Should doctors look to patients for validation of their ideals?

Whats Important To You?

One of my proudest moments as a physician occurred years after I stopped practicing.

At a holiday dinner table a cousin commented that had I faced infertility, I would have opted for adoption over complex medical treatment just as she had done. I was surprised since nothing could be further from the truth; I would have aggressively pursued every medical option.

It was her turn to be surprised since she remembered I was one of the very few doctors supported her decision to forgo infertility treatment without even trying. How, she asked, could I have kept my desires out of our discussion? Because, I answered, it is the job of a physician to support a patient’s choices, not to seek validation by having the patient make the physician’s preferred treatment choice.

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]It is the provider’s ethical obligation to support the patient’s goals not to substitute their own values — midwives and lactation consultants included.[/pullquote]

I believe, as matter of both medical and personal ethics, that doctors should never look to patients for validation of their own ideals. It is the doctor’s legal and medical obligation to support the patient’s goals not to substitute his or her own values.

If a Jehovah’s Witness wants to decline blood transfusions, I have no right to insist that she accept them even though I would eagerly choose them if the need arose. If a patient wants to decline a life saving C-section for her baby, I have no right to insist that she undergo surgery even though I would accept immediately. If a patients wishes to treat her cancer with herbs and supplements instead of chemotherapy, I have no right to insist that she accept chemotherapy in favor of a course of action I know to be worthless.

I suspect most doctors would agree with my views; that’s what we are taught. In contrast, midwives and lactation consultants seem to think that is their job to pressure patients to mirror the choices that midwives and lactation consultants would make. They rationalize it by telling themselves that “normal birth” and breastfeeding are best; midwives and lactation consultants therefore imagine that they have the patient’s best interests at heart but not only is that deeply paternalistic; it is entirely untrue.

As Atul Gawande Tweeted yesterday in reference to new cancer treatments:


The seriously ill have goals for their care besides just survival. When we don’t ask what they are (what tradeoffs they’d make & not make; what quality of life is unacceptable) and tune care accordingly, incl new treatments, the result is suffering.

This also applies to pregnant women. Many have goals for their care that may not include vaginal birth, refusing pain relief and avoiding interventions. Yet many midwives ignore those goals. They “know” that unmedicated vaginal birth is “best” and they force women into accepting it, going as far as creating promotional campaigns for so called normal birth.

It’s not that they don’t understand the concept of separating the patient’s interest from the provider’s interest. They have no trouble counseling women to ignore doctors’ recommendations on C-section, interventions and the advisability of homebirth, claiming that “birth rights are human rights” and often insinuating that doctors’ push interventions for their own benefit. Nonetheless, they appear entirely blind to the concept that birth rights include the right to a timely epidural as soon as a woman asks, the right to request term induction even if there is no medical reason and the right to a C-section on maternal request.

Many midwives are simply incapable of separating the patient’s interest from their interests. Their treatments recommendations for others reflect what they would choose for themselves; they need patients to mirror their preference for unmedicated vaginal birth back to them and they force them to do so. They often insist that patients who don’t agree aren’t properly informed or adequately supported.

The same midwives who would react (appropriately) with horror at a doctor forcing a C-section on a woman who has declined have no trouble forcing an unmedicated vaginal birth on a woman who doesn’t want one. That’s unethical.

Lactation professionals are, if anything, worse. La Leche League won’t even allow you to become a volunteer leader unless you have breastfed a baby for 9 months. Lactation consultants exist for the sole purpose of promoting breastfeeding; they promote a process independent of outcome even though the benefits of that process are trivial and side effects are common. It’s not for the good of babies. Breastfeeding doubles the risk of neonatal hospital readmission, increases the risk of neonatal hypernatremic dehydration and hypoglycemia and is the leading cause (90% of cases) of jaundice induced brain damage. Lactation consultants pressure women to mirror their own feeding choice back to them without regard to a mother’s personal needs, desires and priorities. That’s unethical

The bottom line is that patients don’t exist to support providers; providers exist to support patients whether or not providers approve of patients’ choices. It’s long past time for midwives and lactation consultants to recognize this.