Should we not expect our patients to take some personal responsibility for their health? Along with apartheid paternalistic medicine was swept out the door in 1994. Treatment cannot be forced upon a patient who doesn't wish to take part. Our constitution very clearly reflects this principle by ever lowering the age at which consent to medical and surgical procedures may be granted. A 12 year old may now either consent to or opt out of an operation. Even if a doctor knows that the patient is choosing to walk a road which will surely be strewn with nettles, if the patient is of sound mind and has been adequately informed, she can choose not to have life-saving treatment.
Eight months ago I saw a middle aged woman at the clinic with what was clinically quite obviously a cancerous growth in the breast, threatening to break through the skin. The fact that, before presenting to me, she had already waited what must have been several months since she should have realised something unusual was growing in her, made me suspect that she was too scared to face a doctor and for her worst fears to be confirmed. Such a response is quite predictable and, of course understandable. I am not blunted to the human feelings of trepidation and doubt which we all experience. I, thus, obviously counselled the patient and explained, in simple terms, the different options available to her for obtaining local control of the tumour if not to save her life. I ran a set of tests to confirm the diagnosis and prepare the patient for a radical mastectomy within the following two weeks.
Yesterday, the same patient presented to me again at the clinic. She'd never had the mastectomy. She presented on the correct day for her scheduled surgery. An open biopsy was done and she was given another follow up date at the clinic. This is were things got hazy: the next we saw of her was earlier this week. She says admin never gave her a follow up date. Our notes clearly request a follow up date. What I'm getting at is that this patient should have made sure she got to see a doctor again. Whether or not admin booked her into the system, she should have made sure to see us again, to ask for a date. In the subsequent six months she carried that growing tumour with her every day. Surely she should have questioned what was happening to her, thought it strange that after the last surgery she never got to see the doctors again. The constitutional court of law entrusts a 12 year old to consent to an abortion which may complicate and result in a septic uterus, emergency hysterectomy and loss of the ability to ever bare children. Yet, a grown woman, fully counselled, of sound mind, could not ensure that she had a follow up date to see her surgeon.
During the six months since her last visit, the mass in her breast ulcerated through the skin forming a massive crater. It invaded her chest wall and matted her axilla. By now it would have spread to numerous other organs. In a word, it now is irresectable. The smell from that tumour is so pungent, it makes your nose sting. Local surgical control six months ago would probably not have saved her life. It would have saved her dignity.
Unfortunately, Dr Guinevere, logic is very seldom stronger than emotion, and most people would respond to their emotional needs first instead of to their logic, and therefor, this poor woman responded to her fear. One of the ways people respond to fear is by becoming paralysed with fear, which was exactly what she did. Fight, flight or paralysis, the 3 ways people choose to respond to fear. This is then justified by using "magical thinking", in other words flawed logic, "if I ignore it and pretend it's not happening, it will just diappear". Illogical, but used by many.
ReplyDeleteYou are correct in saying that she should have taken responsibility and obtained the available help, but this logic will never dictate the choices people make.
On a different note though - is it really logical that important decision making is left to 12 year olds, whose frontal lobes have only started developing(and as we know will not be fully developed till they are at least 25years old)? And if your brain is not fully developed, can you be classed as "of sound mind"? Having somthing in the Constitution does not make it logical.(Think: American Gun Laws). And unfortunately, as said before, most people make most of their decisions based on emotions, even if they believe their decision
making is based on logic.Thus, your reaction to your patient's unfortunate "choice".
Dear dr Guinevere,
ReplyDeleteAn excellent, thought provoking, touching though very upsetting piece.
So sad.
Devastating for the patient involved and others like her.
Also very upsetting and highly frustrating for you, who clearly have one mission, and that is to prevent, treat, alleviate, help to the utmost of your ability.
Yet you have to stand by- hands tied.
After reading it, I too thought of the mystery of psychology, and human behaviour.
I tried to think of adequate words to try and explain this phenomenon.
However, I could not have done it better than Isabelle ( first comment)- an excellent explanation. Doesn't it just humble one to realise once again, how complex we are.
May I add a hearty congratulations on your previous post re the Heart of a Lion as well. Fabulous, dramatic and spot on.
After all this, you might consider joining those guys Putting the Green (a previous blog post) -perhaps even in your Stilettos, just to refuel and carry on the good work!
Reading your very interesting post on Responsibility, I was contemplating this awful situation and how disturbing this illogical behaviour was and the obvious despair you must feel.....
ReplyDeleteThen I saw your commentator Isabelle's last paragraph, and I realised I used the words 'despair' and 'feel' in relation to your response. It dawned on me: your own first reaction, though you cerebrally thought of the concept of logic, was an emotional one- and there-in lies the logic of it all- however devastating or self-destructive the consequences in these kind of situations may be.
A 12 year old is able to consent to sex, even and specificaaly with another "underaged" person, according to recent court ruling...Too few adults, too few parents, too few people who are willing to take responsibility on their behalf, and now not even the State.How can any-one in their right mind allow a child to make these life-changing decicions on their own? Or am I misinformed?
ReplyDelete