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Wish-fulfilling medicine in practice: a qualitative study of physician arguments
  1. Eva C A Asscher1,
  2. Ineke Bolt1,2,
  3. Maartje Schermer1
  1. 1ErasmusMC, Department of Medical Ethics and Philosophy of Medicine, Rotterdam, The Netherlands
  2. 2Ethics Institute, Department of Philosophy, Utrecht University, Utrecht, The Netherlands
  1. Correspondence to Dr Eva C A Asscher, ErasmusMC, Department of Medical Ethics and Philosophy of Medicine, Dr Molewaterplein 50, Postbus 2040, Rotterdam 3000CA, The Netherlands; e.asscher{at}erasmusmc.nl

Abstract

There has been a move in medicine towards patient-centred care, leading to more demands from patients for particular therapies and treatments, and for wish-fulfilling medicine: the use of medical services according to the patient's wishes to enhance their subjective functioning, appearance or health. In contrast to conventional medicine, this use of medical services is not needed from a medical point of view. Boundaries in wish-fulfilling medicine are partly set by a physician's decision to fulfil or decline a patient's wish in practice. In order to develop a better understanding of how wish-fulfilling medicine occurs in practice in The Netherlands, a qualitative study (15 semistructured interviews and 1 focus group) was undertaken. The aim was to investigate the range and kind of arguments used by general practitioners and plastic surgeons in wish-fulfilling medicine. These groups represent the public funded realm of medicine as well as privately paid for services. Moreover, GPs and plastic surgeons can both be approached directly by patients in The Netherlands. The physicians studied raised many arguments that were expected: they used patient autonomy, risks and benefits, normality and justice to limit wish-fulfilling medicine. In addition, arguments new to this debate were uncovered, which were frequently used to justify compliance with a patient's request. Such arguments seem familiar from conventional medicine, including empathy, the patient–doctor relationship and reassurance. Moreover, certain arguments that play a significant role in the literature on wish-fulfilling medicine and enhancement were not mentioned, such as concepts of disease and the enhancement–treatment dichotomy and ‘suspect norms’.

  • Biomedical enhancement
  • medical ethics
  • plastic surgery
  • general practitioners
  • qualitative research
  • clinical ethics
  • concept of health
  • enhancement
  • general medicine/internal medicine
  • informed consent
  • telecare
  • quality of life
  • pragmatism
  • good life
  • geriatric care
  • dementia
  • neuroethics
  • patient autonomy
  • competence
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Introduction

Wish-fulfilling medicine can be defined as ‘doctors and other health professionals using medical means (medical technology, drugs, and so on) in a medical setting to fulfil the explicitly stated, prima facie non-medical wish of a patient’.1 Buyx supplies a range of examples for wish-fulfilling medicine, which include enhancing technologies, elective caesarean section, complementary medicine and diagnostics. Thus wish-fulfilling medicine includes non-therapeutic, elective and enhancing procedures, and emphasises the importance of the patient's request. In the present work, we examine what physicians engaged in elective medicine consider to be its moral boundaries and why. Our aim was to investigate the range of arguments physicians raise in practice. Until now, only very little empirical research has been done in this field,2 3 and even less qualitative work. We chose a qualitative design to uncover arguments generated by physicians themselves, instead of relying on responses to theoretically informed questionnaires. For ethical analysis aimed at providing input for professional and public policy, arguments from a theoretical debate are not sufficient; the considerations of physicians are needed as well.

We focus on two types of wish-fulfilling medicine, namely cosmetic interventions and diagnostic testing without medical indication in The Netherlands. We discuss the arguments raised in boundary cases to identify what matters in practice and compare this with in the ethical literature on wish-fulfilling medicine.

