the chance of recurrence is low, you are Conversely, chemotherapy would pro- or a cardiologist discussing cholesterol- young, and we should not leave any ther- long the duration of therapy by many reducing interventions apeutic possibilities untried. Recent months. Further the benefits of che- THE CURRENT DEBATE AND THE studies involving chemotherapy suggest motherapy in terms of survival are improvements in survival without re- smaller and more controversial Given FOUR MODELS currence of breast cancer. Indeed, ti he recent changes in your life, you have In recent decades there has been a National Cancer Institute recommends too many new preoccupations to undergo call for greater patient autonomy or, as chemotherapy for women withyourtype months of chemotherapy for a question- some have called it, "patient sover ofbreast cancer Chemotherapy hasside able benefit. Do I understand you? We eignty, 2 conceived as patient choice effects. Nevertheless, a few months of can talk again in a few days. and control over medical decisions. This hardship now are worth the potential The deliberative physician might be- shift toward the informative model is added years of life without cancer. might say, With node-negative breast cidate the patient's values, but continue, are described as health care providers cancer there are two issues before you: "It seems clear that you should undergo and patients as consumers. It can also local control and systemic control. For radiation therapy. Itoffers maximalsur- be found in the propagation of patient nd the local control, the options are mastec. vival with minimal risk, disfigurement, rights statements, in the promotion of tomy or lumpectomy with or without and disruption of your life. The issue of living will laws, and in rules regarding omy without radiation results potential benefit of chemotherapy for decisions regard: ei or a? radiation. From many studies we know chemotherapy is different, fraught with human expec ntence For instance, that mastectomy radiation result in identical overall sur- tions, I think the best one for you is to The Rights of the Terminally Ill Act stive vival, about 80% 10-year survival. enter a trial that is investigating the authorizes an ad ng administration of ded a n this in a 30% to 40% chance of tumor recur- women with node-negative breast can- life-sustaining treatment irrele. rence in the breast. The second issue cer. First, it ensures that you receive merely provides one way by which a relates to systemic control. We know excellent medical care. At this point, we terminally-ill patient's desires regard that chemotherapy prolongs survivalfor do not know which therapy maximizes the use of life-sustaining procedures premenopausal women who have axil- survival. In a clinical study the schedule can be legally implemented"(emphasis and decisIor philis ok hep- role for women, with node-negative is specified by leading breast eancer ex- require or encourage patients to discuss udies suggest that chemotherapy is of ceive care that is the best available any- physicians before signing such docu no beneft in terms of improving overall where. a second reason to participat ents. Similarly, decisions in"right-to- all studies suggests that there is a sur- contribute something to women with medical decisions. As one court puts, vival benefit. Several years ago, the NCI breast cancer in the future who will face The right to refuse medical treatment is ba- hemotherapy can have a positive ther- sands of women have participated in quires no one 's approval. .(TJhe control apeutic impact. Finally, let me inform studies that inform our current treat- will il- you that there are clinical trials, for ment practices. without those women, inforn est in a benefits of chemotherapy for patients we would probably still be giving you noal and philosophi ecently enroll you in a study if you want. I will mastectomies. By enrolling in a trial you Probably the most forceful endorse. with no be happy to give you any estro mation you feel you need of one generation receive the highest ment of the informative model as the ideal The interpretive physician might out- standard of care available but also en- inheres in informed consent standards. e much of the same information as the hance the care of women in future gen- Prior to the 1970s, the standard for in- ntly di sion to elucidate the mething about whichinterventions are based. "a Since 1972 and the Canter wishes, and conclude, "It sounds to me better. I must tell you that I am not bury case, however, the emphasis ha as if you have conflicting wishes. Un. involved in the study; if you elect to been on a"patient-oriented"standard of derstandably, you seem uncertain how enroll in this trial, you will initially see informed consent in which the physi to balance the demands required for re- another breast cancer expert to plan has a"duty"to provide appropriate med iving additional treatment, rejuvenat- your therapy. I have sought to explain ical factstoempower the patient touse his ng your personal affairs, and maintain- ourcurrent knowledge and offermy rec- or hervalues todetermine whatinterven- omy or me try to express a perspective that fits possible decision your position. Fighting your cancer is Lacking the normal interchange with the informed exercise of a choice, and that my and althy self-image and quality time out. contrived, even caricatures. Neverthe [e]t is the prerog ival and side the hospital. This view seems com- less, they highlight the essence of each attendant on options available and the 0