Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [12]
Dr. Carter told us that although he hoped otherwise, Susan Powell’s condition might change in the future—and with it her point of view. She could develop a symptom related to her high cholesterol, like chest pain from coronary artery disease or dizziness from buildup of plaque in an artery to the brain. In effect, Carter was acknowledging how difficult it is for a patient who feels good to imagine a future illness. But short of developing symptoms, “she’s not likely to get on the medicine.” So, he continued, “in her case, I have to address everything else about her life that could be a cardiac risk factor. I keep close track of her blood pressure. I’m trying to get her to lose some more pounds, and even though she’s quite active, encourage her to do a bit more exercise.”
Carter will also keep telling her to take the drug “because I think that it may make a difference. But clearly there are people with cholesterol numbers as high as or even higher than hers who are well into their eighties and doing fine. She could live a long and happy life without the medication.”
In this short and seemingly straightforward interchange between Susan Powell and Dr. Carter, there is much to learn. From the outset, Susan is the kind of person who wants to be sure that her doctor subscribes to the fundamental principle of patient autonomy. It is the patient who ultimately benefits from a treatment or suffers the consequences of its side effects, so ultimately it is the patient who should decide. As Susan indicated, this principle doesn’t mean that she’s always right or that the doctor shouldn’t challenge her with a contrary point of view. In fact, during one of our interviews, she said bluntly, “I’m not afraid to be challenged. But when I lay out my position, I want to be understood.”
Susan Powell has declined statin therapy for more than five years. Yet she told us, “If I had cancer, it would be different.” That is, if she had an urgent and life-threatening problem like cancer, she wouldn’t avoid treatment. Although she would opt for a treatment that minimized side effects if at all possible, her skeptical approach isn’t enough to rule out radiation or chemotherapy. So Susan Powell’s preferences about medication for elevated cholesterol do not reflect a rigid or fixed mind-set. Preferences about treatment turn out to be more fluid and flexible than many might imagine.
Susan told us a story about a friend of hers that illustrates how Susan herself might approach a cancer diagnosis. “My friend was told she needed surgery to remove a cancer in her throat and then chemotherapy.” The friend told Susan that she didn’t want to undergo the treatment. “I’m not a doctor, but family and people at church still often ask me for medical advice, since I work in the health field.” Susan asked her friend, “What did you read about the treatment? What did the doctor tell you about the side effects? What are you willing to live with? What does it take to really deal with that particular condition?” Susan told her friend, “Look, the choice is yours. We’re all going to die, but if there is the possibility to save your life, to give you the opportunity to live longer, even with all the side effects and problems, would you choose that?” Susan always couches her replies with, “This is my personal opinion. It’s for you to choose.” Her friend ultimately chose the treatment, and while it was very difficult for her, and she is left with impaired speech and difficulty eating certain foods, she’s happy with her choice.
As we’ve seen, Susan’s decision was not simple. She had to weigh information about benefit and risk that can be framed in various ways. Then she had to wrestle with the potent influence of personal stories as well as the power of loss aversion and her doubter orientation.