Doctors and Patients: The Value of Truth

THE OPEN MIND
Host: Richard D. Heffner
Guest: Dr. Jay Katz
Title: “Doctors and Patients: The Value of Truth”
VTR: 3/9/1985

I’m Richard Heffner, your host on The Open Mind. A recent book entitled “The Silent World of Doctor and Patient published by The Free Press refers rather frighteningly to studies indicating that a great many patients do not comply with their doctor’s orders and that their physicians are unaware of that fact. The reason…probably the ancient wall of silence between doctor and patient. The fact, as this perceptive examination of doctor-patient relationships indicates, that so many physicians intuitively believe that consulting their patients about medical decisions is really bad for patient care, and perhaps, even more important, the fact that so many patients really don’t want to be consulted on the grounds as doctors fear that consultation is too much a sign of something less than omnipotence on the part of the human which most of us don’t want to deal with. Well, the author of this book is Jay Katz, M.D., a psychoanalyst who has long taught at Yale Law School. Perhaps because while lawyers still practice the mystification of authority with their own clients, they find reasons and law while doctors shouldn’t do so with their patients.

Dr. Katz, I appreciate your joining me here today and I guess I have to admit that I am a rather stubborn person and I do want to make my own decisions about my own life, but I don’t think I’m stupid. I do greatly admire learning and expertise, so I’ve written down a question for you. I’ve written it down because I want to be very careful about it, and I want to ask whether, well there are two parts to this question. In terms of what doctors generally do, not what they profess, but in terms of what they generally do, and in terms of what the law requires them to do, how well safeguarded is my personal ability to make reasonably well informed choices about my own health and survival these days?

Katz: How much is it safe-guarded?

Heffner: How much is my ability safeguarded by what doctors generally do and by what the law requires them to do?

Katz: What the law requires them to do is actually very – it imposes very minimal requirements upon physicians. Indeed, physicians have misread law and viewed law as imposing many requirements upon them. This is, we need not so by and large, law only requires doctors to inform patients of the risks and benefits of the treatments which they recommend patients to undertake. They have in some jurisdictions unlimited obligations to talk about alternatives, but the extent to which alternatives have to be divulged to patients is not clear. Case law which is responsible for the doctrine of informed consent is rather vague on the legal requirements that it imposes upon the physician, mainly for the reason that law itself is ambivalent as to how much it wants patients to participate in decision-making.

Heffner: You mean because lawyers aren’t so sure about how much they want their own clients to participate in that kind of decision-making?

Katz: Exactly. In my teaching at Yale Law School, I’ve also addressed issues of communication between lawyers and their clients, and it is interesting that even though law in principle is very much committed to the notion of autonomy and self-determination, the respect for autonomy and self-determination gets markedly reduced when clients cross the threshold of the attorney’s office.

Heffner: Do you think that’s true of any profession, any area of professionalism where people have a kind of expertness that they have to protect?

Katz: Exactly. I think this is true for all professions, and probably medicine, one of the most ancient and revered professions, has set the tone also for this kind of behavior. Medicine, for ages, since ancient times, has held to the belief that patients have no capacity to participate in decision-making, that patients are children who should be seen, but not heard.

Heffner: Well, I was about to say, leave it to the doctor, and certainly you and I have said that many times, in different situations. Isn’t it true that I’m really not capable of making judgments about complicated medical issues that I’m likely to be confronted with as I grow older and older still?

Katz: I would suggest that if you leave decision-making completely to your physician that this could be dangerous to your health as the Surgeon General says with respect to cigarette smoking. Because particularly in today’s age with all the tremendous and marvelous technological advances that medicine has made with all the diagnostic and therapeutic interventions that it now can offer to patients, the problem is that there are many alternatives available, and each alternative available to patients has their own risks and benefits, and a patient must participate in deciding whether he wants to face the risks that some of these diagnostic and therapeutic techniques could expose him to.

Heffner: But, Dr. Katz, it seems to me that one could argue the other side, too, that the more that technology permits us or requires us to make rather technical choices among modalities of treatment, the less prepared I am, as a layperson, to pick and choose from among them. I mean, as they become more technical, it would seem to me they require more technical skill and knowledge. How could I possibly keep up with that?

Katz: Of course, the technological information, you do not need. But doctors have to educate themselves to talk with you in layman’s language about risks and benefits, about alternatives, and give you the information so that you can also ask intelligent questions, and on the basis of the back and forth between you and your physician, that the both of you can decide which treatment suits your interest best. For example, recently a distinguished colleague consulted me. He was hospitalized for an acute gall bladder attack secondary to gall stones and his surgeon insisted that he have a colisectomy. He knew me a little bit, and he wanted to discuss the matter with me and I got his permission to talk with the surgeon first. I read something about his medical condition, I talked with some other colleagues, and then I went to see him and in 20 minutes discussed with him the pros and cons of having the gall bladder operation, or not having it and wait for the developments. He might not have another attack, he might have another attack. If he has another attack in ten years, to be sure there is the problem that he may not be as physically healthy as he was at that time, and that surgery could, on that account, be more complicated and more dangerous. But again, these are risks that the patient has to decide whether he wishes to take them or not.

