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A Piece of My Mind
September 17, 2014

Whose Autonomy?

Author Affiliations
  • 1Department of Global Health and Social Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA. 2014;312(11):1099-1100. doi:10.1001/jama.2014.8273

During my medical residency, I took care of a 64-year-old man, Ian (a pseudonym, as are all names in this essay). He had come to the emergency department for an exacerbation of his chronic obstructive pulmonary disease. He also had rheumatoid arthritis, and before I could take a history, his wife Sarah pulled me aside to say that he was in increasing pain from his arthritis. He never missed a dose of methotrexate, but refused to take nonsteroidal anti-inflammatory drugs. I asked if there was some ill effect from them, but she said, “No, it is just part of his self-image to be tough and not treat his pain. But he needs treatment, whether he will say so or not.” When I saw Ian, it was clear that he was in pain, and I inquired about his opposition to NSAIDs, expecting some adverse effect or fear of harm. But he simply said, “I don’t need them. My wife is just putting you up to this.” Sarah responded, “Ian, you’re being ridiculous. You’re in pain!” He rolled his eyes and said, “Fine, just this once, for her,” and acquiesced to a one-time dose. To me this seemed like progress, but in subsequent encounters when I met with Ian alone, he resisted any suggestion of a more stable regimen.