Patient Preferences

The central theme of patient preference is the constant tension between the ideas of autonomy and paternalism. Autonomy has been defined as, "the moral right to choose and follow one's own plan of life and action (Jonsen et al., 2006, p. 52)." The idea of paternalism rests in assuming a position of authority over what is thought to be in the patient's best interest and thus ignoring that patient's preferences (Jonsen et al., 2006, p. 54). Unscrupulous clinicians, armed with biased information given to them by drug companies, might assume a paternalistic stance with their patients if those patients aren't convinced the drugs or products their provider is promoting are equal or on par with alternative, less expensive treatments. If the relationship between the drug rep and clinician is severely biased, either through close friendship or substantial financial incentive, the clinician may feel compelled to use his or her position of authority to override patient preference.

For example, a patient may come to the clinician wanting to control her hypothyroidism with a cost effective, generic brand of medication, but the clinician may be incentivized to recommend the "more accurately dosed" brand name. Despite evidence that there is, in this case, no significant difference between generic and brand name medication, the clinician will stand on the authority of his drug rep biased influence and convince the impressionable patient there is a "significant and clinically felt" difference. The patient may not have the money to afford the name brand, but now he or she is convinced that they must have the superior name brand if they are to "feel better." Under this undue influence, the patient is now ready to over-extend his or her budget to secure the medication. Of course, the clinician will attempt to ease the initial cost of the medicine with samples or coupons, but the patient will ultimately be made responsible for its costs when samples and coupon offers run out or expire.

Furthermore, because the clinician is in a position of authority, he or she will substantially contribute toward achieving a placebo effect in patients through the mere suggestion that a particular drug is better than another, thus strengthening the patient's belief in the fallacy. The patient may feel better not because of an actual drug effect, but by the mere suggestion of its superiority. Patients will thus continue to spend their money needlessly because they have been misled by their medical providers.

While it seems obvious to most that this kind of practice constitutes an obvious breach in medical ethics, it occurs all the time in clinical practice. It's this author's humble opinion that this kind of ethic continues to exist because it has been tolerated for so long and has been comfortably categorized as a "grey area" in medical ethics. Even while the patient has the full capacity to decide what he himself prefers, his preferences are ignored and overridden, and he is duped into believing the all too expensive or sometimes deadly (Vioxx) lie. All the while, through continued promotional campaigns, trumped up clinical trials, and paid physician endorsements pharmaceutical companies and clinicians share in the financial fanfare.

This breach of ethics brings to mind the ethical concepts of scope of disclosure, comprehension, and informed consent. It is important for patients to fully comprehend the decisions they are making. They can make these decisions if all the pertinent facts are fully disclosed them. If they are being intentionally or unintentionally misinformed, how then are they to fully comprehend the impact of their decisions? How are they to make informed consents? The sad fact is this-they are making misinformed consents.