A number of arguments are commonly discussed in the literature with regard to wish-fulfilling medicine. General arguments concern patient autonomy, risks and side effects versus benefits, the goals of medicine, the boundaries between medical treatment and mere wish-fulfilling interventions, arguments relating to justice and cheating, and naturalness or giftedness of one's assets.1–7

Further arguments are raised within particular areas of wish-fulfilling medicine. In the case of cosmetic interventions, there are particular concerns about societal pressures impinging on autonomy.8 By their nature, these pressures are in line with societal norms, which can be sexist or racist. Then, a further argument against these practices is the complicity argument, which criticises some areas of cosmetic surgery for its reinforcement of suspect norms.9 10

Diagnostics at patients' requests raise questions about medicalisation. There are concerns about false negatives and false positives, and about private companies offering these services. Finally, there is an issue surrounding the widespread misperception that these sorts of interventions are harmless, even if there are risks: for instance, false positives and unnecessary follow-up.11

Methods

We conducted a qualitative empirical study to explore the arguments regarding wish-fulfilling medicine used by general practitioners (GP) and plastic surgeons (PS). We choose these two specialties for two reasons. First, we hoped to be inclusive and explore wish-fulfilling medicine in publicly funded medicine and in the privately paid for area. GPs and PSs in commercial clinics can both be approached by patients directly. In The Netherlands other specialties are approached only after a GP referral. Moreover, plastic surgery is a classic example of wish-fulfilling medicine.

We chose a qualitative study design, as this is well suited to investigate attitudes and to identify new arguments.12 We conducted seven semistructured interviews with GPs (four men, three women) and eight semistructured interviews with plastic surgeons (six men, two women), most of whom had a mixed practice of aesthetic and reconstructive work (questionnaires are available from the authors on request). The interviews were followed by a focus group with a further eight GPs (four men, four women, range of ages and experience). The aim of selection was diversity, rather than representation. Subjects were recruited via professional organisations and by snowballing. The sample size was considered large enough as an explorative tool.12 13 Interviews and focus group were transcribed and analysed in Atlas.ti (http://www.atlasti.com/) by bottom-up coding by one of the authors (EA) and two interviews were discussed in detail with all authors. In the interviews we discussed physician-generated examples of procedures at the patient's request and the arguments of the physicians on boundary cases. Mostly, physicians did not use the term wish-fulfilling medicine instead they discussed how sometimes they went along with patients' wishes although medical indication was absent. At the focus group, we discussed exemplary cases to get an overview of the arguments to confirm saturation had been reached in the interviews. Then we explored some of the arguments in more detail.

Results

Arguments in wish-fulfilling medicine

Many arguments raised during the interviews were expected, but some arguments used were new to the debate. Some familiar arguments on wish-fulfilling medicine were not mentioned. When the physicians discussed whether or not they would comply with the wishes of their patients, they focused on the well-being of the patient. During the interviews, many described their consultations as consensus seeking between their personal views and the patient's wishes box 1.

Box 1

Arguments uncovered in the qualitative study

Expected arguments mentioned:

  • Autonomy of the patient's wish

  • Medical risks and side effects & technical limits

  • Normality/naturalness & deviance

  • Expected benefits from the treatment

  • Justice and accessibility

  • Patients understanding of statistics

Expected arguments not mentioned:

  • Disease–enhancement dichotomy

  • Complicity argument/ suspect norms

  • Goals of medicine

New arguments in wish-fulfilling medicine:

  • Maintaining a good relationship with the patient

  • Ability to empathise with wish

  • Reassurance

  • Patient's expectations

Expected arguments

Some of the arguments raised by the physicians are familiar from the literature on wish-fulfilling medicine.

Autonomy versus paternalism

The wish of the patient is always the starting point in wish-fulfilling medicine:‘I start with your wish, what you deem beautiful, that is my starting point. And I need to translate that professionally and assess whether I can provide whatever you want.’ (PS1)

Of course, the existence of a wish does not mean it is autonomous. Different approaches are taken to establish whether this is the case.‘Then I try to establish whether it is a well considered decision, what has influenced it and whether they have considered other options, have looked at the disadvantages. And if someone is very well considered … yeah, eventually you go along with them.’ (GP1)

Physicians also take into account the authenticity of the request, particularly the duration and lack of coercion:‘Whether the patient has wanted it for longer, and really, intrinsically wants it themselves.’ (PS2)

