Developing a medical indication is an everyday process but still lacks a precise definition. In clinical practice, the process is informed by medical expertise and the condition of the individual to be treated. According to the results of a medical-ethical research project, it is also a communicative instrument designed to support—and not patronize—patients in their decision-making.
It is a process that occurs hundreds of times every day in Austrian clinics: The physician devises an indication, and on this basis, discusses the treatment options or clinical findings with the patient. These discussions determine the course of therapy and they must focus on the autonomy of the patient, who needs to consent to the proposed measures after receiving appropriate information.
The term “indication” is used on a daily basis. It guides medical activities and also requires legal and ethical validity, “but neither literature nor experts in the fields of ethics, law and medicine are currently able to define exactly what the term means and how the process should go,” says researcher and physician Karl Hunstorfer in describing the challenge. In a project funded by the Austrian Science Fund FWF, the internal medicine specialist is currently conducting research in the field of medical ethics and is contributing his practical experience as a medical doctor in the oncology ward at the Hospital of the Brothers of St. John of God pital in Vienna. Hunstorfer describes the daily work on his ward, which shows a possible way forward: “Fifty percent is about talking and 50 percent about the pills.”
From recommendation to decision
In an oncology ward, the medical ethics aspects can be explored particularly well. Cancer is a multifaceted disease that hardly ever offers the prospect of a complete cure. Depending on the patient’s age, type and stage of cancer, it usually requires several changes in treatment or treatment objectives or the transition from curative to palliative medicine. Hence, the course of treatment often involves several medical indications, and options are (re-)evaluated according to individual wishes.
Gone are the days when the doctor alone decided on the patient’s course of action. Devising indications is therefore caught between two poles: Physicians apply the growing body of evidence-based medical knowledge, which is considered neutral in terms of value judgements, to patients who have individual needs and conditions as well as their own standards when it comes to deciding what is good for them or important for their lives. Another factor is the increasingly prevalent idea of being able to control the human body and nature. “This is the daily balancing act: Based on theory, recommendations must be made and decisions affecting human beings taken in clinical practice, including the perspectives of successful therapy,” explains Hunstorfer.
Medical indication arises in dialog
In the context of his basic-research project, Hunstorfer also went looking for background information in science theory. He was able to identify origins in antiquity for the notion of “indication” and concrete action. Translated from its Latin roots, indication means “suggested course of action.” Another important foundation is maieutics, i.e., the approach based on dialog propagated by the philosopher Socrates.
By its nature, indication is a dialog: “Medicine operates in clinical practice. In addition to specialist knowledge, experience and treatment standards on the one hand, the individual plays a role during ward rounds. As physicians, we have to inform patients about all available options, listen to what they have to say and involve them in the therapeutic decision. In this context we can come into conflict with our ethical norm of always doing something helpful, something healing,” says Hunstorfer.
Describing the central result of his research, Hunstorfer says, “By its very nature, medical indication is a communicative instrument and a core task of the medical profession. It should encourage doctors to reflect on how to benefit from indication for building a bridge between evidence-based knowledge and a concrete individual. The aim is to educate those affected and to support them in making the best choice for themselves. Ideally, medical indication should encourage the patients to reflect on this issue and make their own decisions.”
The ward round in practice
The project was empirically supported by the psychologist Bettina Baldt, a doctoral student at the University of Vienna. For a week, she recorded doctors’ rounds at the oncology ward of the Hospital of the Brothers of St. John of God and subjected a total of 13 conversations to a linguistic analysis. Baldt paid attention to wording and structure, to the physicians’ response to what was said and the effects that had on the course of the conversation.
She evaluated the material on the basis of four scientifically established patterns of how such decisions are made: The first is patient-dominated, the second defined by the patient and taken by the doctor, the third defined by the doctor and taken by the patient and the fourth is doctor-dominated. In practice, hardly any of the observed decisions were dominated by the patient, one of the reasons being that sometimes, no other therapy options were available. In addition, the conversations never included merely two people, but always involved physician-nursing teams and even relatives.
Future studies will therefore have to look at how patients deal with the imbalance between medical expertise and the right to self-determination, to a decision taken by the patients for which they accept responsibility. In this context, instruments such as clinical ethics counseling, or an ethics council, are good and already established tools, which could be further developed. According to Karl Hunstorfer, it would also be important to develop methods that capture how patients experience the decision-making process. Researchers should also look at how a current prognosis is dealt with in the future if the chosen therapy does not succeed, but fails.