I have read several articles in leading journals – most recently in the Annals of Internal Medicine about tailoring mammography recommendations to patient risk – which come to the same conclusion: no matter what physicians’ recommendations are, we must respect patient preferences. There are various difficulties with this:

1. Patients, in fact anyone, are often hard-pressed to state just what their preferences are. There are a number of reasons for this: the fact that information is often not adequately conveyed; the tyranny of choice from the overabundance of medical information; and, at bottom, the truth that some situations are not ones we are prepared to state preferences about. “Would you rather die in a nursing home or in a hospital?” is, for those not yet in such a situation, equivalent to asking, “Would you rather perish by Dalek or Vader?”

2. We don’t actually respect patients’ preferences, much of the time. We try to make them do things which they would not ordinarily do. Which leads us to…

3. Preferences change. Many change their desires and even their approach to life over time. When we “respect a preference,” whose preference, at what stage of life, are we respecting, and how much respect are we really supposed to show?