Thrombolysis for acute stroke

Ivan Moseley

doi:10.7861/clinmedicine.9-6-629

Editor – Akinsanya and colleagues (Clin Med June 2009 pp 239–41) pertinently discuss the course to be taken when a patient with acute stroke may not be capable of consenting to thrombolysis, weighing potential benefit against respect for autonomy.

I agree with their conclusions, but once the concept of the autonomous patient whose views must be respected is weakened on any grounds, the door opens to wider rejection of respect for autonomy in favour of beneficence. I suggest the truly autonomous patient – capable of infallibly choosing the best course, all things considered, in the individual case – is rare outside the courts and textbooks of medical ethics. People capable of making the best choice (all things, and so on) of jam in the supermarket may have problems choosing the best (all things, and so on) treatment.

Some of those problems were identified by Eraker and Politser.¹ Patients, unlike shoppers, may wish to avoid responsibility for a ‘wrong’ decision. They may be disinclined to make a concrete choice and insisting that they do can result in ‘undue extreme judgements, by requiring [them] to express their wishes with more clarity and coherence than warranted’. There may be significant cognitive or imaginative limits to their appreciating the consequences of their choice. Gains and losses, certain and chance outcomes, may be differentially weighted (as in ‘risk aversion’), frustrating decision analysis.

Doctors and patients come together to achieve a result beneficial to the latter's present and future quality of life. A desire for a less than optimal outcome (all things, and so on) is irrational. If information on which to choose the objective or actual optimal outcome is limited, a subjective and/or antecedent choice must be made – ‘antecedent’ being that which appears best before the result is known. Objective and subjective, antecedent and actual may coincide, but when they do not, it seems irrational to prefer a less efficacious subjective choice simply because it is ‘autonomous’. Thus, I would argue, a doctor suspecting that a choice (all things, and so on) is not optimal because of limitations to the patient's autonomy, should try persuasion. At what stage the patient's wishes can legitimately be ignored remains a teaser.

Footnotes

Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk

Reference

↵
1. Eraker EA
, Politser P. How decision are reached: physician and patient. In: Dowie J, Elstein A (eds), Professional judgement. A reader in clinical decision making. Cambridge: Cambridge University Press, 1988:544–65.

Thrombolysis for acute stroke

We agree with Dr Moseley that few patients with acute stroke will be able to make completely autonomous decisions regarding thrombolysis and treatment decisions will shift towards beneficence. Beneficence can be considered an ethical imperative for doctors to act in their patients’ ‘best interests’. Unlike paternalism, where the doctor decides what those ‘best interests’ are without reference to a patient's wishes, implicit in the concept of beneficence is a respect for patient autonomy as part of their ‘best interests’.

Treatment decisions require judgements by both physicians and patients. The physician has knowledge of the likely medical outcomes but needs insight into a patient's understanding of their illness and attitudes to treatment, death and disability. The patient wishes to understand the diagnosis, prognosis and options. Ideally these two parts of the jigsaw match enabling an autonomous decision to be made.

The information physicians give may be imperfect as the risks and benefits of a treatment cannot be exactly known and because the evidence base behind a therapy is frequently open to interpretation. Patients will often be unable to fully understand their clinical condition, how their disease will impact on them and the risks and benefits of treatment options. Health utility scores that take into account trade-offs between quality of life and survival durations have been developed but are more useful when comparing healthcare programmes. For specific cases competent patients are the best judge of their own welfare.

We should not dismiss choices we disagree with as non-autonomous but rejection of a treatment likely to be of great benefit, unless based on longstanding convictions (such as those of a Jehovah's witness), is likely to indicate that fear and poor understanding prevents consent rather than an autonomous choice.

The suddenness, seriousness, time sensitive and uncertain prognosis means that thrombolysis for acute stroke is one of the most difficult treatment decisions that a patient ever has to make. Fully autonomous decisions do not exist and we can only aim for maximum autonomy and very often treatment decisions will be based upon beneficence.

Footnotes

Please submit letters for the Editor's consideration within three weeks of receipt of the Journal. Letters should ideally be limited to 350 words, and sent by email to: Clinicalmedicine{at}rcplondon.ac.uk