Two Areas of Patient Care, Two Attitudes Toward Autonomy

Posted in: Health Law

A friend of my family’s, whom I will call Peter, recently went to see several doctors and then spent an evening regaling us with war stories. The condition which drove Peter into the arms of medical professionals is melanoma, a kind of skin cancer. In addition to feeling scared for someone I have known and liked for many years, I also found interesting the way in which Peter’s doctors, with few exceptions, seemed to speak to him about his care and about the options that he had. Their manner of discussing things differed from how another group of medical professionals—abortion providers—speak to their clients. In this column, I will consider why this difference might exist.

Non-Abortion Medical Care

When Peter went to see the first doctor on his list, he initially did what most patients do when visiting the doctor. He got on a scale, he had his blood pressure taken, along with resting heart rate, etc. As Peter was put through these preliminary paces, nurses told him about the pills he could be taking to improve his blood pressure (which was slightly elevated), and the steps he might take to remediate his weight (more than slightly elevated). He wondered about side effects for the pills so he pulled them up on his phone. As Peter squinted through the text, the physician, Dr. A., arrived in the examining room and introduced himself.

Dr. A. explained Peter’s cancer and what the right treatment regime would be. It would include surgery, radiation, chemotherapy, and immunotherapy. It sounded to me like Dr. A. knew what he was talking about, and I said as much. But Peter replied (to Dr. A. and later to me) that he had read a great deal about his diagnosis and that he intended to pursue some but not all of the recommended treatments. He had his reasons, he said. The doctor looked at Peter and shook his head, saying “you have a wife and three children, right?” I was thinking the exact same thing as Peter told us what the doctor said.

Peter confirmed that he did have a family. “I think they would want you to do everything possible to live as long as you can,” the doctor continued, a sentiment in which I, once again, concurred. Peter then asserted, “I have made my decision about the treatment.”

The doctor replied, “I understand that you think you are making a good choice. You’ll be seeing Dr. X next week, right? He will go over all this with you, and you’ll see that you are better off undergoing the therapies that we recommend. There really isn’t any disagreement about what you should do. You’ll see that when you speak with Dr. X.”

Peter, by then discouraged, thanked the doctor for his time and began to dress. “Can I answer any questions for you?” asked the doctor, possibly nonplussed by a patient putting his clothes on before the doctor had left the room. “No,” replied Peter. “No questions.” An equally tense visit with Dr. X followed this appointment, one at which a doctor once again urged a patient to undergo what the doctors all agreed was the most promising course of treatment, though the patient wished to forgo the offered care.

Abortion Treatment

Now consider the way in which medical professionals are likely to treat a woman at an abortion clinic. Let us call the patient Laurie and the doctor with whom she is to meet Dr. T.

Laurie will tell Dr. T. (or the nurse with whom she meets first) that she wishes to terminate her pregnancy. Dr. T. will ask some questions about Laurie’s health and then perform a physical examination to determine how far along Laurie’s pregnancy has progressed. Depending on what state the two are in, the doctor may give her a pro forma “informed consent” that is obviously not the doctor’s own words, stating that abortion is not a form of birth control or that adoption is an alternative to abortion. Laurie will almost certainly understand that Dr. T. is saying what she is legally required to say and that is all. Laurie may have an ultrasound (which is generally a routine part of abortion care) at which the doctor may offer her the opportunity to look at the image of her embryo or fetus.

If the gestational age of the embryo or fetus falls within the range of what the law as well as the clinic permits, then the doctor will almost certainly perform the abortion. The law might mandate a waiting period, and if it does, the doctor will probably apologize for the resulting delay. Dr. T. may also ask questions to ensure that Laurie truly wants an abortion and was not pushed into having one by a boyfriend or family member. Assuming that she is at a real abortion clinic and not a “crisis pregnancy center” (a pro-life center that essentially masquerades as an abortion clinic), the one thing that the doctor will not do is attempt to pressure Laurie into keeping a pregnancy that she wants to end (or, for that matter, into ending a pregnancy that she wants to keep).

One could come up with health arguments for making one or the other choice, if one were so inclined. For example, the more children a woman bears, the lower her apparent long-term risk of breast cancer. Yet a doctor will not be trying to get a patient on board with either having or not having the child, contrary to the patient’s expressed wishes, whatever they might be.

