Garcia-Prats

The Front Line

Physician as patient advocate:
Sometimes it's harder than expected

by Joseph A. Garcia-Prats, M.D.
Professor of Pediatrics—Neonatology
Professor of Ethics

Physicians make treatment recommendations to their patients based upon the best medical evidence available with the goal of improving their patients’ health. This patient–physician relationship in adult medicine is based on the principle of respect for patient autonomy and the role of the physician as fiduciary. In this clinical scenario, the principle of the patient’s autonomy obligates the physician to identify and acknowledge the patient’s values and beliefs and to offer medically reasonable alternatives based on those values and beliefs. Competent adult patients are sovereign over themselves and can make autonomous decisions about their medical care. Whether the physician believes these choices are wise or foolish, they should be supported. Thus, as fiduciary, a physician uses his or her medical competence to protect and promote the health of the patient, not to promote the physician’s self-interest.

With neonatal or pediatric patients, no true physician–patient relationship exists. Rather, the relationship is between the physician and the patient’s surrogate, usually the parent(s). The principle of patient autonomy is altered—the surrogate is expected to make decisions in the best interest of the patient. Several considerations must be recognized. In contrast to competent adult patients being sovereign over themselves, parents are not sovereign over their minor children. The parental obligation is one of responsibility, not of rights, except when they act as fiduciaries for the child.

However, parents may not always act in the best interests of their minor children. At those times, the neonatologist or pediatrician is obliged to assume the role of patient advocate and press for the most appropriate course of treatment or withholding treatment. A significant amount of time and effort goes into moving this process through the stages of collegial consensus; parental education, confrontation, disagreement; hospital ethics committee review and support; legal steps to obtain court support for the compassionate, medically appropriate course; and implementing the course of action.

So when the surrogate’s decisions are in question, the burden falls upon the physician to prove that those decisions are not in the best interest of the infant.