OncoLog, Volume 35, Number 1, January-March 1990 Page: 3
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January-March 1990 Vol. 35, No. 1
The patient should also be apprised of the availability
and efficacy of "salvage" therapy in the event that the
initial treatment is unsuccessful. If effective salvage therapy
is available, the patient may opt for less aggressive initial
treatment. Alternatively, if salvage therapy is unavailable or
of limited efficacy (as is often the case), most patients will
choose to "go for broke" with their initial treatment,
Peters said.
"In most cases, when our goal is cure, it's simply
illogical to reduce the toxicity of the initial treatment,
since the patient may have to face higher morbidity during
salvage therapy," Peters said.
The degree to which a physician discusses each of these
points is dictated not only by the availability of time and
resources but also by the severity of the case. "You have to
talk to the patient in great depth when the stakes are
extremely high," Peters said. "For instance, a couple of
years ago we saw a young patient with a noncancerous
tumor in the base of the skull. The tumor had destroyed
part of the vertebral column, but there was no way to
remove the tumor surgically. Irradiation of the spinal cord
was unavoidable, so we had to talk to him and his parents
at great length as to where we wanted to aim the treat-
ment and how much of a risk we wanted to take, since it
was possible that radiation-induced spinal necrosis would
paralyze him. We spent a long time discussing the pros
and cons of different levels of treatment before agreeing
upon a mutually acceptable point to aim at."Physicians Treat Less Aggressively after Lawsuits
Peters' views are not simply based on subjective percep-
tion. A staff member of Peters' department, Neil Sherman,
M.D., recently conducted an anonymous survey of radio-
therapists who had trained or worked at M. D. Anderson
at some point during the past 40 years. "He asked how
many had been sued-rightly or wrongly, justified or not.
He found that by the time the average radiotherapist hadbeen out of training for 20 years, there was about a 50/50
chance of being sued. And of the ones being sued (regard-
less of outcome), one-third said that they treat people less
aggressively now than they did before they were sued."
This reluctance to treat aggressively is not limited to
experienced doctors. Peters has found that a defensive
attitude is becoming more common among residents in
training. "I'm on the examining board for certification in
radiation oncology, and I try to present a case to the
students to see if they would be prepared to risk a major
complication in order to save a patient's life. It's depress-
ing to see how many of them won't take the slightest risk,
and when you ask them why, they'll say they don't want to
be sued. This attitude is most unfair to the majority of
patients who will not sue you but want to get the best
available treatment."
Community Standard of Treatment Intensity
Is Lowering
As a result of these changing attitudes, the acceptable
level of "standard" treatment is being reduced. Ironically,
this reduction may only exacerbate the current excesses of
litigation. "When everyone starts acting defensively, the
community standard of care, in terms of 'aggressiveness,'
gets pushed downward, and so one who is acting reason-
ably in absolute terms can be judged to be exceeding
community standards. This is unfortunate because the
question of whether a physician conformed to community
standards is often asked when determining negligence.
That's a very serious problem. I recently reviewed a case
in which a doctor was being sued for a treatment compli-
cation. Expert witnesses said that the treatment given
would have been perfectly acceptable 10 years ago but did
not now meet prevailing standards. What they were really
saying was that the standard of taking a modest risk to
maximize the chance of cure has changed, and that we live
in a society that wants no risk. I don't subscribe to that
view at all. If the situation demands taking a risk, then
the physician should not be averse to taking it for fear of
being sued."
Peters does not know what tack the current situation
will take. Reform in the legal system, more specific in-
formed consent legislation, and better education of
physicians in training are being discussed. But regardless of
whether these measures are taken, the responsibility still
rests with the physician. According to Peters, physicians
owe it to their patients to describe all options, legal issues
notwithstanding. "We have to be bold enough to take
some risk if we're going to do the maximum good." .
Physicians who desire additional information may write Lester J.
Peters, M.D., Division of Radiotherapy, Box 97, The University of Texas
M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston,
Texas 77030, or call (713)>792-3411.
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M.D. Anderson Hospital and Tumor Institute. OncoLog, Volume 35, Number 1, January-March 1990, periodical, January 1990; Houston, Texas. (https://texashistory.unt.edu/ark:/67531/metapth903734/m1/3/: accessed June 17, 2024), University of North Texas Libraries, The Portal to Texas History, https://texashistory.unt.edu; crediting UNT Libraries Government Documents Department.