In addition, the doctor will not be making moral arguments for one or another position. She will not be telling Laurie to keep the pregnancy, because life begins at conception or because she might come to regret the decision to end the life of an innocent living being or anything like that. Likewise, Dr. T. will not tell Laurie that she should definitely terminate the pregnancy if she cannot afford to provide a child with what he or she needs. However Laurie wants to handle the pregnancy, her doctor will support her choice. Contrary to what some pro-life advocates say, the pro-choice position is not “pro-abortion” (nor is it anti). It is pro-patient-autonomy. One can quarrel with this position on account of the embryo’s or fetus’s life, and I am not here contesting the validity of that viewpoint, but abortion providers are generally comfortable with a “yes” or a “no” from the patient.

Why the Difference?

One reason that Peter may have encountered doctors strongly urging him to undergo the prescribed treatment is that a doctor tends to view his job as saving patients’ lives and improving their health. To the extent that a patient wishes to make a choice that will reduce the odds of his long-term survival or otherwise compromise his health, some doctors will discourage that choice. Some will do what people do when they are trying to persuade someone else to change his mind—make arguments, invoke expertise and experience, and refer to other experts who will offer the same advice/pressure.

Another reason for the hard-sell may be that an overwhelming majority of patients follow their doctors’ recommendations. This is not to say that when a doctor says, “you could benefit from some weight loss,” patients consistently go ahead and lose the weight. The instruction there is vague and open-ended. But doctors who prescribe treatments in which the patient comes in and the doctor supervises what happens tend to see an enormous amount of compliance. When people almost always do what you recommend, the experience can have a way of firming up your commitment to persuading everyone who you believe should follow the recommendation. Whatever small percentage of noncompliance there is, in other words, may come to seem like the product of irrationality.

We do have a tradition of autonomy in this country when it comes to medical treatment. For a doctor to treat a patient without consent constitutes a criminal battery. The right to refuse treatment, moreover, includes not only a prohibition against compelled medicine or surgery but also a requirement that doctors provide the patient with sufficient information to enable informed consent to treatment. When doctors fail to act on consent, patients who become sicker or who are unhappy with the results may bring a lawsuit against their doctors.

Yet the reality is that the doctor/patient relationship remains hierarchical (just think of the “robes” that patients typically wear in the hospital versus the scrubs and white coats that doctors usually wear), and people ordinarily submit to their doctor’s will rather than asserting themselves in the face of unwelcome counsel. Some doctors, in turn, may be mostly concerned about extending life as much as possible and less focused on furthering their patients’ goals. Though patients have the last word on whether to undergo treatment, then, doctors are in truth the ones driving the decisions much of the time. Like an election in a totalitarian state, the fact that upwards of 90 percent of the population votes with the ruling party evidences something other than a democratic consensus of autonomous individuals.

By contrast, many of the doctors who perform abortions do so because they wholeheartedly embrace the right of a woman to decide whether to remain pregnant or not. The primary mission, then, is facilitating bodily integrity and autonomy, and the provision of surgery or medicine is intended to serve that primary mission. The goal is not to extend or preserve life as much as possible. It is to provide safe abortions to those women who truly wish to have them.


If I am right in my observations, then we can understand why a trip to an abortion clinic may involve greater patient empowerment than does a trip to a doctor for diagnosis and treatment of a serious illness. The point of an abortion clinic in modern-day America is to help women who wish to terminate their pregnancies do so. At the same time, doctors must take every precaution to avoid abortions where the woman is unsure about her decision. It is not surprising that in these conditions, we will see little pressure of the sort that might lead a patient to do (or not do) something she does not (or does) want to do. Outside of this context, doctors are less fixated on patient autonomy, except of the legalistic “sign here” variety. They may accordingly feel free to make moral arguments (do this for your family) and to repeat all of their arguments, as Peter’s doctors did, to try to push the patient into “choosing life” (which means a statistically higher likelihood of long-term survival), a choice that I candidly told Peter I wished he would make.

One could address this problem by compelling non-abortion doctors to listen to abortion doctors and their patients talk about what real patient autonomy looks like. It may be easy for doctors outside of the abortion area to forget that their patients are adults who are empowered to select their treatment and to make decisions of which the doctor might disapprove. In the abortion clinic, doctors and patients may feel like allies in a political fight, both of whom believe in patient choice. Doctors in the less political areas may then need to learn to listen to a patient and to respect the patient’s wishes, even when those wishes seem “mistaken” to the doctor. Abortion doctors self-select for patient empowerment. Other doctors—whether pro-choice or pro-life—could therefore learn a great deal about deference to and respect for patients from providers of this more controversial service.

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