. Physicians honestly and sincerely want their patients to get better, and they use this manipulative process to that end. Additionally, it is clear that physicians have biases that affect treatment decisions. Social class, income, gender, and ethnic background have been shown to influence physician decisionmaking.(19) What is a unique suggestion, however, even though these biases affect treatment decisions, is that they are unavoidable and that physicians should openly admit these biases to their patients. What might motivate physicians to manipulate patients' advance directive decisions? Ageism, limited resources and financial constraints, the pressure by hospital corporations, compassion and quality of life standards, and concepts of "futility" may all play a role either individually or in combination.

Ageism

Prejudice towards older persons, often referred to as ageism, exists in the health care setting and is one reason why physicians manipulate these patient decisions. Attitudes of both medical students and faculty, although similar to society as a whole, are largely negative towards older people.(20) Ageist stereotypes, developed during medical training, are the first "referents" physicians use when dealing with aged patients.(21) In the book House of God, the term GOMER, an acronym for "Get Out of My Emergency Room," is defined as "a human being who has lost--often through age--what goes into being a human being."(22) GOMER is frequently heard in the hospital and reflects an ageist attitude. Terms such as this have the same connotation as racial slurs and perpetuate similar conscious and unconscious attitudes. Furthermore, writers citing a supposed lack of "utility" of older patients, in order to support their recommendation that they step aside for the young, only fuel these prejudicial fires.(23) Research indicates that ageist attitudes affect a physician's therapeutic decisions towards older patients. For example, a study done by Sheldon Greenfield, M.D., showed a bias against older patients in the treatment of breast cancer.(24) Physicians in this study were less likely to give older patients the benefit of optimal care.(25) Other studies--cases of tube feeding, for example--indicate that physicians treat middle-aged patients much more aggressively than older patients even when clinical outcomes are similar for both age groups.(26) Moreover, attending physicians perform fewer examinations and tests on older patients than on younger patients.(27) It is of interest to note that these types of biases extend to other groups of patients, such as those with AIDS and physical disabilities.(28)

Limited Resources

Advocates of advance directives frame their support in terms of autonomy and compassion. However, as Philip Clark, Sc.D., recently claimed, "Just beneath the surface concern here with the humanitarian desire to end suffering is the more significant economic motive involving productivity and the return on dollars invested."(29) Clearly, with respect to older persons, the cost of resuscitation and care in the last few years of life is high, and if these individuals can be persuaded to specify that treatment not be undertaken, the financial savings could be significant.(30) In a different article, Dr. Orentlicher explained: "The Act [PSDA] is expected to decrease provider costs, assuming that many patients--especially older people--will opt to limit the expensive, intensive treatment they may receive in hospitals."(31) It should be noted, however, that the resuscitation outcomes in the pediatric population are much bleaker than in the older population.(32) Furthermore, advanced age, as an independent criterion, does not determine survivability after resuscitation.(33) Does this necessitate that we should insist on advance directives for pediatric patients?(34) This proposal is rarely, if ever, suggested. Additionally, treatments for certain forms of cancer have long-term outcomes much worse than that from CPR, yet we continue to administer them without a thought to the outcome statistics.(35) There may also be cost discrepancies among other groups, none of whom are aged. For example, "it may cost more to care for a sick baby than for a twenty year old with a similar condition."(36) This alone does not necessitate that one group of individuals be denied this care.

Hospital Corporations

The support for advance directives by hospital corporations could have as its basis hidden agendas other than "patient autonomy." The growing influence of health care corporations, such as HMO and insurance conglomerates, further contributes to the problem of ageism.(37) Sociologist Paul Starr suggests that these corporations could conceivably "lean on" physicians to control costs.(38) As Slaby and Tancredi suggest, "An economically based ethic cannot deal with the...