I once forcibly saved a man’s life
Refusal to vaccinate reveals costs of stressing patient autonomy
Twenty years ago, when I was working in the intensive care unit, I saved a young man’s life. He was 19 years old, and he was frothing at the mouth from life-threatening fluid filling his lungs after he injected heroin. I did nothing brilliant – I simply placed a breathing tube in his throat so he could receive oxygen through a ventilator, a routine procedure in every hospital. Two days later, he was better and walked out of the hospital. But the story was not so simple.
While the patient was gasping for air before I placed the tube, he told me he did not want the tube in his throat. I quickly explained to him that without the tube and the ventilator, he would die. But even as he was close to death, he was still adamant that he did not want the tube. I had to make a split-second decision, and I disregarded his wishes and placed the tube. When he left the hospital, he neither thanked me nor castigated me.
When members of my staff reviewed the case, several of them were furious with me. They vehemently disagreed with the decision to ignore his wishes and place the tube, even if it meant he died. I explained that in the heat of the moment, I felt that he was speaking out of fear and that I could not be certain that was a true expression of his wishes. Those who disagreed were unmoved – I had violated the patient’s autonomy, and they were adamant that was the one sacrosanct value that doctors should never reject.
Whether you agree with my decision, I bring it up to illustrate a fundamental conflict in the debate about COVID-19 vaccination, a debate that the medical community has unwittingly encouraged.
For at least 50 years, autonomy – the patient’s right to determine his or her own care – has been stressed by both the medical and lay communities as the paramount value in medicine. Self-determination is embedded in the American ethos and has a long tradition in American medicine, dating to a 1914 medical negligence case. Autonomy, often restated as “my body, my decision,” is the bedrock principle behind medical issues including abortion, physician-assisted death and informed consent to treatment. The field of psychiatry has undergone a revolution in the previous generation, emphasizing much greater deference to patient self-determination.
Health care ethicists and practitioners have stressed autonomy at the expense of competing values including medical paternalism, or that the doctor knows best, which is basically what I was invoking in the intubation decision; and utilitarianism, or attempting to achieve the greatest good for the greatest number. For example, more people
would be saved if everyone was mandated to donate one kidney to increase the number of transplantable kidneys, but kidney donation remains voluntary because we cannot and should not mandate kidney donation. Autonomy prevails.
While most patients appreciate the emphasis on self-determination, some long for the “good old days” when doctors made the decisions for patients. A number of patients have complained to me that they have asked their doctor what to do in a specific situation only to be met with the answer, “I can only give you information; I can’t decide for you.” The patients’ frustration is understandable, but on the whole, neither medical professionals nor patients would prefer going back to the “good old days.”
However, now the medical community faces a serious problem to which its members have unknowingly contributed with their long-standing wholesale emphasis on autonomy. Put simply, the consensus in this community declares that essentially all eligible Americans should be vaccinated against COVID-19. Mandated universal vaccination would certainly cut the number of COVID-19 cases and
deaths dramatically. Why not take that step?
Most of the anti-vaccination arguments do not stand up to scrutiny – the vaccines have been tested and are effective, safe and can be legally mandated in many settings. But one argument many people use as part of their refusal to be vaccinated is “my body, my choice,” the very principle of autonomy doctors and health care professionals have long prioritized as the cardinal virtue of medicine.
In a sense, the chickens have come home to roost. With nearly 700,000 US deaths officially attributable to COVID-19, it can rightly be considered a public health emergency. In this case, autonomy might be subordinated to the greater good of the public; thousands of lives would be saved if the utilitarian argument prevailed.
But how can physicians expect everyone to turn on a dime when for decades the medical community has been hammering home the preeminence of autonomy? Only now are we realizing that the price of that message was much higher than we thought. (Chicago Tribune/TNS)