Malpractice Prevention Through The Sharing Of Uncertainty
- Gutheil TG, Bursztajn HJ, Brodsky A. Malpractice prevention through the sharing of uncertainty: informed consent and the therapeutic alliance. N Engl J Med. 1984;311:49-51. Reprinted in Grand Rounds on Medical Malpractice article 3.2, p.131-133.
Informed Consent and the Therapeutic Alliance
Uncertainty presents a commonly acknowledged threat to the doctor-patient
alliance [1]; anxious patients seeking doctors also
seek the reassurance of medical certainty. But anxiety about undiscovered
causes and undetermined outcomes sets doctor and patient apart if both
react defensively; even worse, anxiety over uncertainty may evoke feelings
of helplessness, hopelessness, and worthlessness.
Increasingly, patients and families who experience tragic disappointments
in their expectations of medicine attempt to assuage their grief, helplessness,
and despair by suing — that is, blaming — the physician. In doing so,
they often fail to discriminate among errors of negligence, other errors,
natural variations, and acts of fate. Under the stress of life-and-death
decision making, physicians also readily experience negative outcomes
as blows to their sense of competence and professional pride. In the
midst of such tragedy the physician is tempted to terminate the relationship,
saying, "There is nothing more I can do." For the patient,
then, a malpractice suit becomes the mechanism by which to force the "abandoning" physician
to share both the responsibility for the outcome and — less obviously
— the experience of distress and rage occasioned by suffering. [2]
Informed Consent: A Double-Edged Sword
At first sight, the informed-consent procedure seems to offer a way of
ameliorating these strains. Nonetheless, physicians by and large have
not welcomed informed consent. Besides viewing it as "red tape" and
the imposition of a legal constraint on the exercise of professional
judgment, physicians have expressed misgivings about the clinical ramifications
of informed consent. [3,4]
In fact, the clinical impact of informed consent is double-edged. [5,6]
Despite its positive effects of clarify ing options and stimulating mutual
understanding, the procedure is not without risk. It can bring to a crisis
latent problems that the patient may have in accepting uncertainty —
problems that can take two strikingly opposite forms.
At one extreme, calling attention to risks (especially in the chilling
style of an informed-consent form) can touch off feelings of helplessness
by crystallizing the patient's awareness that the situation really is
uncertain. At the other extreme, the seemingly authoritative list of
complications with their numerical probabilities, which lay persons have
been found to desire, [7] can be used as a magical ritual
to dispel the uncertainty. [8] Ironically, such an overly
tidy disclosure can inflate the magical hope that "all bases have
been covered," and disappointment may lead to malpractice suits.
The twin dangers, then, lie in exaggerating how little or how much the
physician knows.
Ideally, the clinical utility of informed consent lies in bridging the
gap between either of the two fantasies — helpless ignorance or omnipotent
certainty — and a more complicated reality. To achieve this goal, however,
physicians must stop thinking of informed consent as a formality (the
recital of options and signing of the form) and enter into it with their
patients as a process of mutual discovery. [9] Informed
consent as we envision it here is not an empty gesture toward liability
reduction but an interaction between physician and patient, a dialogue
intended not only to satisfy this legal requirement but to do more as
well. The real clinical opportunity offered by informed consent is that
of transforming uncertainty from a threat to the doctor—patient alliance
into the very basis on which an alliance can be formed. 1 This is particularly
important, since a sense of working together with the doctor may be one
of the major elements in avoiding negative reactions to treatment. [10]
An approach to this problem is outlined below.
Practical Considerations
Understand the Origins of the Patient's Fantasies of Certainty
Patients invoke wishful or magical thinking as a defense against feelings
of helplessness. The fears, doubts, and actual disablements of illness
reactivate memories of childhood helplessness and, in turn, of the grandiose
and magical thoughts that are virtually the child's only defense. When
illness presents a threat to one's well-being — to one's very being,
in fact — one attempts to resolve the discrepancy between the perception
of powerlessness and the wish for omnipotence by transferring the latter
to the physician. The patient says to the physician, in effect, "Okay,
I am not perfect, but you will make me good as new. I cede to you the
magical powers of my infantile self" [11] The
patient thus forms with the physician what psychiatrists call an "irrational" or "narcissistic" alliance,
in which the patient approaches the physician as child to parent rather
than as adult to adult. [12] In this context the patient
is simply not receptive to any disavowal of certainty on the physician's
part, hearing it instead as an alienating rejection of the omnipotent,
magical role scripted for the physician.
Magical notions of science play a key part in such fantasies of cure.
