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Year : 2021  |  Volume : 2  |  Issue : 2  |  Page : 159-162

The case for paternalism

Professor Emeritus of Nephrology, Apollo Hospital, Chennai, Tamil Nadu, India

Date of Submission31-May-2021
Date of Acceptance03-Jun-2021
Date of Web Publication30-Aug-2021

Correspondence Address:
Dr. Muthu Krishna Mani
Apollo Hospital, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_49_21

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How to cite this article:
Mani MK. The case for paternalism. J Med Evid 2021;2:159-62

How to cite this URL:
Mani MK. The case for paternalism. J Med Evid [serial online] 2021 [cited 2021 Sep 25];2:159-62. Available from: http://www.journaljme.org/text.asp?2021/2/2/159/324967

I first began treating patients on my own in 1959, as a houseman in the Government General Hospital, Madras. Technically, I was not the treating doctor. I acted on behalf of my chief, but in fact, there were so many patients that we would never have completed the 2-h outpatient session within the 5 h it actually took us if we had paused to consult the chief or his assistant for all but the most complicated patients. Informed consent did not exist. The fact that the patient had come to the clinic implied consent to all we did for him, and we prescribed mixtures or tablets (rarely injections in those days) and sent him off with cursory instructions. The question of consent arose only on the surgical side, and there, it was hardly informed. The patient was told, you have this tumour or this ulcer or this block, and it cannot be cured with medicines. You will have to undergo an operation on such and such a day. The patient signed his consent, though sometimes he would abscond from the ward the night before he was due to be cut open, and we assumed that consent was withdrawn.

With very few exceptions (arsenic or mercury), the medicines we used in those days hardly had any effects, good or bad, and we did not inform the patient of that, or the fact that he had to cure himself and the medicines were only to make him and us feel that we were doing something for him. There was clearly no need for a physician to ask for consent. The surgeon had to obtain consent, for the patient had to come to the operation theatre. By the time I became a houseman, I was determined to be a physician, so I attended surgical postings only when it was mandatory. However, I came across the greatest ethical problem I have ever been involved in.

I was house surgeon to the famous neurosurgeon Dr. B. Ramamurthi, one of the pioneers in that discipline in this country. We had a patient with a subdural haematoma and he was dying. He had headaches, convulsions and paralysis. Dr. Ramamurthi explained to him that he could achieve nothing with medicines. He needed surgery, a very simple and safe procedure. Dr. Ramamurthi would guarantee success and complete relief from his problems, and if he did not have the operation he would die. The patient was unshakeable. He would take any number of tablets or injections, he said, but under no circumstances would he undergo surgery.

When days of explanations failed and he stayed firm, Dr. Ramamurthi finally yielded and said he would only try an injection. The injection was thiopental sodium, and the anaesthetic team was waiting in the verandah with a Boyle's apparatus. The moment the patient lost consciousness, they rushed in and intubated him, and he was then shaved and prepared and moved to the operation theatre, and Dr. Ramamurthi evacuated the haematoma against his will and without his consent. He recovered completely, was truly grateful when he saw and felt the outcome, and left the hospital blessing our chief and all of us for having disobeyed him and saved his life.

What would you have done? Today we would probably send such a patient home, or keep him in the ward and watch him die. The raison d'etre of the medical profession is to cure disease and save lives, and Dr. Ramamurthi fulfilled his obligation though in a most unethical manner. Would any of you strike him off the register?

Perhaps the term informed consent crept into the literature sometime after I became a consultant on my own. I do not remember it being used earlier. It was the time when medicine became more invasive, more expensive, more capable of doing harm and when patients and courts were more ready to punish doctors when anything went wrong. It became mandatory during the last quarter of the twentieth century. The practice of medicine has become more defensive. Today, we give our patients long lectures on the possible complications of everything we do, the chances of recovery and the costs. If we do not have the time, we give them literature. We have modified consent forms and the patient has to certify that he has been informed of all possible complications, and the chances of success and failure, and he has decided that he will go through the procedure or the treatment and accept the outcome, and absolves his doctors of responsibility. Sometimes, we make him write the whole consent form out in his own handwriting, and as far as possible we have a close relation of his to witness his signature. Despite all these precautions, some patients or their relatives sue if things go wrong.

Many associations have published so-called 'evidence-based guidelines' for treating various diseases, and doctors today play safe and stick to those guidelines rather than their own opinions. The fact that the evidence is often based on the opinion of a group of doctors who may not have any more experience or knowledge than you have is irrelevant. It is certainly safer, and it is good defensive medicine. It is also safe to take a second opinion before embarking on any therapy that might have adverse effects. The doctor consulted might order a whole new set of tests that would double the patient's expenditure, but that should not matter as long as he will back us up if we are sued.

