Strange Medical Ethics: A Personal Tale

My wife just completed a procedure for a blacked carotid artery, obviously a stroke risk. She had the same procedure two years ago on the other side of her neck. In the discussions with the surgeon, he emphasized that this was a serious condition and had been put off too long: the artery was 80-90% blocked.

“You have a choice,” he said. “I can take care of this side just like last time, and the problem will be gone.”

“Or you can take part in an NIH study that will use experimental drugs and treatment over the next five years. It’s your choice.”

I had to interject. “What do you recommend?” I asked. “It’s up to you,” he replied. I said, “You just said this is a serious problem that poses the risk of a debilitating stroke. You said that you could fix the problem next week, and it would be gone. Why would my wife choose to endure the condition for five years?”

“For the good of humanity,” he answered. Well, my wife said: “Operate,” and as of today, it’s over: artery unblocked. Still, I’m troubled. It’s not the doctor’s role to advocate for “humanity.” His first duty is to his patient. It is unethical to in any way encourage a patient to accept a risky and uncertain treatment course when a better one is available.

The doctor should have told my wife about the study, and he should have firmly advised against it, in her best interests.

22 thoughts on “Strange Medical Ethics: A Personal Tale

  1. In my experience doctors these day s are incredibly timid and neutral about recommending anything to a patient in the name of “autonomy”. Except for the Covid shot, that I got a lecture for declining to get a booster.

      • Thankfully not. The only thing about guns I get is a written statement on my kids’ checkup report saying that guns should be stored safely. And that is because they’re required to do it by state law.

  2. I hope this takes care of her medical issue permanently.

    Jack wrote, “The doctor should have told my wife about the study, and he should have firmly advised against it, in her best interests.”

    I completely agree with your opinion on this, with an artery that is 80%-90% blocked the patient should be considered to be in imminent danger of a stroke. It sounds like the Doctor is a bit of a puppet getting undue pressure from other sources outside the confines of effective doctor patient relationship to ignore the imminent danger and “silently push”, by not making recommendations against, the alternative experimental treatment over surgery. I think what the doctor did, knowing the imminent danger she was in, was medically unethical and it may be an appropriate time to search for another doctor after the follow-up care is completed.

    Side Note: Proximity wise the NIH study is kind of in your own backyard, I bet that that NIH study wouldn’t even be offered to patients in the same condition in south central Wisconsin.

    Question: Is there a way to find out if her Doctor is somehow linked to the study he referenced?

  3. My dear wife has often said: “why do you ask me without a recommendation? Is it because of my extensive medical training and experience [non-existent]? What would you do or (if Dr is male and problem doesn’t happen to males) recommend for your wife ?” Trusting, of course, that the doc didn’t want to eliminate his wife.

    • … What would you do or (if Dr is male and problem doesn’t happen to males) recommend for your wife ?” Trusting, of course, that the doc didn’t want to eliminate his wife.

      Crippen!

  4. Medical trials comparing existing and novel therapies aren’t approved by Ethics Review Boards unless there is significant clinical equipoise — that is, uncertainty about which is better.
    In this case, I think your wife’s doctor underplayed the potential advantages of the new approach (which, without knowing anything else, include at the very least avoiding the risks of surgery).
    Technically, though, “for the good of humanity” was still the correct answer; as much as there is sometimes a possibly of personal gain when participating in human health research, prospective participants are discouraged from letting that (the so-called therapeutic misconception) influence their decision.
    As for asking for increasingly seeking patient input, that’s definitely part of Western medicine moving away from what was called paternalistic medicine. Doctors are encouraged to describe risks and benefits of alternatives without necessarily recommending one over the other. Your mileage may vary with this approach.

    • A great quote from that piece:

      “demanding that wet markets be closed to halt an emerging zoonosis might be technically correct, but if it does not account for those who make their livelihoods from such markets, One Health will only worsen the lives of those it claims to care about.”

      The Lancet, of all the top medical journals, has had the highest rate of retracting articles in recent decades.

  5. My wife’s doctor (who just retired in December) would present her with options and then say, “…the choice is up to you, but if I were in your position, I would…” and then give his recommendation. We very much appreciated that frankness.

    You are exactly right. The doctor should consider a patient’s individual needs before anything “for mankind’s benefit.” His/her job is to treat the patient in the room, not the entire planet or even a subset of it.

    • What troubles me is the more typical patient. I was there; my wife is no shrinking violet with doctors. Too many patients are relatively ignorant and submissive to “experts.” I remember a conversation I had with young, female, black cabbie in DC. I mentioned that she was picking me up from a legal ethics seminar, and she asked me if it was right that her lawyer negotiated a settlement for a lawsuit she brought without doing barely any work. “Now I have to take that settlement, and it just isn’t right,” she said. “Well, you don’t have to accept a settlement just because your lawyer negotiated it, ” I said. She thought she had to accept it, because that’s what her lawyer said.

  6. With the condition as advanced as your wife’s, it was inappropriate for him to mention that particular choice at all, and especially to dither on whether he recommended it. If it had been 10-20%, I can see making her aware of the non-surgical option (which probably comes with frequent monitoring, which could be a benefit.)
    Which brings up another question: What about the ethics of bringing up a study that offers other types of compensation? Do those entice people, especially those in financial straits, to take a gamble on risks to their health?

  7. The more I think about this, the angrier I get. This guy is a licensed physician. He’s not a minister. What a glib thing to say to a patient. This is another example of what the left’s destruction of organized religion has accomplished. Leftyism is the new religion. This guy is a de facto Lefty priest. He’s no longer treating physical disease; he’s preaching a religion. This is wrong on too many levels. And insidiously dangerous. I think I’d even be justified in saying this is an existential threat if lefties hadn’t made a joke of that concept. But it certainly was threatening Grace’s life, i.e., her existence.

  8. This is a general comment: I think the doctor was not wrong to present the choice of an investigative nonsurgical option to Mrs Marshall.
    80-90% stenosis does NOT mean 80-90% chance of stroke, especially if she hasn’t had a stroke or stroke symptoms before. The risks and benefits of carotid endarterectomy are very much active research questions. Scooping plaque out from a major artery of the neck is no mere trifle.

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