CASE PRESENTATION

P.G. is a 61-yr-old male who returns, after a year's absence, because of a concern about his risk for colon cancer. He was referred by his primary physician a year previously for colonoscopy, primarily because of his age although at the time, the history was elicited that his father, at the age of 68, had colon polyps. There was no history of colon cancer in the family. He reported regular bowel habits, and denied rectal bleeding. His physical examination was normal.

The colonoscopy performed a year earlier was uncomplicated. The exam was carried to the terminal ileum and the prep was judged to be excellent. A diminutive polyp was removed from the cecum and the pathology revealed a tubular adenoma. The patient was placed on the recall list for 3 yr.

At the time of the current visit, the patient notes that a coworker was recently diagnosed with advanced colon cancer and was not expected to survive. He had become concerned, and with the knowledge that he had a polyp, requests another colonoscopy this year. His interval history revealed no new symptoms or problems. When told that his insurance company might not pay for a surveillance exam so soon, his response was that he was willing to pay for it himself.

COMMENT

Why not proceed? There is no clear indication for a surveillance colonoscopy this year, but it is a low-risk procedure in a healthy individual, and if his insurance denied the claim, the patient himself has offered to pay. "If I don't do it, he will probably find someone who will so wouldn't it be simpler to just put him on the schedule? And what if a major lesion was missed last year—if I refuse, and he turns up next year with colon cancer, I would probably be sued." These are the kinds of thoughts that might run through one's mind in a setting like this. And while all would agree that the odds of the exam being normal are high, our ability to reassure our patients—and ourselves—meets a need by allaying anxiety.

Patient Rights and Autonomy versus Safety and Justice

Patient autonomy emerged over the last half of the 20th century as a major principle in the ethical practice of medicine. Theretofore, doctors often unilaterally made decisions for patients but a series of notable events, initially in the research arena, empowered patients to take charge of their own affairs (¹). No one doubts that the physician understands the illness, but the patient understands him or herself and is thus better able to judge what would work best. Autonomy has often been expressed as negative rights, the rights that allow a competent patient to refuse treatment and this concept is generally accepted, both in practice and in the courts (²). Over the years, patient rights have, for some, been expanded to include positive rights—the right to request a treatment or an intervention even if the physician objects. However, this broader interpretation of patient rights is problematic (³). We all would agree that the patient who needs a screening colonoscopy has the right to refuse it—but does he or she also have the right to request it when, as in this case, there is no apparent indication?

In P.G.'s case, from a purely medical perspective, the procedure requested is unwarranted; moreover, one could even make an argument that the planned follow-up exam in 3 yr is also not indicated. There is evidence that a solitary diminutive adenoma conveys no excess cancer risk implying that such patients can follow surveillance guidelines for average risk patients (⁴). While the patient's father had a polyp, the type is unknown, and even if it was neoplastic, its occurrence over age 65 makes it almost certainly a sporadic lesion with no familial implications. The ability to reassure patients is certainly more than a trivial benefit in someone trying to cope with anxiety, but is it sufficient to justify a procedure? If we respect autonomy, interpreted as positive as well as negative rights, and we view reassurance as a beneficent act, perhaps it is. But there are other aspects of this question that have bearing on the decision.

The first issue to consider is safety. Of the thousands of exams likely performed every day, complications are vanishingly small—but they are not zero. For diagnostic colonoscopy without intervention, the major complication rate and death rate are 0.4% and 0.02%, respectively (⁵). Perforation is the complication with the most associated morbidity and, rarely, mortality. But is it rare enough to justify a procedure that is not indicated? While acquiescing to the patient's demand for a procedure may respect him as an individual, allowing him to embark on a course which lacks sufficient medical indication, with which there may be complications, no matter how small, does not. Moreover, the fiduciary and advisory components of the doctor–patient relationship are abdicated in favor of solely a technical role; in this sense, the integrity of the physician as a professional is being challenged. Independent of this is the liability risk, were a complication to be incurred.

Another issue is justice—justice from the perspective of receiving one's due. Individual freedoms are a major theme in the U.S. constitution that is pervasive in all aspects of life including health care. And as technology over the past 50 yr has created more and more opportunity to intervene in health-related matters, many feel that requests for treatment or diagnostic tests are consistent with this perspective. We do not have a universal health-care system in this country in which resources are allocated in a controlled manner and where costs limit what is available and to whom. Health care in the United States is available to those who are able to pay for it. Thus, it is not surprising that requests by patients for clinical services are relatively common; in a recent survey, approximately 25% of visits to primary care physicians included a request for a variety of services, including tests, new prescriptions, and referrals to specialists (⁶). Health-related distress, defined as being worried about one's health and the possibility of a serious illness, increased the likelihood that a request for a clinical service would occur. As a part of the patient empowerment movement noted earlier, individuals have become more interested in their personal health than in times past, regularly access health-care sites on the Internet, and as a result of direct-to-consumer advertising, are knowledgeable about many commonly prescribed medications and treatments.