Heffner: You said you acted as intermediary.

Katz|: I acted as intermediary.

Heffner: Is that an indication that it is not likely that when I see a physician, a surgeon in this instance, that I will, myself, have available to me from the surgeon that kind of information, that kind of exchange, that kind of conversation as you call it?

Katz: By and large, it is unlikely that you will be exposed to that kind of dialogue because physicians still feel, though there are exceptions, that they are the decision-makers, and that it is best for patients to trust their physicians to make the right decisions for them.

Heffner: Is this something that stems from meanness of spirit?

Katz: No, it does not stem from meanness of spirit at all. Indeed, if it were that, then it could easily be eradicated. It goes back to ancient beliefs that doctors are the decision-makers. That, indeed, Hippocrates, in his writings to the extent to which he addressed physician-patient participation in decision-making said, “conceal everything from the patient, reveal nothing of the patient’s present or future condition”, and throughout medical history, physicians generally have taken the position that it is the decision that they must make.

Heffner: But, Dr. Katz, that is why I want to ask whether that stems from meanness of spirit. There must have been some life-preserving reason for that posture since it has come down over the years.

Katz: No, it’s very hard to figure out where it comes from. It is just an unquestioned belief that is part of professional…the thesis of professionalism. When later on, people tried, in the nineteenth and twentieth century, tried to justify why doctors should make decisions for patients, they argued that patients cannot understand the esoteric knowledge of medicine, that the art of medicine requires long training, requires wisdom, judgment, that medicine’s knowledge is esoteric, patients cannot understand it, so patients would be much better off if doctors make decisions for them.

Heffner: Well, until you get to the conclusion, so that patients would be much better off if doctors made the decisions for them, wouldn’t a reasonable person have to subscribe to everything that comes before the technological knowledge required, the lack of information, generally, on the part of most patients, the lack of background. I mean, is this such an untruth?

Katz: Yes, and no. but particularly since the Age of Science, medicine has acquired much greater ability to distinguish between what it knows, doesn’t know, and what is as yet conjectural. And since so much knowledge in medicine is beset by ignorance, it is very, very important for patients to be informed by physicians about what they truly know and what they do not know so that patients can then make the decision whether to have one treatment rather than another. And it is not difficult, it is not really that difficult to explain to patients the indications for a gall bladder operation, for a doctor to explain to a patient whether to undergo a radical mastectomy or modified radical mastectomy, whether to have chemotherapy, and/or radiation therapy or not. If doctors were educated for this kind of a task , they could do it and a great many patients could understand what doctors would communicate to them about burdens, the difficulties of choosing, the problems of choosing one treatment over another.

Heffner: You seem to feel that if the doctor were to say, “I really am not so sure myself”, that that would be a first step.

Katz: yes indeed, you know with respect to breast cancer, one thing a physician should tell to his woman patient is we really do not know which treatment is best. We have a number of good treatments, but which treatment is best, that we still have no knowledge about, and then go on from there.

Heffner: Dr. Katz, let me ask you a question that is parallel to one that I ask of many of my guests. Is there no downside to the position you take? Is there no upside to the position that you describe now, that patients would be made frantic by the knowledge that I, the physician, don’t know. Do patients depend up on physicians, indeed, that their recovery, that their very health, depends upon being able to say that, “father, physician knows best”. Is there nothing to that?

Katz: There is probably something to it, and there may be a great deal to it.

Heffner: IF there is a great deal to it, why do you wish to push that away?

Katz: At least I would ask a physician to learn to distinguish between those patients who wish to participate in decision-making and those patients who prefer to have doctors make decisions for them. Those distinctions are not being made these days. There will be, I would think, a small or maybe ea considerable number of patients who say, “Doctor, I trust you, I have faith in you, I want you to make these decisions for me”. But with one caveat, because doctors constantly tell me, look this is what my patients tell me. They say, when I invite them to participate in decision-making, they say, “Oh no, you are the doctor, you decide”. And the caveat is that you explore at least briefly with the patient as to his reasons for putting all responsibility on your shoulders because I would suspect that in a number of instances, he will learn that patients do so because they do not want to impose on the doctor’s time, that they feel that the doctor is a busy man, that he has may lives to save, and with their “silly questions” they keep him from obligations.

Heffner: isn’t that all true?

Katz: Yes, and no. it may be necessary that then the doctor will have to see fewer patients, but the patients that he sees will be better served by engaging in this kind of dialogue with them.

Heffner: Now let me ask you, realistically, how likely is it that that will take place. That the sacrifice, economic sacrifice, will be made that fewer patients are seen in order to meet the needs that you described.

