Patient, Heal Thyself How the "New Medicine" Puts the

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 Patient, Heal Thyself
robert m.
v e at c h How the New Medicine Puts the
Patient in Charge

1 2009
1
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Library of Congress Cataloging-in-Publication Data

Veatch, Robert M.
Patient, heal thyself: how the new medicine puts the patient in charge / Robert M. Veatch.
p.; cm. Includes bibliographical references.
ISBN 978–0–19–531372–7
1. Medicine--Decision making. 2. Medical ethics. 3. Medical care--United States. I. Title. [DNLM: 1. Patient
Participation--trends. 2. Delivery of Health Care--trends. 3. Personal Autonomy. 4. Philosophy, Medical.
5. Physician-Patient Relations. W 85 V394p 2008]
R723.5.V43 2008 610--dc22
2008003515

9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
 For
Willard Gaylin
Andre E. Hellegers (1926-1979)
Edmund D. Pellegrino
Victor W. Sidel
physicians who have mastered the art of respecting patients
and given them the freedom to heal
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preface

Decision making in medicine has long posed an intriguing and complex

problem. The technical, scientific issues of diagnosis, prognosis, and treat-
ment raise such complicated, esoteric issues that no ordinary patient could
ever master even a fraction of the necessary knowledge. Since ancient times,
patients have had to rely on experts—physicians and other health profes-
sional experts—to penetrate the thickets of medical science.
At the same time, the expert cannot possibly know or understand the
patient’s unique beliefs, values, and preferences that are crucial for knowing
what serves the patient’s interest. Worse, still, as medical professionals be-
come specialized and separate themselves from the broader community of
laypeople, in a sense they become alienated from the patient perspective.
They think about medical choices differently and choose options based on
values that are not shared by others. In fact, the Hippocratic notion of pro-
fessionalism suggests that by taking an oath, the physician sets himself or
herself apart from other citizens. He or she “professes” a set of obligations
that require loyalty to the profession. Just as patients cannot think like
health professionals, who have been trained to view medicine with a set of
concepts and theories unknown to laypeople, so, likewise, physicians and
other health professionals lose the capacity to think like the patient.
The male obstetrician who has delivered a thousand babies cannot possi-
bly get into the mind-set of the young woman in labor for the first time.
The oncologist who has chosen out of all the thousands of occupations to
give his life to fighting cancer and has cared for thousands of patients who
have gone on to die cannot think like the frightened, newly diagnosed
breast cancer patient who may have many critical responsibilities flash be-
fore her when she learns her diagnosis.
Several times a day TV commercials advise people to “ask your doctor”
about some drug when the doctor has no idea what the patient’s goals and
desires are. It is absurd for a man to ask his doctor, of all people, whether
Viagra is right for him. If he is going to ask, the first person should be his
wife or other partner. Similarly, as we shall see in chapter 2, asking the phy-
sician whether diet or drugs is better for high cholesterol makes no sense in
the era of the new medicine and rarely escapes my ridicule. Of course, phy-
sicians may be able to provide some technical assistance about whether a
particular drug could produce an effect the patient desires, but they are
not in a position to “prescribe” that the changes the drug will produce are
good for the patient. Patients, themselves, will have to take charge of those
decisions.
In my 40 years of work in the field of biomedical ethics, my primary
concern has been the division of labor between the health professional (pri-
marily the physician) and the layperson (primarily the patient). Medicine is
so complex that great specialization and division of labor are necessary to
master even one tiny aspect, yet no professional expert can possibly expect
to understand and think like the patient whose life hangs in the balance.
Increasingly, as I dealt with issues in bioethics, I felt a tension between
the standard way of thinking about medical choices and the way I saw
emerging in my thinking and in the new practices in the patient-physician
relation. The discovery of intensely ethical choices in certain special areas of
medicine—abortion, euthanasia, and gene manipulation, for example—only
made the tension worse. Both physicians and laypeople now acknowledge
that these special choices required a moral perspective that comes from out-
side medicine, but then they immediately shifted back to more traditional
ways of thinking about more ordinary decisions about asthma, arthritis, or
antibiotics. It was as if physicians occasionally had to call time-out from
their routine, scientifically based medicine to let patients do their value
thing on the special, value-loaded choices.
Many years ago I realized that my understanding of medicine was at
odds with normal modern thinking. I began to recognize that literally
every medical choice required a value perspective and that the health pro-
fessional could not claim expertise on that value dimension. Gradually, I
have discovered that others are beginning to recognize this as well. They are
moving to a “new medicine” in which patients must be in charge of making
the calls.

