Second opinions are invaluable to anyspecialist who ... whether a second opinion should be sought. ... behalf of a patient, to insist on a second opinion if there.
explanation for the bizarre behaviour of the doctor who nature of the disorder and the appropriateness of the offered admission without a referral. treatment are particularly likely to be in question, and Second opinions are invaluable to any specialist who where the cooperation of the patient is most necessary. deals with chronic and severe illnesses. Every so often, A doctor unable to persuade the patient or relative by patients and their psychiatrists have poor relation- negotiation ought to be anxious rather than reluctant to ships, and in these circumstances the patient's general get an independent view, and if necessary transfer practitioner should seriously consider requesting a responsibility. change of consultant. However, patients must be I do not see a doctor's desire to be in charge of a protected from second (or third or fourth) opinions patient's body or mind, or a doctor's obsession with a from naive doctors who lack experience in prolonged particular treatment, to be relevant to the debate. Any community care of people with major mental illness. doctor with that particular state of mind is unlikely to Some fairly uncontroversial information can be be a good doctor, and both peer group review and the given to this family based on the few details we have consultant contract should be brought into play to here. Unfortunately, it makes rather depressing read- protect the patient's interests. ing, but the false hopes raised by other psychiatrists I do, however, recognise two real problems. One is have to be countered. Firstly, psychoanalytically based that there may not be a readily available independent psychotherapy in the private sector is surely contrain- and equally expert second opinion-still less someone dicated. Secondly, a "one off" admission to a distant to take over treatment. This is certainly true in the case hospital will be of no value. If M does go to a tertiary of learning disability. Another is that second opinions referral centre she will sit about for months being and extracontractual referals are not free, and people's assessed by well meaning trainee psychiatrists and enthusiasm for having them will inevitably have to be paramedical workers.2 Various psychological treat- balanced against the ability of the NHS (in its current ments will be tried, but these are available throughout organisational and financial state) to pay for them. the country and, sadly, none is known to influence outcome. Expensive brain scans will be done-but only for research purposes. Only a few years ago she would have been sent home on, for example, chlorpromazine 100 mg four times a day. Now clozapine is available, and this can be ofconsiderable help in a small number of patients if they and their doctors accept the slight risk of agranulocytosis. Previous experience in prescribing this drug is unimportant, however, since treatment regimens are rigidly supervised by the Clozaril Patient Monitoring Service. This patient needs continuing care from a community psychiatric nurse who has come to terms with the fact that most people with major psychoses do not recover, although they can be helped. She should also have long term contact with an NHS consultant psychiatrist who works well with the local multidisciplinary community mental health team. Most importantly, she must sign up with a general practitioner, who will shield her from the controversies in psychiatry and who will make the final decision on whether a second opinion should be sought.
Ethical issues Carl Elliott
I have to confess that this story bewilders me. That three doctors over a period of two and a half years would refuse to refer a seriously mentally ill patient at the apparently reasonable request of the patient's distraught father seems baffling. That the father's reaction to this would be to submit a restrained article to a medical journal is even more surprising; in the United States, where I come from, he would probably have retained an attorney. Most bewildering, though, is the notion that there should be any question about a patient's right to a referral and a second opinion. To me it seems so self evident that a doctor should not have the right to block a sick person from seeking another medical opinion that to argue the point seems rather 1 CRAG/SCOTMEG Worling Group on Mental Illness. Semices for people superfluous. Perhaps there is something about the affeced by schizophrenia. A good practice staement. Edinburgh: Scottish doctors' reasons for refusing a referral in this case, or Office, 1995. about the NHS bureaucracy, that I do not know. 2 Psychiatry-a discipline that has lost its way. Lancet 1985;i:731-2. The main purposes of a second opinion are to ensure that a doctor is not making a mistake in treatment or diagnosis and to allow patients access to alternative Patients' rights methods and practitioners that might be better able to help them. Unless doctors are all infallible (or equally fallible) and all treatments are effective (or equally E B McGinnis ineffective), access to a second medical opinion will be necessary to ensure decent health care. This is not to say that patients have a right to treatment that is I would always advise a patient, or a relative acting on harmful or outside the standard care or that they have a behalf of a patient, to insist on a second opinion if there right to an unlimited number of medical opinions. is an apparently good reason for questioning the first Doctor shopping is costly, and it can have therapeutic opinion. I would always advise any doctor dealing with dangers of its own. But even as a pragmatic, cost saving a dispute about treatment in circumstances where measure, restricting a patient's right to a second there is no legal requirement for a second opinion to opinion is dubious. A second opinion that prevents a seek an advisory second opinion. There are two mentally ill patient from becoming acutely psychotic important reasons for this firm line: a doctor cannot and requiring hospitalisation, for example, will have insist on a patient accepting a particular type of been well worth the public investment. treatment, and a patient (or a relative on the patient's Preserving the right to a second opinion is especially behalf) cannot insist on a doctor giving him or her a crucial in psychiatry. Firstly, perhaps more than most particular type of treatment. Patient (or relative) and medical disciplines, good psychiatric treatment doctor therefore need to negotiate. The second opinion requires a sound therapeutic relationship. That is in some circumstances an important part of the relationship will suffer if a patient is unhappy with his negotiation and in the interests of both doctor and or her psychiatrist or with the current treatment, and patient. so will the patient's care. Secondly, more than most This approach is all the more important where the disciplines, psychiatry is riven by professional differBMJ
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ences as to how mental illness should be treated. If the prevailing standard of care encompasses many different treatments, one must ensure that patients are not denied access to the best treatment for them. Psychiatric patients are often especially vulnerable because they may not be competent to make their own medical decisions. In such cases the ethically appropriate surrogate decision maker is generally a family member who is closely attached to the patient, such as a parent or spouse-not the psychiatrist. In rare cases, of course, families make decisions about treatment that are contrary to the best interests of a patient. In such cases a psychiatrist might be justified in overriding their decisions and might well also be bound, for reasons of confidentiality, from speaking about it in a public forum. If this is the case, however, a second opinion will only corroborate the psychiatrist's judgment. The occupational hazard of medicine is arrogance. If nothing else, allowing peers to scrutinise our decisions is advisable for reasons ofhumility. My thanks to Bruce Charlton, Hal Elliott, Laurence Kirmayer, and Charles Weijer for their comments.
