‘I just don’t know. You’re the doctor’, she replies, after we have discussed the pros and cons of undergoing a knee replacement. Of course I know I’m the doctor. But that won’t get you out of making the decision, dear. ‘Well,’ I start sympathetically, ‘you have to weigh up the benefits of curing the pain you have had in your knee for years, versus the recovery period and other risks we discussed’, hoping this logical reasoning will be the final blow to her indecision.
‘Oh, oh, well ... I suppose …’ as I await the response, leaning forward in eager anticipation that we have made a breakthrough. ‘I just don’t know. What do you think?’ And around we go again. Mrs X has all the information she needs to make a decision. I proudly present the risks and benefits backed up by numbers from a recent lecture from a local orthopaedic consultant. I even present it all in layman’s terms, for heaven’s sake. What more does she want? Perhaps I have overloaded her with too much information. Or maybe she just wants someone to make that decision for her? Is she able to cope with this freedom of choice? Somehow, with only one minute of the consultation left, I feel myself almost wanting to make the decision for her. Which, at the end of the day, also seems to be what she wants.
As I summon all my powers to resist sighing deeply, Mrs X suddenly reminds me of one of the central themes of Dostoyevsky’s great novel, The Brothers Karamazov. Namely that freedom, or autonomy, is one of man’s greatest burdens. Dostoyevsky’s 1880 masterpiece is essentially the story of three brothers and their fractious relationship with their unruly and base father. However, the simple plot synopsis belies the strong underlying themes of the novel, including commentaries on philosophy, theology, crime, the human condition, and the fate of the human race.
In Book V of the novel, the middle brother, Ivan, recites a poem he has written entitled The Grand Inquisitor to his younger brother Alexei. This chapter of the same name is perhaps the greatest achievement of the book and one of the most famous passages in literature. It has even been the subject of a short film starring John Gielgud in 1975.1 In it, a medieval cardinal from the Spanish Inquisition meets the second coming of Christ. The aged cardinal goes on to level several accusations at Christ, including the accusation that man cannot deal with the freedom bestowed upon him:
‘Instead of taking over men’s freedom, you increased it and forever burdened the kingdom of the human soul with all its torments … man had henceforth to decide for himself, with a free heart, what is good and what is evil, having only your image before him as a guide — but did it not occur to you that he would eventually reject and dispute even your image and your truth if he was oppressed by so terrible a burden as freedom of choice?’
We regularly see examples of those who cannot deal with their freedom of choice. The obese person who can’t stop eating; the alcoholic who can’t stop drinking. Obviously, there are other factors affecting these examples, but a choice is still being made. Perhaps more importantly for our profession is the power we can potentially have over our patients who find it difficult to make choices. Again, from The Grand Inquisitor:
‘You want to go into the world, and you are going empty-handed, with some promise of freedom, which they in their simplicity and innate lawlessness cannot even comprehend, which they dread and fear — for nothing has ever been more insufferable for man and for human society than freedom! But do you see these stones in this bare, scorching desert? Turn them into bread and mankind will run after you like sheep, grateful and obedient, though eternally trembling lest you withdraw your hand and your loaves cease for them.’
Can our advice and medical opinions act as bread in the bare, scorching desert of our patient’s ignorance? If we go down the often tempting road of making decisions for our patients, can we create a dependence on ourselves a la Balint’s ‘the doctor as the drug’?2
Mrs X seems very uncomfortable. I cannot help but feel that this is all my fault. I’m just doing what I was taught. I am caught between the modern ‘shared decision making’ models of managing patients and Mrs X’s old fashioned paternalistic expectations my predecessors have instilled into her.3
Nonetheless, she is more unhappy now than when she first smiled on entering my room, just as Dostoyevsky’s The Grand Inquisitor predicted, perhaps? Sometimes in our consultations a middle ground must be sought between shared decision making and the paternalistic. Otherwise, we may find that putting all the onus on the patient is just too much to bear. For both the doctor and the patient.
- © British Journal of General Practice 2015