viii | p r e f a c e
 This volume is the culmination of this career-long journey toward what
I call a new or postmodern medicine. It is a medicine that had its begin-
nings in the exciting days of the 1970s when patients first began demand-
ing their right to make medical choices based on their own values. It is a
medicine now irreversibly launched as the replacement for what is now old-
fashioned modern medicine. It is a medicine that is radically different from
modern medicine in the role the layperson must play in medical decision
making.
In this volume I bring together my thoughts over the past decades. I
make a case that a new medicine is well on its way to emerging and that it
is destined to replace modern medicine. It is a medicine that will rely on
professional medical expertise as much or more than before for more techni-
cal matters of diagnosis, prognosis, and treatment options, but will require
a much more active patient in charge of choosing which options are best
for his or her own medical decisions. It is a world in which physicians and
health professionals will become assistants of patient who will have to take
charge and heal themselves.
This manuscript has been in preparation for several years. Some of the
ideas have germinated, often in only partially developed form, in articles I
have written over the years:
Portions of chapters 3–6 incorporate some parts of “Doctor Does Not
Know Best: Why in the New Century Physicians Must Stop Trying
to Benefit Patients,” Journal of Medicine and Philosophy 25, no. 6 (De-
cember 2000):701–721, by permission of Oxford University Press.
Portions of chapters 11 and 12 are adapted from “Abandoning Informed
Consent,” Hastings Center Report 25, no. 2 (March–April 1995):5–12,
© The Hastings Center. Reprinted with permission.
Portions of chapters 16 and 17 are adapted from “Single Payers and Multi-
ple Lists: Must Everyone Get the Same Coverage in a Universal Health
Plan?” Kennedy Institute of Ethics Journal 7, no. 2 (1997): 153–169.
Portions of chapters 20 and 21 draw on “Indifference of Subjects: An Al-
ternative to Equipoise in Randomized Clinical Trials,” in Bioethics,
ed. Ellen Frankel Paul, Fred D. Miller, Jr., and Jeffrey Paul, 295–323
(Cambridge: Cambridge University Press, 2002). Reprinted with the
permission of Cambridge University Press.
Portions of chapters 23–24 incorporate “Technology Assessment: Inevi-
tably a Value Judgment,” in Getting Doctors to Listen: Ethics and Out-
comes Data in Context, ed. Philip J. Boyle, 180–195 (Washington,
DC: Georgetown University Press, 1998) © 1998 by Georgetown

p r e f a c e | ix
 University Press, reprinted with permission; and “Consensus of Ex-
pertise: The Role of Consensus of Experts in Formulating Public Pol-
icy and Estimating Facts,” The Journal of Medicine and Philosophy 16
(1991):427–445, by permission of Oxford University Press.
In all of these chapters new material is included and material from articles
has been revised and integrated into a coherent account of what I am calling
the new medicine.

