The L.A.P.D. searched the office of Michael Jackson's doctor yesterday. According to DEA spokesperson Rusty Payne, whose agency is assisting with the investigation, the search warrant was issued relating to the drug propofol. Propofol is a powerful anesthetic and is almost never used outside of an operating room or ICU setting - certainly not the kind of thing any doctor would ever admit to prescribing on an outpatient basis. So far, there seems to be only speculation as to why authorities suspect Michael Jackson had propofol in his system. According to E! online (I'll have more reliabe sources for you when this blog generates enough revenue to hire a full-time researcher) the preliminary results of a second autopsy turned up lethal amounts of propofol.
Obviously, we need a lot more information before deciding on the gullt of innocence of Michael Jackson's doctor. But, what if he did OD on propofol? Maybe that's what his doctor was using to treat insomnia. I'm only playing devil's advocate here, and I challenge the reader to not so quickly dismiss the above described scenario as malpractice at best, manslaughter at worst. After all, in primary care we give patients drugs to help them sleep all the time. These drugs have risks; people can and do overdose on them. Your response is probably along the lines of, "But propofol for insomnia! This is madness. The risks of giving someone propofol in an unmonitored setting vastly outweigh the benefit of helping them sleep!" Sure, I don't disagree with you. But how does one decide where to invoke one's own values preferentially over patient values? I mean, if the patient truly understands the risks, maybe the risk does outweigh the benefit from his or her perspective.
One solution is, simply always let the patient decide. If he understands the risks and benefits of treatment, prescribe whatever he wants. You're just the expert consultant, the patient is the one directing care.
At other extreme are those who wouldn't subject their patients to any risk whatsoever unless they have clear evidence that treatment will result in decreased for morbidity or mortality. Such a doctor will never treat something like insomnia until someone can prove that people with untreated insomnia die sooner or have some other, quantifiable, adverse outcome and that said outcome is worse than the risks of treatment.
Most of us fall somewhere in the middle. But where? How do you decide? This question is particularly relevant to treating patients with chronic pain. How much pain medication do they need? Who decides? The solution I favor is to legalize all narcotics. Make them widely available so that people can treat themselves taking doctors out of the equation completely. There is no science, after all, to inform us as to how much pain medication is "enough." There is no "optimal" dose aside from 0mg PO q4hrs prn. The less you take the better. You don't need a doctor to tell you that. Of course, that doesn't mean you shouldn't see a doctor. Your doctor may be able to diagnose and fix whatever it is that's causing the pain, obviating the need for pain medication. That would be ideal. Unfortunately, doctors aren't always able to do this. Which puts us in the unenviable position of either prescribing or withholding medications that only increase morbidity and mortality and have only subjective benefit?