If a patient comes to me with a condition in which I do not have deep experience or knowledge, I would use the guidelines suggested by a reputed organisation, but I would observe the response and build up my own opinion. As my experience grew, I would modify the treatment. May I stress to you that India is rich above all nations in disease? We see patients in hundreds where the Western physician struggles to get his numbers into double figures. Every one of us should document our experience and review our results periodically, say once a year. We can then speak authoritatively on what happens to a disease with whatever treatment we have used. We should publish our findings, especially if they differ from the published literature.

There are situations where the patient and his family should be given complete information, sometimes calling for several meetings. Renal transplantation is one such. There is never a guarantee of success, and immunosuppression carries risks, sometimes to life. There is an alternative, staying on long-term dialysis. There is often a need for a relation to give a kidney. The donor needs even more detailed information. She has a 1 in 3000 risk of dying as a direct result of surgery, and 8% risk of serious complications. Perhaps two or three in a thousand would years later go into renal failure severe enough to need dialysis or transplantation. I have to be sure that the donor really understands all this and yet wants to give a kidney. There is always at least one confidential session with the prospective donor, with no one else present, and I always assure her (less often him) that I would give a medical reason for rejecting her if she is reluctant to lose a kidney. From the recipient's point of view, many immunosuppressive agents are available with varying possibilities of success, incidence and severity of complications and above all, cost. Clearly, there is a need for detailed information, discussion and consent with understanding.

Today, there is an abundance of information available on the Internet. A distant relation of mine, a very computer savvy young lady, met me one evening laden with some hundreds of sheets of computer printouts. Her father had a carcinoma of the prostate and was on treatment at the Tata Memorial Hospital in Mumbai. The doctor treating him had suggested a line of treatment and told the patient and his family that they were welcome to think it over and come back to him. This anxious daughter had found half a dozen different possible approaches through Google, and there were strong arguments for and against every one of them. She wanted my advice on what to do. I told her she should burn the pile of paper she was carrying, go back to the doctor and do whatever he suggested. Perhaps this was not sound advice. I did not think of the consequences in terms of global warming.

This is a problem that always bedevils the concept of informed consent. The majority of lay people, and perhaps some doctors too, are not accustomed to assessing statistical possibilities, and making a reasoned decision. When you describe the available options, in other words give the patient all the information, how do you think he chooses between them? Most often, he goes to another doctor, or to a few relations or friends, and asks for their opinion. If one of them is more assertive and has formed an opinion already, his advice usually carries the day. I am often consulted in fields which are not my own. I always tell the patient to do as his doctor recommends.

A friend of mine is a scientist who has retired after a long career in a hospital. Her mother had COVID infection before vaccines became available, and fortunately recovered. She has many siblings, and so has her husband, and all but one of them have been vaccinated and are well. The sole standout is her husband, who is sure he will get clots if he takes any vaccine. The Central Health Ministry says there have been 0.61 incidences of such clotting per million doses of vaccine. No amount of persuasion, of trying to explain that this figure is so low as to be almost none, and the protection may be the difference between life and death, has made him change his mind. He is certainly not alone in our country. I would certainly be paternalistic with him, and try my best to force him to take the vaccine.

A young man, a chronic smoker, consulted me for an episode of haematuria. He had proteinuria, so I suspected he might have IgA nephropathy. He also had a tumour in one kidney. I told him he should have the tumour removed, and further treatment for it depended on what it might turn out to be, but my impression from the radiological appearance was that it would prove benign. At the same time, a biopsy could be done from the surrounding non-tumorous tissue to make a diagnosis of the disease and decide on the treatment. I referred him to a urologist with a request that he do a partial nephrectomy, get rid of the tumour and have it histologically examined, and do a biopsy from the rest of the kidney. Since I was not 100% sure of the diagnosis and the prognosis, I would like to conserve as much of kidney tissue as possible. I did not anticipate that the urologist would believe strongly in informed consent. He told the patient he could remove only the tumour, which was a more difficult procedure and had a greater risk of complications, or he could remove the whole kidney, which would be a much simpler procedure. The patient opted to have the simpler procedure. He did not come back to me, and the surgeon did the nephrectomy with absolutely no problems. The tumour was benign, and he had IgA nephropathy, was resistant to treatment and went on to develop renal failure. He did not die of it because he kept smoking and died of a myocardial infarction before he needed dialysis.

This was clearly informed consent. However, if he had come back to me after seeing the urologist and before surgery, I would have pressed him to opt for partial nephrectomy, which is what I had referred him for. I would have insisted that he should conserve as much of kidney tissue as possible. Later, I berated the surgeon for having taken the easy way out, but he told me clearly that he had discussed it with the patient and the patient opted for nephrectomy, so this was informed consent and he had done the right thing, and I would have been wrong to force him to do a partial nephrectomy. I must confess that I would have used every pressure within my power to force the patient to have a partial nephrectomy and conserve as much of functioning kidney tissue as possible. I might have been able to preserve his renal function for much longer. I am not as bold as Dr. Ramamurthi. I would not have done a partial nephrectomy without his consent, but I would have used all my authority and powers of persuasion to influence him to accept my point of view.