Cost of Testing "on Demand"

Still, the procedure cannot be done without incurring costs. If it is the insurance company's money, the impact is not immediately felt but ultimately, payment for unwarranted procedures will contribute to rising health-care costs. Is the situation any different if the patient, as in this case, offers to pay? Considered in the light of individual freedoms discussed above, the patient's offer to pay for the procedure himself seems reasonable. It nonetheless remains morally troublesome because it supports the unevenness of health-care access in this country and is at the same time unfair to the next patient, otherwise identical and with the same health-care insurance, but who lacks the personal resources to allow him to purchase this service. And having said this, ability to pay from one's own pocket does not make the procedure any more indicated, the safety issues discussed above notwithstanding. Siegler has suggested that this form of medicine can be construed as a libertarian model, "...in which health care is seen as a product to be provided by physician-technicians and consumed by patient-clients." (⁷). Providing a service under this model, he goes on to say, "...does not negate the normative claim that such behavior is unfitting and inappropriate in medicine."

Situations like this are ripe for gaming, the practice of manipulating the system in order to secure payment for the procedure by the insurance company (⁸). Fresh blood on the toilet tissue after straining to evacuate a hard stool, for example, becomes rectal bleeding on the precertification request. While not blatantly dishonest, it is still a manipulation of the truth. While an unlikely scenario for the case presented here, since the patient has offered to pay, it is a temptation in other circumstances in which a need is more compelling but for which payment is uncertain. Patients can also be participants in gaming; they may make "veiled requests" by relating a cluster of symptoms characteristic of a specific disorder for which a test or procedure would logically follow (⁶).

Role of Doctor–Patient Interaction

Pellegrino has described the doctor–patient relationship as a "moral equation" in which both parties have rights and obligations (²). The patient owes respect to the physician's autonomy and asking him/her for an unwarranted service is, as noted above, a challenge to his/her integrity. We as physicians can still respect patient autonomy, even if we deny the request for service, by trying to understand why the service is being demanded, building capacity in the patient knowledge base, and addressing the need in a more rational fashion. In this case the patient is alarmed because of the friend who will soon die with advanced colon cancer; what he is really asking is reassurance that he does not have colon cancer—can not that request be met without performing an unneeded colonoscopy? Reviewing last year's procedure, including endophotographic documentation, and the discussion of current knowledge about the polyp-cancer sequence including the time, often years, for cancer to develop may fill a knowledge gap for this patient that might allow him to think more rationally about his request. Doctor–patient communication and humanistic qualities are thought to be more important in building patient trust than whether or not the physician provides a requested service (⁹). Thus, acknowledging the patient's anxiety is an important part of this interaction. Efforts to reduce anxiety would likely have more long-term value than repeating a colonoscopy. Technology like colonoscopy is a double-edged sword. Its impact on the evaluation and management of gastrointestinal disease, in particular colon cancer, is unparalleled but because it is easy to apply, our threshold for using it becomes quite low. Regardless of the patient request, however, as one observer has noted, performance of a requested procedure when it is not clinically indicated is a deviation from standard care, and as such is subject to criticism (¹⁰). Clinical judgment, including knowing when not to perform a procedure, is as important as knowing the indications.

OUTCOME

The gastroenterologist in this case refused to perform the endoscopy. He provided the patient with educational information about colon cancer and referred him to Web sites where many of these issues are accurately discussed. He reassured the patient about the quality of this exam a year previously, and armed with new information, P.G. agreed to defer his request and access more information from the recommended Internet sites. He declined a referral for stress management, however.

References

1. Beecher, HE. Ethics and clinical research. N Engl J Med 1966;274: 1354–1360. | PubMed | ChemPort |
2. Pellegrino, ED. Patient and physician autonomy: Conflicting rights and obligations in the physician-patient relationship. J Contemp Health Law Policy 1994;10: 47–68.
3. Brett, AS, McCullough, LB. When patients request specific interventions. N Engl J Med 1986;315: 1347–1351.
4. Atkin, WS, Morson, BC, Cuzick, J. Long-term risk of colorectal cancer after excision of rectosigmoid adenomas. N Engl J Med 1992;326: 658–662.
5. Davila, ML, Keeffe, EB. Complications of gastrointestinal endoscopy. In: Feldman M, Friedman LS, Sleisenger MH, eds. Sleisenger and Fordtran's gastrointestinal and liver disease, 7th Ed. Elsevier: Philadelphia; 2002: 539–548.
6. Kravitz, RL, Bell, RA, Rahman, A, et al. Direct observation of requests for clinical services in office practice. Arch Intern Med 2003;163: 1673–1681.
7. Siegler, M. Physicians' refusals of patient demands: An application of medical discernment. In: Bayer R, Caplan AL, Daniels N, eds. In search of equity. Health needs and the health care system. Plenum Press: New York; 1983: 199–227.
8. Morreim, EH. Gaming the system; dodging the rules, ruling the dodgers. Arch Intern Med 1991;151: 443–447.
9. Gallagher, TH, Lo, B, Chesney, M, et al. How do physicians respond to patients' requests for costly, unindicated services? J Gen Intern Med 1997;12: 663–668.
10. Coates, J. Patient requests for unwarranted treatment. N Z Med J 2002;115: 23.