x | p r e f a c e
acknowledgments

I have over the years given prominent attention to the individual case. In
collaboration with others, I have written six different collections of case
studies, some of which have gone through multiple editions. I incorporate
some cases in this volume to illustrate the themes I develop. A few of the
cases are stories I have told before, particularly in the new edition of Case
Studies in Medical Ethics, which is also published by Oxford University Press,
but all reflect some real-life event that shows how values from outside med-
icine must shape medical decisions.
I had help from many people in developing the ideas and text for this
manuscript. My colleagues at the Kennedy Institute of Ethics have been a
continual stimulus for decades. They will recognize some of their input in this
volume. The professional librarians of the National Reference Center for Bio-
ethics Literature, the Kennedy Institute’s library, are a rich resource that any
academic researcher would treasure. Their knowledge of the field and its lit-
erature has been enormously helpful, as has been the support of Linda Powell,
Moheba Hanif, and Sally Schofield. Alexander Curtis and Traviss Cassidy have
read large portions of the manuscript and offered many helpful suggestions.
My wife, Ann, has heard many of these ideas so often that she can antici-
pate my thinking. She has tolerated these unusual interests and research
projects in a graceful and supporting way, for which I am grateful.
At Oxford University Press, Peter Ohlin has shepherded this project
with professional skill and talent. This is my fifth volume with Oxford. It is
a press of great quality for which I express my appreciation.
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contents

List of Cases xv

The New Medicine: An Introduction 3

part I: why doctor does not know

best
1. The Puzzling Case of the Broken Arm 21
2. Hernias, Diets, and Drugs 25
3. Why Physicians Cannot Know What Will
Benefit Patients 33
4. Sacrificing Patient Benefit to Protect Patient
Rights 43
5. Societal Interests and Duties to Others 51
6. The New, Limited, Twenty-First-Century Role
for Physicians as Patient Assistants 57
7. Abandoning Modern Medical Concepts: Doctor’s
“Orders” and Hospital “Discharge” 65
8. Medicine Can’t “Indicate”: So Why Do We Talk
That Way? 71
9. “Treatments of Choice” and “Medical Necessity”:
Who Is Fooling Whom? 83
 part II: new concepts for the new
medicine
10. Abandoning Informed Consent 91
11. Why Physicians Get It Wrong and the
Alternatives to Consent: Patient Choice and Deep
Value Pairing 103
12. The End of Prescribing: Why Prescription Writing
Is Irrational 111
13. The Alternatives to Prescribing 119
14. Are Fat People Overweight? 135
15. Beyond Prettiness: Death, Disease,
and Being Fat 141
16. Universal but Varied Health Insurance: Only
Separate Is Equal 155
17. Health Insurance: The Case for Multiple Lists 161
18. Why Hospice Care Should Not Be a Part of Ideal
Health Care: I. The History of the Hospice 175
19. Why Hospice Care Should Not Be a Part of Ideal
Health Care: II. Hospice in a Postmodern Era 183

part III: the new medicine and the new

medical science
20. Randomized Human Experimentation: The
Modern Dilemma 195
21. Randomized Human Experimentation: A Proposal
for the New Medicine 209
22. Clinical Practice Guidelines and Why They Are
Wrong 219
23. Outcomes Research and How Values Sneak into
Finding of Fact 229
24. The Consensus of Medical Experts and Why It Is
Wrong So Often 239
Epilogue: A Patient Manifesto 253
Notes 259
Index 277

xiv | c o n t e n t s
list of cases

Case Intro. 1. Karen Ann Quinlan: The

Groundbreaking Case 6
Case Intro. 2. Radical Mastectomy versus
Lumpectomy 9
Case 1.1. The Puzzling Case of the
Broken Arm 22
Case 2.1. Driving after Hernia
Repair 25
Case 2.2. Exercise, Diet, or Drugs to
Lower Cholesterol 27
Case 5.1. A Kidney for Your
Patient 53
Case 5.2. A Pap Smear for Nervous
Nellie 54
Case 5.3. Why We Shouldn’t Distribute
Kidneys Efficiently 55
Case 6.1. Livers and Money in HMOs 58
Case 7.1. Discharging the Supreme
Commander 68
Case 8.1. The Baby Doe Regulations and
Medical Indications 79
Case 9.1. The Cardiac Arrhythmia 84