The Problem of Paitent Choice

Your health, your choice.

Excert from Patients not Profits.

The Kantian imperative, “you can because you must”, has been inverted to become; “you must because you can”[1].This has happened with the NHS mantra, ‘Your health, your choice’[2][3]. In other words you must be healthy, (and slim and beautiful), because you can. Fat or thin, sedentary or active, smoker or non-smoker, whole foods or junk-foods, in short, whether you are in control of your life or not, according to ‘Your health, your choice’, it all comes down to a matter of personal preference. Health differentials based on social class and circumstances out of your control are blamed on lifestyle choices.[4]

In developed countries such as ours, there is a social gradient in health, which means that the lower your socioeconomic group the greater risk you have of suffering from almost all types of illness, especially cardiovascular disease and most types of cancer. As the level of inequality increases, as it has done over the last 30 years, the social gradient widens even if the level of absolute poverty stays the same. As the rich get richer, the poor get relatively poorer and consequently become more socially excluded as the costs of participating in society increase. The health gradient “cannot be attributed, in the main, to diet, smoking or other determinants of ‘lifestyle’”[5]

The result of the government’s failure to protect health by increasing social inclusion through education, employment, and housing, is to shift the burden of responsibility onto patients who are expected to improve their lifestyles, and doctors who have to spend more and more time promoting healthy choices. Corporations are encouraged by the Government to offer a market driven culture of dependency; your choice, you choose yourself the products you need to be healthy.

The naive consumerist position is based on the imaginary construct of an ideal consumer based on rational choice theory which assumes that people are fully informed and fully able to understand the information, are rational and not subject to bias, are self interested rather than altruistic, in other words, fully autonomous.

This position assumes that society consists of equally autonomous individuals making rational choices in their own best interests. Autonomy is not equally distributed; it’s strongly associated with educational and financial empowerment so the least educated, poorest and unhealthiest are also the least autonomous. Illness undermines autonomy in several ways. Though mental illness most obviously adversely affects our judgement, most of us recognise that we think less clearly when we’re suffering from any illness. When chronic illness such as diabetes or heart failure is compounded by depression as they frequently are, your reasoning skills are seriously impaired. Physically disabling illness causing pain, breathlessness or visual impairment restricts your ability to choose where to go for your treatment because travel is so difficult. Chronic illness is financially disabling, resulting in unemployment or high costs for care or adaptations, so that choices that incur additional costs are closed off. People with learning difficulties and many elderly people find choices difficult and anxiety provoking and they value quality and continuity rather than choice.[6] Some people’s poor health and other difficulties are themselves testament to their failure to make rational choices that serve their best interests. It seems absurd to encourage them to continue to rely on their proven poor judgement for something as important as their healthcare, indeed it is a paradox that people’s poor health is blamed on unhealthy lifestyle choices in the first place and then they are told to choose how to improve their health.

When people are ill and hence most vulnerable, they need doctors who know them well enough to understand how illness robs them of autonomy, doctors who are skilled enough to step in and take care of their patients by sharing the burden of responsibility at a time when it weighs most heavily. In contrast the commercial health industry exploits illness and anxiety with advertising and fear-mongering to encourage people to choose and consume their products.

I opened the window of my consulting room wide in the hope that the smell of cigarettes would fade before the evening clinic. I had just been to visit SD at her home which was always thick with smoke and the 1970s decor –memories of my own childhood, was stained yellow like an old pub. For the last 2 years I’d been visiting her to check on her blood pressure and give her a general check up. She was well aware of the risks of smoking and hypertension and had guessed rightly that she had suffered a stroke during the night, but wanted to see me before calling an ambulance. She had started smoking 60 years ago as a 15 year old. Then she smoked Lucky Strike because that’s what everyone was smoking, but for the last 20 years or so she’s smoked whatever was cheapest at the local store. That’s what everyone smokes these days. You can even buy single cigarettes for 30 pence if you can’t afford a packet. Disabled by severe arthritis, she rarely goes out, but she’s always cheerful and denies being lonely. She has tried giving up cigarettes on a few occasions, and managed for a couple of years before her husband died, but started again afterwards to help fill the gaps in the day. She tried again after a chest infection shortly after we first met, but became depressed and rapidly returned to her cheerful self when she started smoking again. She gestured to her flat and the estate around, “when you live somewhere like this, it’s not like where you live doctor, we don’t mind smoking here”

Even in the absence of market pressure, the assumption underlying choice is that people like SD and doctors like me are equally able to take control of our lives and define ourselves by our choices. It assumes, wrongly, that providing information is enough to empower people to choose a healthy lifestyle. Offering choice without addressing the conditions within which people live their lives, the experiences that affect their decisions, and aspirations which shape their vision of the future, widens inequality by empowering those ready to make those choices and alienates those people who have very different priorities.

RT has pain in her knees and ankles, she starts telling me about them as we walk from the waiting room to my consulting room. She is also morbidly obese and eats to cope with her emotions. She finds herself overwhelmed by first comfort and then remorse as she cries throughout her eating binges. She has spent thousands of pounds on countless diets including one from a private clinic that injected her with amphetamines and resulted in a psychotic episode. She has spent hundreds of pounds on gym-memberships and bought dozens of self-help guides, none of which have had a lasting effect. Recently we discussed referral for gastric bypass surgery but the thought of the risks and future complications frightened her. She rarely goes out except to work or to collect her daughter from school. For a long while she stopped going to the doctor, because whatever she wanted to talk about, all they seemed interested in was her weight, “it was like they stopped seeing me as a person”.

[1] Zizek. S. You May! London Review of Books 18th March 1999 http://www.lrb.co.uk/v21/n06/zize01_.html (accessed 2.2.9)

[2] http://www.nhs.uk/Pages/homepage.aspx

[3] http://www.nhs.uk/choices/Pages/Aboutpatientchoice.aspx

[4] Heath, I. A Mystery of General Practice in Matters of Life and Death, Key Writings. Radcliffe Publishing 2008, 97

[5] Marmot, M. Status Syndrome, How your social standing directly affects your health. Bloomsbury 2005, 249

[6] BMA News May 23 2009 p.10

Annemarie Mol’s wonderful book, The logic of Care. Health and the Problem of Patient Choice discusses in detail the complicated relationships that are necessary between health professionals and patients and highlights important differences between care and choice that are not discussed above.

2 responses to “The Problem of Paitent Choice

  1. Pingback: Consultation or charade..? « Launchpad: By and for mental health service users

  2. Pingback: DH consultation on greater choice and control: a sham. | Abetternhs's Blog

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