"Who shall decide when doctors disagree?" wondered Alexander Pope more than two centuries ago. Today the old quandary has taken on new urgency as difficult medical decisions once left to the doctor are increasingly falling to the patient.
Either because their insurance requires it or because they want another view of their options, more patients are seeking second opinions. Meanwhile, dramatic developments in medical care give patients more choices that doctors are increasingly ready to discuss.
In the process patients are discovering to their dismay that medicine rarely offers cut and dried answers.
"Patients are clearly agonizing," said Dr. Robert Brook, vice chairman of the department of medicine at the University of California Los Angeles Medical Center. "If I go to one doctor and he says operate and another says don't, whether I have the surgery or not I'm going to be slightly uncomfortable with the decision."
Laurence and Shari Doyle of Parlin, N.J., kept a scoreboard of opinions when their daughter was born with a mild congenital deformity of her skull. Some doctors voted for operating; others said surgery wouldn't help. The baby had successful surgery late last year.
"You go through such emotional turmoil, hoping you're doing the right thing," said Mr. Doyle.
In a poll of more than 1,000 New York City employees required to have a second opinion before surgery, 12 percent complained that the second opinion led to unnecessary anxiety.
Still, health care experts say the process is worthwhile.
"The confusion and anxiety is certainly better than having one opinion and not being confused, when that opinion may be wrong for you," said Dr. Stephen Rosenberg, who conducted the survey.
Dr. Brook, too, is convinced the trend toward greater patient activism will be for the good,although he acknowledges the transition may be rough for patients and doctors alike.
"Our culture now expects answers and certainty from their doctors, and patients are going to have to get used to the idea that we don't always know what works," he said.
Doctors, he added, are going to have to learn better ways to advise their patients about options without bullying them.
"Too often it comes down to a patient's asking, 'What do you think?' and I'll say, 'Let's do it,' making the decision for him," Dr. Brook said.
Doctors are developing interactive video programs to help patients understand the merits and limitations of various treatments and to decide how they mesh with their values.
One video helps men with enlarged prostates decide whether to have surgery. While swollen prostates can cause annoying urinary problems, surgery often leaves men with abnormal sexual function.
"We have found men have very different priorities," said Dr. Albert Mulley, an internist at Massachusetts General Hospital, who helped develop the program. "For one 72-year-old, loss of sexual function may be a very big problem, while for another it may not be an issue. We want to help patients make a choice based on an understanding of the trade-offs, just the way they buy an automobile."
Dr. Mulley and his collaborators are working on similar programs to help people decide about high blood pressure treatment, back surgeryand whether to have a mastectomy for breast cancer.
"The conviction that the doctor knows best -- the Ben Casey, Kildare sort of trust -- made it easier for patients, but it probably wasn't good for care," said Dr. Alan Z. A. Manevitz, a psychiatrist at New York Hospital's Payne Whitney Clinic.
To confuse matters further, the recent proliferation of new medical technologies has meant there are more ways to treat a disease.
"Often there won't be a clear-cut diagnosis or a clear-cut next procedure and lots of people can't deal with that," said Dr. James Halper, a psychiatrist at North Shore University Hospital in New York. "There's something comforting about someone saying we're going to open your belly and take out this or that."