Sue Ieraci: The risks of choice

THE concepts of choice and autonomy are highly valued in our society. In health care, as with many other areas of life, people exercise choices based on their own understanding of risks and benefits.

In the past, most people would rely on information from their doctors about risks and benefits, but today many people do their own “research” — which often means going to the internet for a free consultation with Dr Google.

In the past, people received information filtered through the views of the health care professional who was responsible for their care. On the net, this information may be filtered through a range of special-interest groups, lay commentators and people with vested interests — none of whom is held responsible for the wellbeing of the reader.

So, what does this say about “patient choice”? What should be the status of misinformed choice based on false or biased information? To what extent should a registered health care provider have to respect or, indeed, support a choice based on misinformation?

There is no doubt that mentally competent adults in our society have the right to make their own choices, safe or otherwise. But is a doctor obliged to “support” those choices?

This issue is part of the discourse about home birth in Australia. A study on home birth-related neonatal mortality in SA showed a sevenfold higher risk of intrapartum death and a 27-fold higher risk of death from intrapartum asphyxia. The coroner in that state is also currently examining a number of individual cases involving home birth.

One of the arguments as to why doctors should support a woman’s choice of home birth is that if registered doctors or midwives refuse to support the mother’s decision to deliver at home she might decide to go it alone, thereby magnifying the risk.

Is this a valid argument? Should a doctor or registered midwife, knowing that a woman will deliver alone at home if not supported, attend the home in an attempt to mitigate the risk? Does failure to do so constitute abandonment?

This discussion relies on the way the woman — or any patient — understands risk. Is their understanding based on fact, ideology or misinformation? Would they make the same decision in the face of different information?

If a doctor does his or her best to redirect the patient’s choices, but is unsuccessful, what ongoing responsibility should they hold? Can health care providers be expected to act against their better judgement to mitigate the effects of risky patient choices?

Ultimately, we all make choices every day that can impact on our wellbeing. When things go wrong, the health care system is there to rescue us from our own behaviour — whether that be extreme sports, overeating or drug abuse.

We send medical teams to the Grand Prix circuit. Should we send a medical team to a home birth of twins?

Dr Sue Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She also runs the health system consultancy SI-napse.

Posted 16 January 2012

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