Let me give you another example from my own experience.[1] I have been fortunate to have had several thousands of patients with chronic renal failure seeking my advice, and still more fortunate in that they have remained faithful, have followed my instructions and kept in touch with me regularly, and have come for their annual follow up. It is generally accepted by nephrologists that blocking the renin-angiotensin system (RAS) with angiotensin converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARBs) retards the progression of chronic renal failure by reducing proteinuria, reducing hyperfiltration damage and controlling hypertension. These are double edged weapons in that they can cause dangerous hyperkalaemia, can occasionally reduce glomerular filtration (GFR) too much and cause acute renal failure or worsen chronic renal failure, and can drop the blood pressure too low. Accordingly, guidelines now suggest that we should restrict the dosage to a rather low level, and should not combine ACEi and ARBs, though it is accepted that the combination would be more effective in the reduction of proteinuria.

Just think of those complications. Hyperkalaemia, azotaemia, hypotension. These can be recognised with the utmost of ease even in the most remote corners of India. Why should the patient be restricted to a 'safe' dose of ACEi or ARBs if a larger dose would be more effective, if you could work out a system by which the complications could be avoided? The internet has penetrated almost everywhere in India, and villages where it has not have a Public Call Office which usually has a fax machine. I do not accept oral information or give oral instructions because of the risks of their being misunderstood, and insist on written communications which should be preserved and reviewed every time the patient comes to me. I start with a low dose, monitor the effects after a week (blood pressure, serum potassium and creatinine) and build up the dose gradually to the limits of tolerance, and as long as I can see a beneficial effect. If the patient does not co-operate adequately, he is unsuitable for this line of treatment and moves to my control group, so this is clearly not a randomised control trial. That does not bother me. With these measures, the rate of decline of renal function has been brought from a loss of GFR of 8.6 ml/min/year in diabetic nephropathy to 2.5 ml/min/year, in chronic glomerulonephritis from 5.8 to 2.6, in chronic interstitial nephritis from 3.4 to 1.2, and so on in all diseases. In the total of some thousands of patients with chronic renal failure of all causes, the decline is reduced from an average of 5.7 ml/min/year to 2 ml/min/year. If patients with all renal diseases are detected as soon as their GFR falls below normal and put on appropriate therapy, we can give them an astonishing prolongation of life before they reach the end stage, from an average of 15 years without such intensive therapy to 40 years with it, which means that most of them will attain their normal life span without need for dialysis or transplantation.

When I know I can safely achieve these phenomenal results, I do not discuss options with the patient. I give instructions. I can continue this line of treatment as long as the patient does his tests a week after I have increased the dose and sends me the reports promptly. If he does not, I continue with other measures (diet and control of electrolyte disturbances and blood pressure) and do not take chances with the potentially dangerous blockage of the RAS. And if the patient realises what he is missing out (usually by comparing his results with another of my patients) and promises he will be more obedient in future, I would give him another trial. If he defaults again, I would not take him up for the high dose treatment.

This is clearly arrogant paternalism. If you are critical of my approach, please take another glance at the data two paragraphs above. It is my responsibility to do the best I can for any patient who comes to me, and I do. When the results are so beneficial to the patient, would I be justified in giving him a host of alternative suggestions and leaving him to make a choice which is clearly inferior? He would consult some other doctor who would tell him that he should not take so high a dose of these medicines, and he would opt for less efficient treatment.

Let me summarise my views. Where different lines of treatment are available, and there is no overwhelming evidence that one is superior to all the others, there is a need for full information on all options and informed consent, as in end stage renal disease.

If I have a clear line of treatment that is much superior to other options, I would give my patient instructions and not choices. Of course, I would let him know what he could expect by way of problems and costs, and the prospects of success. Given the fact that most of our patients do not want to be forced to think about options that they do not understand clearly, this is my responsibility, and this is what the patient has come to me for. I would not be justified in offering him a second-rate option when the best is available. This is what we have taken the profession for.

When the patient is obstinate and will not accept what I regard as the best course, like vaccination against COVID-19 or having a partial nephrectomy in an incurable renal disease with the probability of decline in renal function, I have no choice but to accept the patient's decision. I would not refuse to treat him, and I would do the best I can for him, but after making it plain that this is not the best option.

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  References Top

Mani MK. What we should do for chronic renal failure in India. J Mahatma Gandhi Inst Med Sci 2017;22:73-7.  Back to cited text no. 1
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