“Respecting autonomy means that we need to respect that people are able to make their own choices, even if they come for advice. An autonomous patient is someone who does something with intention, with understanding and without any controlling influences. Controlling influences, in turn, affect the voluntary choice of the individual”



The medical council has recently distributed a letter to all medical practitioners admonishing them not to give advice against receiving the AH1N1 vaccine. This letter raises several issues, which, if not contemplated well, may lead to public mistrust in the profession in general. The main question is whether medicine is subject to the personal opinion of the practitioner or whether the practitioner should always impart impartial information which the health authority tells him or her to do so.

While doctors have traditionally cherished their independence when it comes to imparting treatment, times have also changed. This is acknowledged in the ever-lengthening publication of the British Medical Association, Medical Ethics Today. “What patients now expect from doctors is quite different from the expectations of the parents and grandparents. Much of this is due to societal change and differing views about how, for example, fundamental concepts such as benefit, harm, and best interests should be interpreted.”

In addition, the increasing focus on patients’ rights has led to a position where the arbiter of what is ethical lies usually in the hands of the law. Therefore doctors, whilst still allowed to express their opinion, have to make it clear that this may be only their opinion and they still have to emphasise what the health authorities are usually pointing out to the public. Family Doctors are especially numerous enough and strategically placed to give relevant and timely information to the public. Dealing with risk communication is difficult enough for the public health authorities and health departments and should probably not be made more difficult by the front-liners.

Doctors do indeed read and continue to receive evidence-based information. Sometimes however there are indeed conflicting articles in the medical journals, such as a recent article which was rather strongly against vaccination, which appeared in the British journal of General Practice. The journals do however point out that these articles are opinions and do not reflect standard policy and neither are they intended to confuse doctors or to encourage them to do other than what departments of health recommend. They are simply meant to keep the on-going debates and to continue in the scientific tradition developed by Karl Popper (a philosopher of science – who said that good science means that anything is always challengeable.

We are dealing with human lives however and when doctors are faced with health authorities, who do not simply come up with ideas, but are following the advice of the World Health Organisation and the World Medical Association, then one is taking simply too much on his or her shoulders when one advises patients not to take a vaccine which is being promoted to avoid pandemics. There are indeed politicians who may go public and make an issue about industry or the United States, who are gaining by promoting such a vaccine. We do not hide behind the fact that medicine has to make use of industry and that there are many companies who indeed get rich in such times, as there are people who get rich during times of war. It does not mean we do not buy arms and not defend ourselves. An interview with a Nordic politician appeared on the internet who actually strongly came out saying that the whole vaccine thing was a hoax to make us spend money. Others said it was an exercise to test how we can manage an eventual bird flu pandemic. Others even said that people are trying to kill half of the world’s population. One would expect doctors to go reasonably beyond such scaremongering and that if they do not have any solid information, not mere opinions, that vaccination is dangerous, then they should not give their patients wrongful information. Patients trust their doctors. The doctor-patient relationship is a fiduciary relationship, and if doctors go around telling people not to take the vaccine, then many people will indeed not take it because they trust their GP/family doctor.

If in all honesty doctors cannot refrain from discouraging their patients not to take the vaccine, then they should be ready to point to the relevant evidence and accept if they are wrong. Prudence, a virtue which we cherish to hopefully have in our practices, should move us to a point where we should only tell people what the health departments are advising and when asked about risks, discuss these frankly and without scaring people off. It is interesting that a student asked me this week whether we should give our personal opinion. If asked for a personal opinion then maybe we can consider this; if not, then we have to ask ourselves whether we are giving this information to try to push the patient one way or another in making a choice. What this boils down to is the Principle of Respecting the Autonomy of Patients.

Respecting autonomy means that we need to respect that people are able to make their own choices, even if they come for advice. An autonomous patient is someone who does something with intention, with understanding and without any controlling influences. Controlling influences, in turn, affect the voluntary choice of the individual. The concept of an informed choice, and informed consent, is a derivative of the principle to respect autonomy. For a valid informed choice, the patient must receive at least the information which a reasonable person would want to know; the doctor has to make sure that the patient is understanding, is competent to make a choice, and is making a voluntary choice, and finally the consent has to be given. The voluntary choice, in turn, is affected by three main things: Coercion, manipulation (a thwarting of the truth), and persuasion.

Some question whether persuasion is legitimate. A person who needs persuasion is evidently still unable to make a choice voluntarily. He or she needs that push. There is a clear difference between trying to persuade someone and giving further information so that the person can make a choice. We should allow people then to make their own choices, for clearly if I continue to give more and more information until the patient is ‘persuaded’, then one not only risks manipulation of the truth (for I may be emphasising only my bias), but we certainly would be putting pressure on the individual. Discretion is the rule of the day. Clearly when it comes to answering questions about our personal opinion, one has to take this into consideration. I have to be aware that giving my personal opinion is a legitimate question and reflects the trust the person has in me. I must realise at this point the power I hold in my hands, lest I be guilty of malpractice – which is a failure to impart a duty of a standard of care I owe, as a professional, to the patient. Should harm be caused by this breach of duty, I would be held liable for negligence.

Thomas Percival, one of the first to write about modern medical ethics (after Hippocrates) in 1803 made a statement which is still relevant today, as evidenced in the BMA book mentioned above: The life of a sick person can be shortened not only by the acts, but also by the words of the manner of the doctor. This was written in the context of not discouraging sick people. But it is also applicable today, when we have made a paradigm shift towards preventive medicine. My words can indeed affect outcomes. If I am putting my personal opinion on the line instead of that of the official health statements on a country, I must clearly be considering that I must be able to justify my words and acts in front of a medical council – the ultimate thermostat of the actions of each medical professional.



Pierre Mallia is Associate Professor in Family Medicine, Patients’ Rights and Bioethics at the University of Malta; he is also Ethics Advisor to the Medical Council of Malta. He is also former president of the Malta College of Family Doctors.