Or in other words:‘It needs to be a wish that has been there for a longer time. It should not be that a husband or wife pushes one into it. Yes, you need to know that someone does not suddenly desire the procedure. That is why we have a cooling off period of 2 weeks before any surgery takes place.’ (PS3)

However, sometimes a patient's request is denied. This can be for a variety of reasons, sometimes implicitly paternalistic.‘Yeah, sometimes the physician needs to be above it all, I think. Together and in discussion, yes, but not going along indiscriminately with the patient's desires, because I think, maybe the patient is not aware that his outlook can change […] Or [the patient is not] able to see the consequences or the risks.’ (GP2)

Medical risks, side effects and technical limitations

An important argument raised against fulfilling patients' wishes is related to medical risks particularly on a healthy body:‘You know it is a procedure on a healthy body (…) with potential, quite unpleasant side effects.’ (GP1)

This can be expressed in a Dutch saying: ‘Sometimes the treatment is worse than the ailment.’ (GP3).

When side effects were severe, or the risks were run repeatedly, respondents decided against the fulfilment of the wishes.

Beauty and normality

In the discussion about beautifying procedures at the request of the patient, various arguments are raised. An argument in favour of going along with the wishes of the patient was returning to normality. If someone was ‘objectively abnormal’, that made compliance with the request easier.

There was a widespread belief abnormality may be objective: ‘It can be an objective observation. Someone can have a very abnormal nose…’ (PS5)

One of the physicians described this extensively:‘You start with your experience, the proportions of the body and the patient's wishes. And of course there is a large grey area. But there are guidelines for yourself that you follow.’ (PS3)

However, the subjectiveness of normality was raised in discussions; some physicians mentioned a cultural influence:‘Yes it [AA or A cup] is too small. The norm we use, says it is too small. Is it too small? You can decide. I don't know. French women love small, pert breasts. American women want very large breasts.’ (PS5).

Justice and financial arguments

The limits of the procedures the physicians deemed acceptable also depended on financial considerations: was it paid for by the patient or collective health insurance? In the case of collectively funded procedures, considerations focus on whether the patient has any issues or functional limitations. When the patient pays for the procedures themselves, more is allowed but there are limits: ‘Not at all costs, because it is not the case of ‘you request something, we perform it.’ I really can't stand that.’ (GP5)

Financial and justice arguments played a significant role in the discussions on diagnostics. An example is a privately paid total body scan, which has a high number of false positives. This leads to financial concerns about follow-up diagnostics: ‘A positive result leads to panic, which is not necessary. And the follow-up will cost a very large amount, which needs to be paid for by our health system’ (GP3).

A more general justice concern that was raised was that either diagnostics are useless and should not be done at all, or if they are useful they should be offered to all patients, instead of only to those requesting and paying for them. This may apply only for tests physicians consider medically valid, not for beautifying practices:‘And yes, in the end it comes down to the fact that we do have separate systems. I mean we need to acknowledge that there are people staying in homeless shelters and people staying in the Hilton. In other words, there are people who can afford certain things and others who cannot. And you can call that injustice, but I… Yes, I can live with it.’ (PS1)

Justice and financial arguments are used to restrict access to wish-fulfilling medicine when financed from collective insurance. When patients pay for these procedures, some respondents feel released from the responsibility to decide whether a procedure should be provided: ‘If it is really cosmetic, yeah, then it needs to be requested at the insurers to see whether it will be reimbursed. Then it is not my problem.’ (GP5).

New arguments in the sphere of wish-fulfilling medicine

The physicians studied also raised arguments that are not usually mentioned in the literature on wish-fulfilling medicine. Most of these arguments are familiar from conventional medicine: the importance of the patient–doctor relationship, the need to empathise with the patient and the central place of reassurance in general practice. In addition, many of the interviewed physicians discussed managing the high expectations of patients.

Maintenance of the relationship

In order to maintain a positive relationship with the patient, many physicians studied negotiate with them about wish-fulfilling medicine. A shared history was a reason for the interviewed GPs and PSs to comply with a patient's wishes. An additional reason for GPs was keeping their patients in the first line of care.‘You might say, I won't do the test, but even though there won't be anything found, I rather throw a few euros at a simple test, because it won't be more expensive than that. Then they'll stay in the first line [of care].’ (GP5).

