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08/25/2014

Limning Autonomy in Surgery

Several years ago while still a surgery resident I was stuck with a needle while operating on a patient with hepatitis C and HIV. The infectious disease team at that institution started me immediately on the latest anti-retroviral cocktail to decrease my chances of becoming infected with HIV. I took the cocktail for about a week and then, unable to tolerate the horrible gastrointestinal side-effects, I stopped taking them. Sure, I was placing short-term priorities (operating without nausea and diarrhea) ahead of long-term priorities (not sero-converting) but I was making an informed decision about my treatment. It may have not been a prudent decision and it was definitely against medical advice, but the decision was an exercise in expressing my autonomy.

It has always struck me that my surgical patients do not have exactly the same opportunity to make decisions for themselves. For example, once they agree to a procedure, they turn over the intra-operative decision-making to the surgeon. They don’t get a chance to say, “This operation is going a little too long and I think you are removing more tissue than I expected in order to get rid of this tumor. I would like to stop this now.” In a sense, the patient undergoing surgery surrenders her autonomy in hopes of a cure. The expectation is that she will be returned to a state of self-regulation after the ordeal.

This is quite different than my relationship with the infectious disease doctor. He did not say, “Look, for the next 30 days you are going to take these meds exactly as I say—no matter what—because we both agree you do not want to get HIV. Yes you will suffer, but this is just how it is going to be.” The nature of the medical intervention, self-administered medication over a period of time, gave me the space to alter my prior decision to take a course of prophylactic drugs.

When you are under anesthesia it is a different matter. You are unconscious; perhaps paralyzed. If the intra-operative course needs to change drastically the surgeon may stop and speak to your surrogate decision-maker, but usually she just continues the procedure according to what she thinks are in your best interests. The patient is not and cannot be a part of the numerous decisions that are made in the course of an operation. Powerless, the patient must trust his surgeon that she will make all the right decisions to achieve what they agreed upon is the goal of the operation.

These observations on the nature of the patient-surgeon relationship have several implications which I hope to explore in future posts, including what I consider a burden of responsibility on the part of the surgeon. This responsibility of the surgeon to the patient is greater than that of the infectious disease doctor to me in my case, for example. It is this reality of a drastically limited autonomy that makes the consumer / provider understanding of healthcare grossly inadequate when applied to surgery.

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