The physician is a representative of science, which is conceived of (certainly
in the unconscious but consciously in some cases) as a source of absolutely
certain knowledge. [1] Unfortunately, the trust in scientific
omnipotence may easily degenerate into paranoid distrust: the patient,
already a helpless victim of illness, now feels like the helpless victim
of an all-powerful science as well. If the patient is allowed to remain
in this dependent state, subsequent outcomes of a disillusioning nature
may lead to further regression and refusal to assume responsibility for
self-monitoring and self-care or, regrettably, to litigation.
Empathize with the Patient's Unrealistic Wishes
The physician should resist what might seem the logical move of dismantling
the unrealistic foundation of the narcissistic alliance by confronting
it head-on; one cannot expect to take away the wishful thinking (and
the resulting unhealthy attachment to the physician) without providing
a different kind of comfort — and attempting a different kind of alliance
— in its place.
Paradoxically, the best way to effect this substitution is to empathize
with the patient's wish for certainty and with its specific manifestations
as understandable human reactions to a difficult and painful situation.
Explicit identification with the patient's fantasies is conveyed through
such remarks as, "I wish I could give you a medication that was
sure to have only positive effects" and "There is just no guarantee
you'll live through this — I wish there were," which invite the
patient to exchange idealization for identification. The patient can
now approach the physician not as a childhood fantasy ideal but as another
vulnerable human being facing — and hence, sharing — the same uncertainty.
The physician is linked with the realistic, adult part of the patient
in what is called a "rational"
alliance, with two adults collaborating to reach a reasonable agreement
based in reality. Instead of squaring off defensively against each other,
doctor and patient are brought together by the shared acknowl-edgment
of clinical uncertainty and of the fantasies used to deny it. [12]
Wean the Patient from the Fantasy of Certainty
Once the patient and physician are looking at the fantasy together, the
physician can guide the patient in seeing it for what it is. Indeed,
the very words used to establish the identification and alliance between
patient and physician can begin the work of separating the patient from
the fantasy. Expressions like "I wish it were possible . . . ," even
as they validate the wish as a wish, imply tactfully that it is contrary
to fact. Clarifying statements (e.g., "Many people do believe that
one can specify in advance every possible complication of an operation")
offer the patient tactful support in taking a critical look at beliefs
that he or she may share with "many people." [13]
Having provided this emotional and interpersonal grounding, the physician
can proceed to the explicit disavowal of omnipotence and the substantive
education of the patient about uncertainty. Both the implicit and explicit
teaching separate the reality of human science from the fantasy of godlike
science. Now the patient is a participant-observer rather than, say,
simply the object of the physician's "experiment." It must
be stressed, though, that this alliance and the awareness it generates
rest on assurance of the physician's continuing availability to share
the uncertainty — expressed, for example, in statements such as, "I'll
be with you every step of the way." Implicit in this statement is
the promise of a continuing relationship, even if there is a tragic outcome.
When this promise is fulfilled, the patient is less likely to feel a
need to force the physician to share the experience of the misfortune
by means of a malpractice suit.
Note that our approach stresses the selection of what to say to patients
rather than such advice as taking more time with patients or telling
them more. In practice, less time is taken and more is understood: sound
efficiency of communication, not mere volume of words, is the desideratum.
Conclusion
Informed consent need not be a mere formality with a limited medicolegal
function. Rather, it can be a focal point in establishing a therapeutic
alliance. Seen as a dialogue in which both the cognitive and affective
implications of uncertainty are acknowledged and shared, informed consent
is a powerful clinical tool. Through its use, helplessness is replaced
by a degree of control as the patient becomes a coexperimenter rather
than a passive object of experimentation. Hopelessness is replaced by
a degree of hope as the patient comes to see that uncertainty does not
imply irrationality, defeat, or abandonment. Finally, the alliance between
the patient and physician, instead of being Undermined by the specious
denial of uncertainty, is strengthened by the mutuality of its acceptance.
The legal benefits flow from the clinical ones. The Usual perfunctory
approach to informed consent can be characterized as a form of defensive
medicine. Undertaken primarily to protect the physician from legal liability,
it often fails to do even that. In contrast, the therapeutic use of informed
consent to enlist the patient in an active alliance with the physician
discourages overly simplistic blaming and reduces the alienation from
the physician that leads the patient to seek legal remedies for dissatisfaction.
This is true malpractice prevention, which offers the physician stronger
legal protection by allowing both doctor and patient to deepen their
understanding while building a supportive and trusting relationship —
a relationship based not on unrealistic certainty but on honesty in facing
the uncertainty inherent in clinical practice.
Massachusetts Mental
Health Center
Boston, MA 02115
Thomas G. Gutheil, M.D.
Harold Bursztajn, M.D.
Archie Brodsky, B.A.
Supported in part by a grant (5T01-MH-16460-03) from
the National Institute of Mental Health.
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