A different doctor described this clearly:‘To maintain an open relationship, yes. That is central to a general practitioner.’ (GP6).

(Although one might expect that plastic surgeons would want to maintain the relationship so that patients came back for more procedures, this was not the case in our study.)

Empathy

Whether the physicians could empathise with a patient's request was an important consideration.‘It may be the case, for example, that someone has a very extended belly, and then I can imagine, if it becomes a severe sagging belly, which also causes mechanical problems, I know several examples of this, and I can empathise with that, if someone has something done about it.’ (GP5)

If a request is really out of the ordinary, physicians have serious doubts:‘My own intrinsic motivation lacks, when I think that [request] is absurd, I would create [by operating] something abnormal. That is not empathy engendering for me.’ (PS6)

Another physician described it thus:‘It is of course difficult, to what extent is it necessary for the physician to be able to empathise, whether you agree with it? And to what extent is it up to the patient themselves. Yeah, I think that I don't go along with the patient completely.’ (GP2)

The other new arguments seemed to be specific to a particular area of wish fulfilling medicine: either diagnostic testing or beautifying treatments.

Reassurance

An important argument raised to support diagnostic testing was reassurance, mentioned by the GPs studied. They considered reassurance of their patients central to their role. One described himself as a ‘fear charmer’ in the focus group.‘Do you want something from me, as extra reassurance? I'd be pleased. Blood pressure and those sorts of things, checks, listening to the heart, largely a ritual and not really contributing, but then they are reassured.’ (GP7)

Similarly, one GP described reassurance mingled with beauty:‘They really mind that, if there is an ugly mole somewhere. We get that question a lot. Sometimes there is some fear too, but you can reassure either by me, or through a referral to a dermatologist.’ (GP4)

The focus group also discussed the lack of coping strategies of many patients, and their desire for quick fixes:‘I think it is something about this day and age: that people very quickly say, this is wrong and I want you to solve it.’

Many respondents consider this a dilemma, they want to reassure, but cannot without providing useless diagnostics.‘I get the feeling that I can only move forward with them, once they have been reassured. So I always agree with them, they go for blood tests, but afterwards come back to discuss [the underlying concerns].’ (GP7).

Patient expectations

A more practical consideration to decide whether to fulfil wishes is the patients' expectations for the procedures. This was important to the studied PSs. They were more reticent when patients were expecting social miracles from beautifying interventions:‘Often men can think if my nose is less crooked […] then I can finally chat up a girl in the pub. But an ass*** will stay an ass with or without a crooked nose. The girl won't notice, but still think this man is not my type. And then he complains about the failure.’ (PS4)‘Whether they have a reasonable expectation of the surgery: if they think I'll look like a 30 year old again, and then I'll be happier and my boyfriend will like me more, and I'll find a job, the strangest things may influence the patient's judgement and I try to get that clear, what do they expect of this procedure? And is that realistic?’ (PS2)

If the expectations of a patient are unrealistic, this is a reason not to comply with the patient's wishes.

Theoretical arguments not mentioned

There were several arguments from the literature that were not mentioned by the GPs and PSs. Notable absences included the enhancement–treatment distinction, goals of medicine, medicalisation and concepts of disease. The idea of ‘suspect norms’ in aesthetic interventions was also not mentioned.9 The focus group discussed a case (the correction of slanted eyes in an Asian woman) that raised this issue, but the GPs did not discuss this element. One GP expressed intuitive dislike of the case: ‘that makes my skin crawl’, but this was not discussed further. Instead they debated medical risks and the likeliness of achieving the desired result, whether the patient was experiencing an underlying physical or psychological problem, the level of ‘mutilation’ caused by the surgery. After explicitly being asked whether race played a role, one GP expressed his concern in suspect norms terms:‘I find it difficult if she does not want to look Chinese. Because that way, I feel that I collaborate and corroborate that that is not good […] that feels wrong.’

However, no one followed up on this.

