Responsibility. The word rolls around the tongue, then slips out. I’m confident my grade school classmate, who was never without her dictionary, would have looked it up and noted among myriad definitions terms such as “accountability”, “duty”, “control”, “act independently”, “requirement”, or “moral obligation.” While in these definitions assignation has been given to individuals and groups, the preponderance have been allocated to individuals. I fear in this day and age that is no longer the case as, in my opinion, individual responsibility has been subsumed by advocates for group/society/government responsibility. This is never more evident than in health care.
I am confident that you all are aware of the raging debate in healthcare–right vs. privilege. Pick your stance. Regardless of your opinion, though, responsibility cannot be avoided. I was privileged to be part of three excellent medical practices and with that came the responsibility to provide the best advice and care I could to my patients. They, in turn, had the responsibility to assess this advice/care, decide if it was worthwhile or not and, if the former, to follow through or continue with it. Was it their right or privilege as it pertains to their health? Does it matter? They still had the responsibility.
Let me give you several scenarios to think about with a question at the end of each one. Read each and spend a minute or so thinking about how you would adjudicate the outcome. I’ll then give followup.
A). A 65 year old man with COPD due to smoking one pack of cigarettes a day is found to have a single nodule (“spot”) in the upper lobe of his right lung. Additional testing strongly suggests this nodule is cancerous. He is felt to be a surgical candidate for removal of the right upper lobe. However, because of significant cough and sputum (mucus) production the patient was strongly advised to quit smoking for at least two months (literature support for this) and take his medications. Smoking cessation assistance was offered. Surgery would be scheduled after a reassessment in two months. Should surgery be denied to the patient if he doesn’t quit smoking?
B). A morbidly obese woman is evaluated at a reputable bariatric clinic for weight loss surgery involving gastric banding. She receives instructions in dieting, portion size, and exercise as this would be the type of regimen she would have to follow postoperatively. She is to return in 3 months for re-evaluation. Should she have the procedure if she does not comply with her instructions?
C) A 42 year old alcoholic has had multiple hospitalizations for complications, especially bleeding, related to liver disease from his ongoing drinking of alcohol. Over time he has had multiple non-surgical procedures to treat/control his bleeding and there is nothing left to consider other than a liver transplant. Should the patient be offered a liver transplant if he does not abstain from alcohol?
D) A 20ish year old patient has end stage renal disease due to a chronic illness. Dialysis is required 3 times a week. The patient routinely misses dialysis days showing up either at the dialysis unit or, more often, at the ER when feeling poorly. The patient has received counseling on numerous occasions but to no avail as the patient feels they can best decide when dialysis is needed. The patient understands that showing up as an emergency disrupts dialysis access for other patients as there is rarely a vacant dialysis bed or additional dialysis nurses available. This has been a recurrent theme for the past several years. The patient is again brought to the ER, moribund, and in need of urgent dialysis. Should the patient be dialyzed?
As you can see, in each of the above scenarios each patient had been given a responsibility for an action that would have had a direct impact on their health. So what did you decide? Thumbs up or thumbs down?
In “A” the patient returned after two months but attempts to quit smoking were minimal. Citing increased risk the surgeon declined to operate and offered alternative treatments. Desiring surgery the patient went elsewhere and had an extended hospitalization because of multiple post-op respiratory complications. In “B” if the patient had not complied with the instructions given at the time of her initial assessment she would not have had the gastric banding because, if she could not control her diet and portion size pre-op, it was highly unlikely she would have complied post-op and this could have lead to significant complications. In “C” the patient had been repeatedly advised that he had to be abstinent from alcohol for at least 6 months before liver transplantation could have been considered. He continued to drink and never underwent transplantation. In “D” the patient was dialyzed, recovered, and has continued to disrupt the health care system as before.
As you can imagine from the above scenarios, patients A,C,D, by shirking their responsibility to try to improve their health situation, only added to the burden and cost of the health care system (you paid for “A” {Medicare} and “D” {Medicaid}). And, yes, before you scream, “But people do try to be responsible and still end up with untoward results!”, I understand and agree. The key word is try, really and truly. To me, and to other physicians, fully recognizing the challenges that our patients face, only ask that patients try and, if need be (which is often the case), to keep on trying to improve their health. When that happens we’re there for them and will continue to provide the support and care they need and are more than willing to go that “extra mile” when we see the effort being made on their part. What wears us out is the patient who, implicitly implying their “right” to health care, takes no responsibility for their health, does what they want to do no matter how egregious to their health, and then shows up on the health care doorstep demanding, “Doctor fix me!”
(If you wish to leave a comment, click on the particular blog title on the sidebar. This will open up that topic again and at the bottom of the narrative there will be a comment section). Earlier blogs: Inaugural, Oscar, “That will be $108”, SODA POP, can be found with “search.”