The general practitioner's role Angela Douglas In commenting on this article, I am conscious of the dangers of drawing conclusions from only one side of the story, and so I shall concentrate on some general issues raised. Firstly, who is the patient? M's needs are the subject of the letter and are the responsibility of the doctors caring for her. Her parents, however, will have needs of their own, and attempts should be made to ensure that the two are not confused. Both will need to be addressed but not necessarily by the same professional. Decisions about treatment are ideally taken by the patient based on advice from doctors and discussion with whoever the patient may choose. A competent
patient decides whether to accept that advice or to seek another opinion. Psychiatric illness may raise a question of competence, and it becomes a matter of judgment whether a patient is capable of making decisions about his or her treatment. The communication pathways affecting treatment become triangular; the patient's carer in one corner, the general practitioner in another, the consultant in the third, and the patient in the middle; each influenced independently by others. When a patient is unable to give informed consent, the decision making process shifts to the outside of the triangle. At each corner is a person with power and influence, and each will wish to act in what he or she thinks is the best interest of the patient. A balanced triangle, with good communication all round, benefits the patient. Tensions arise when there is disagreement between interested parties. This may result in a power struggle about who is right. If this occurs the patient will be the loser. If the tension becomes too great the triangle breaks up, leaving the patient unsupported in one area or another. Disagreement between the people at two of the corners of the triangle leaves the third either to side with one and alienate the other or to act as mediator. The general practitioner is well placed to fulfil the latter role, being used to coordinating treatment of patients in the community and likely to have a long term perspective. The general practitioner may be the one person who knows all the interested parties well. Unfortunately M has no general practitioner, and a previous general practitioner and consultant disagreed with her father. The triangle was lost and tension polarised along one axis, with the patient in the middle. Both parties acted in good faith, but one was more influential and the other was disempowered. Conflict may cause the relationship between doctor and patient to break down. If this occurs an alternative impartial opinion is required. NHS resources must be used responsibly, and the purpose of a second opinion is not the avoidance of uncomfortable truths. But a doctor who refuses to refer a patient for a second opinion must be sure that the current treatment is optimal or that referral itself will harm the patient. The doctor who holds to this in the face of opposition bears enormous responsibility. He or she may be right, but there are few absolutes in medicine.
Letterfrom Peru Peru revisited Hans Veeken
M6decins Sans FrontiLres, PO Box 10014, 1001 EA Amsterdam, Netherlands Hans Veeken, public health consultant BMF 1995311:6724
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"Twelve years I have been away from my village, twelve years; that is a long time, you know." The old man looks at me as if he expects that I cannot grasp the suffering he went through. Maybe I cannot, but the picture speaks for itself. His village, Umaro, had sparkled in the valley when we approached it from the mountain. The descent by car was spectacular, as was the bridge we had to cross by foot. The bridge was made of two cables suspended from one side of the river to the other. Across the wires were planks, but many were missing and, worse, some were so rotten that we dared not tread on them; we had to jump, with the turbulent stream 20 metres below. The village had once been a prosperous place, but now only remnants of this past, overgrown by weeds, remained. The old man shows us around. "The church
has no roof, only the walls stand, but the bell shines in the sun," he says proudly. "It has been stolen twice, but we retrieved it." Umaro, a small village in the middle of the Andes, is an example of the situation faced by returnees. Twelve years ago the residents were forced to leave their village, owing to the attacks of the "terrucos" (terrorists of Sendero Luminoso). "Over 60 of my people have died," he tells me as we walk on. "After four attacks there was no other way than to leave our village. I moved with my family to Ayacucho, others to Lima or Ica, but we stayed in contact. We always wanted to return; it is not easy to leave your place when you are 70," he says. "How long have you been back?" I ask him. "We returned one year ago," he answers, "but it is
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