As I slogged through the early chapters, I felt that I was reading a book whose authors had never quite discerned who their audience should be. Was the book written for doctors who ought to be more aware that patients approach their care from a variety of perspectives and values? Or was it for patients who had to decide how much deciding they wanted to do? Reading stories of people who sought multiple medical opinions and interviewed several doctors, I found myself asking: what world are these authors writing about? In the U.S. medical environment, most of have very few choices about what doctor we may see about our complaints. We therefore mostly feel constrained to take that doctor's say-so about our treatment. Mitt Romney may be able to fire his insurance company and therefore have choices about what doctor he sees, but most of use feel lucky to have either insurance or any doctor.
I will say I found the discussion of patients' and doctors' discernment about end of life care more nuanced than some of the other sections. I know from trying to be present over several years to my own mother's decline and eventual death that meaningful conversations about final wishes may not be possible. I would like to think that I'll eventually find the courage to be able to face my death and to be clear with whoever is caring for me about my wishes -- but I recognize that if faced with the need to do this tomorrow, I wouldn't know my own mind.
These authors include a good description of the pressures on the medical system that contribute to some patients nearing death without having their wishes discovered or heard.
Or, to put it more charitably, this efficient system makes itself unable to listen to the patient.
I don't know what we do about this. We want the marvelous healing that modern, expensive, scientific medicine can deliver, at its best. Maybe it's just that, at some point, for all of us, medicine can do no more -- and no improvements in efficiency are going to change that. At some point, medicine is no longer about decisions; decisions are over. The whole thrust of the healing discipline fights that end; no wonder it doesn't handle it gracefully.