Paternalism in Medicine
Today I had academic day, which is my only chance to sit around and compare notes with other residents. We frequently discuss cases, particularly ones that had a counselling/psychological/touchy-feely component that we were unsure about how to approach.
The case brought to the group today by one of my fellow residents was the story of a 19-year-old who came to see her seeking the birth control pill. Might have been straightforward, but she was also asking for a refill of Imitrex, a migraine medication. The birth control pill raises a woman's risk of blood clots, which will make her more likely to have a stroke. Have a certain kind of migraine (with aura, where you get visual and/or neurologic signs that preceed the headache) also raises the risk of stroke. To be taking both together raises your risk of stroke by more than either one alone.
The bottom line is that the Society of Obstetrics and Gynecologists of Canada says that migraines with aura are an 'absolute contraindication' to prescribing the birth control pill. So the group was saying that she shouldn't have prescribed the pill (she didn't in the end, but her preceptor ended up caving and giving it to her). I was the lone voice of dissention.
Don't get me wrong, I'm not in a big hurry to prescribe drugs with harmful interactions, but I wasn't sure if it was right to outright refuse the girl her prescription. I was of the opinion that if you are able to appreciate the consequences of your actions, you should be able to make the decision for yourself. For example, if I were to explain that the risk of stroke for a 20 year old woman on the birth control pill is 1 in 1000, and the risk of stroke for the same woman if she gets migraines with aura is 2 in 1000, but if you put the two together your risk of stroke goes up to 8 in 1000. (fictional statistics for emphasis)
Well, if that woman decides that the benefits of taking the birth control pill outweigh the 6 in 1000 risk of stroke, who is to say that it isn't her right to say so? The group shot me down-- lawsuits are stressful, it's ABSOLUTELY contraindicated (thanks, I got that the first time), her reasons for going on the pill were frivolous (who are we to judge her reasons?)...
I stood firm. She was an adult. If she understood the risks, I didn't see why we couldn't leave the decision in her hands. All appropriately documented, of course, to cover my ass in the event that she DID stroke out and I end up being sued.
So now my group probably thinks I'm negligent. I'll likely be voted 'most likely to be sued first' at our next dinner party.
This medicine stuff is complicated.