Katz: I am not sure. My expectation is that the kind of things that I am writing about, if they ever are going to be implemented, will not be implemented for a long time. But at the same time, it is possible that patients and consumers will ask for greater participation and decision-making. When what is very likely, the public will become aware that too many coronary bypass surgery operations are being performed, that between conservative being ten percent and maybe a third of these operations are really unnecessary, that conservative medical treatment may be just as good as the surgeries that are being performed. Yet the patients have not been made aware of the fact. They may begin to ask, “What is going on here? We need to be included more in the decision-making process. We feel that we are in danger of being injured, subjected to unnecessary surgery by the silent treatment we have been and are getting”.

Heffner: You know, as I read The Silent World of Doctor and Patient, I told you before the program, I was frightened by it, frightened by the realization of so much of what happens in my own life in relation to physicians is described by you as endemic to the nature these days of most doctor-patient relationships, it made me feel much more pessimistic, it made me feel that it is much less likely that we would work of this. In truth, it seems to me that the unsilent world that you would wish for, the world of communication, the world of conversation was something that did exist to some greater extent, thirty years ago, forty years ago, fifty years ago. It exists, and it seems to be less and less, today. Is that a perception that you share, or that you disagree with?

Katz: It may be, I’m not sure how much more doctors spoke then with respect to decision-making. And by the way, I want to make it absolutely clear that I’m not talking about your ordinary kind of chit chat between doctor and patient. I talk about decision-making. Fifty, sixty years ago, doctors did not have, yet, the scientific discrimination to distinguish between what they knew and did not know as they have today. Indeed, what I am advocating has only become possible with the Age of Science. We now have this kind of capacity, and yet, we are still conducting ourselves as if we were living in the prescientific age, when soothing words, caring presence, help-giving nature and helping hand was almost all that physicians had to offer.

Heffner: Now that the medical profession has more to offer by way of outstanding scientific information, where would this begin, in medical school, in the training of physicians?

Katz: It has to begin in medical school, and, you know, it’s interesting that Harvard Medical School recently has instituted a new program that will address some of these issues that I have discussed in the book. It is also interesting that the impetus for change at Harvard Medical School did not come from the Medical School faculty, but from a former law professor, now President of Harvard University, namely Derek Bok, who in report to the Harvard Board of Overseers decried the unsatisfactory state of medical education at Harvard Medical School.

Heffner: Yet, as you describe what young doctors, young to-be doctors experience, it would seem that the authoritarianism that leads to the refusal to have the conversation you want is basic to medical training itself.

Katz: It is, you know, and therefore, from persons like Derek Bok, and then from the Dean of Harvard Medical School, other medical schools, change has to come about, but it will take time, and a great deal of thought. Indeed, whenever I am visiting a professor at various medical schools, as I was some weeks ago, when I meet with first and second year medical students, I have a lovely time with them. They are interested, they are stimulated, they are excited, they ask questions. But when I also interact with them, I appreciate that by their third and fourth year, their elders will change them again. And then, on one recent occasion, I was talking about my book (inaudible) the senior physician sitting in the front row treating me with respectful disdain and disbelief. And when they ask questions, again and again they asserted that they did not believe that patients had the capacity to participate in decision-making.

Heffner: Well, they said that and I would ask you whether doctors who have not experienced some kind of very basic program in preparing themselves psychologically for this can and whether you’re not making, I won’t say demands, but requests that simply aren’t likely to be met.

Katz: Because you believe that the teachers themselves have to be…

Heffner: Because you describe their unwillingness to have these conversations is something that is much more deeply psychologically rooted than the matter of the medical training itself.

Katz: Yes, but, these psychological issues can be brought out into the open and then confronted and changed. To give one example from my own personal history, my original work was in human experimentation in the days when I was amongst a handful of people who were beginning to argue that medical research subjects had to be asked for permission so that they could be, they had to be invited into the, that permission had to be asked from them before they are to be experimented upon. To begin with, I was again talking to a silent world, but that has very much changed in the last fifteen years. Attitudes towards research subjects have changed remarkably. It is possible that from my writings and the writings of others, there will eventually be a change in medical thinking, medical education. At least to that extent I am also an optimist.

Heffner: Dr. Katz, I hope so, and as we end the program, I must say that I was impressed by your reference to the Grand Inquisitor and Dostoevsky’s emphasis upon the terrible gift of freedom, and I suspect, too, that doctors aren’t so terribly wrong that we patients don’t want to accept that gift. We will talk about it again in a future program. Thank you so much for joining me today. Thanks too, to you in audience. I hope that you’ll join us again here next time on The Open Mind. Meanwhile, as an old friend used to say, “Good night and good luck.”

This is Richard Heffner, your host on The Open Mind. We’d like to know your ideas and your opinions on the subject we’ve just discussed. Please send your comments to me in care of The Open Mind at this station.