Discussion

Considering the widespread academic debate on wish-fulfilling medicine and enhancement,1 14–16 we were interested to see which arguments physicians raise. Wish-fulfilling medicine is taking place in consultations at our general and plastic surgery practices. The arguments used to decide on boundary cases are ethically significant: insight into these arguments is necessary as input for an ethical analysis and evaluation of their strength and in this to way to further the public and policy debate on a responsible use and regulation of wish fulfilling medicine. We focused on GPs and PSs, which in the Dutch health system can be approached directly by (prospective) patients and represent publicly funded and privately paid for areas of medicine.

This study obviously has its limitations. We were interested in uncovering new arguments and thus chose a qualitative study focusing on Dutch physicians, which cannot provide generalised arguments about wish-fulfilling medicine. This would require further study. Moreover, GP practice in The Netherlands is publicly funded, whereas plastic surgery (when wish fulfilling) is privately paid for. There may be differences with completely market-driven healthcare systems, which have not been assessed. As the study is qualitative, we cannot draw conclusions about the differences between GPs and PSs. However, some differences between GPs and PSs were observed, which are likely related to the different procedures they offer. The PSs studied mentioned the expectations of patients, which seem related to the appearance-improving procedures they perform; in contrast, the studied GPs discussed reassurance in connection to diagnostics.

Some arguments from the literature surrounding wish-fulfilling medicine were not mentioned during the interviews. The idea that medicine's goal is to treat diseases and promote health and not to produce enhancement or fulfil wishes was not mentioned. The physicians in our study focused on doing well for the patient. The patient's wish was taken very seriously, but often as an expression of needing help or reassurance, rather than wanting a procedure. When deciding whether to perform a requested procedure, the respondents were driven by their desire to help patients, to do good even if this was medically unnecessary. The idea that some consider wish-fulfilling medicine a ‘relief of suffering’ was seen before in Holtz' survey.2 However, sometimes the ‘good’ can imply reassurance, even if that requires unnecessary diagnostics or for example, medication.17 Another means to achieve the patient's good is the maintenance of the patient–doctor relationship.18 This finding seems to be in line with the view that dichotomous, theoretical concepts (such as disease concepts and the treatment–enhancement distinction) provide physicians no normative orientation.19 Reference to the concept of normality is made, though the respondents acknowledge its subjectivity.

In deciding whether to comply with a request, many respondents used the empathy argument,20 which can mean many things. For example, it may be difficult to empathise with a patient wanting a risky procedure with few likely gains: thus the lack of empathy covers the risks of the procedures and a judgement of the benefits. A focus on balancing risks and benefits has been reported before2 3 and can be related to empathy. Once this risk–benefit balancing becomes explicit, a discussion and a reasoned decision can follow. If, however, empathy is difficult, because a patient desires something the physician finds weird, the lack of empathy merely shows the unease felt by the physician.21 It is questionable to what degree ‘unease’ as such, without further qualification, constitutes a good reason to refrain from performing the procedure. In short, the empathy argument is a container argument, which can be useful as a shorthand, but needs to be unpacked to assess its validity.

In conclusion, the physicians interviewed come across wish-fulfilling medicine in the practice of medicine. When confronted with challenging cases, conventional medical reasoning is used to decide whether or not to go along with the patient's wishes. The respondents focus on doing good by their patient, in the patient's context and with the individual patient's risk–benefit balance. Moreover, the studied physicians often advance in a consensus-seeking manner with their patients. This is important, as physicians currently are the de facto gatekeepers of many wish-fulfilling and enhancement procedures. (The fact that physicians play a de facto role in gate keeping of wish-fulfilling medicine does not mean they should be the gatekeepers.) Taking the reasoning and arguments of physicians into account is essential when discussing the role of physicians in wish-fulfilling medicine now, and under which circumstances new forms of wish-fulfilling medicine may be acceptable in the future.

References

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Footnotes

  • Funding ZonMw (The Netherlands Organisation for Health Research and Development), grant number 141010006.

  • Competing interests None.

  • Ethics approval This is not necessary under Dutch law for interview studies with competent adult physicians.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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