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Bioethics & Medical Ethics
Paul Walker ponders the best type of relationship between a doctor and a patient.
How well do you get on with your doctor? Every clinical consultation involves two people interacting, so should be seen as a relationship, and a moral encounter. The Hippocratic Oath, to do the best for the patient, and similar commitments grounded in a classical virtue ethics framework have been professed at graduation ceremonies of young doctors over centuries. Individual clinicians, however, can relate to individual patients and their families in different ways. Here I will simplify the various models of the doctor-patient relationship to three: the paternalistic model; the radical individualism model; and the shared decision-making model.
The Paternalistic Model
The ‘paternalistic model’ emphasises that the doctor’s caring is based upon long medical training and expert, specialised, and often technical knowledge. This model may be summarised as ‘doctor knows best’. Here the values important to the patient are accorded less importance than what the doctor believes is in the patient’s best interest.
This model is based predominantly upon the ethical principle of beneficence (meaning, ‘to do good to’), with patients receiving that intervention which, in the doctor’s assessment, is best suited to the patient in order to help restore them to health or to relieve their suffering. This principle requires that the doctor place the benefit of the patient above their own; and that they not make decisions for financial or other gain, and they also seek assistance from other clinicians when that is in the patient’s best interests. However, in non-emergency (‘elective’) situations, the paternalistic model brings the principle of beneficence into conflict with the principle of patient autonomy.
The paradigm shift over the past quarter century from paternalistic doctor-centred decision-making to autonomous patient- centred decision-making is arguably the most significant recent change in the Western medical landscape. It is a consequence of a variety of factors: contemporary society’s drive towards the rights of self; an increasing value pluralism, and hence moral heterogeneity; forays into health education by the media, directly and through medical docudramas; the weakening of most forms of authority; as well as the greater technical success of medicine in restoring function and prolonging life. Interestingly, Edmund Pellegrino also credits the entry of the professional philosopher into medical ethics as an impetus towards patient autonomy as the dominant approach (see ‘The Four-Principles and the Doctor-Patient Relationship: The Need for a Better Linkage’ in Principles of Health Care Ethics, R. Gillon (Ed), 1994).
The increasing preeminence of the principle of patient autonomy has led to the widespread abandoning of the paternalistic model in elective medical consultations. The paternalistic model is most readily accepted in emergency settings, where immediate life-saving action, often driven by medical protocol, is vital. Ideally, medical paternalism is restricted to value-neutral decisions, such as the size of endotracheal tube to be placed in a child of a given age and weight. But the decision to resuscitate or not, for example, is extremely value-laden. The fact that, despite the doctor’s best intentions, there is always uncertainty in clinical medicine about diagnosis and the individual patient’s response to treatment, is also of concern in the paternalistic model.
The Radical Individualism Model
At the opposite extreme to the paternalistic model is what could be termed the ‘radical individualism model’. This model is founded upon a recognition that patients have absolute autonomy, and absolute rights over their own bodies. The model assumes that each patient is capable of identifying therapeutic alternatives, and also that doctors are obligated to carry out patients’ requests, regardless of whether the doctors agree with them (and logically, regardless of their cost or futility). In this model, while patients may choose to take advice from doctors, they are required to make the decisions themselves, as best they can.
A similar model has been termed the consumer model. Here health care is a commodity to be obtained by the consumer (the patient) with due diligence, seeking information but not value judgement from the potential market supplier (the doctor). The moral responsibilities of clinicians are to inform patients of their diagnoses and the range of treatment options available, and provide the requested service with competence. Relabelling doctors in commercial terms, as ‘health care providers’, and patients as ‘consumers’, underlines the patient’s control of the health care interaction. This is reflected in charters of patient’s rights and legally-enforced duties of informed consent, aimed specifically at empowering consumers to make their own decisions.
A danger of this model is that it could undermine the ethos of caring that motivates doctors, who may well emotionally disengage from the process after explaining the options, since the decisions are now entirely up to the patient. It is challenging from the patient’s perspective too, in that it requires them to grasp a vast amount of technical information, while ill, and then re-evaluate it as treatment proceeds. Moreover, the model is impoverished in that it does not recognise the nature of the patient’s being-in-the-world, and thus necessarily in relationship with other individuals: their family, community, other patients who may be competing for limited resources, or clinicians who are aware of the limits of medical technology in terms of what’s feasible and what may not be.
Seeking medical help is not the same as going to a supermarket for groceries. Medicine is not morally neutral; it is aimed at actively, compassionately caring for and helping people. Put another way, rather than focusing medical ethics upon decision-making in identifiable moments of ethical dilemmas, we should concentrate on maximising the several goods of the patient. These include the techno-medical good (the technically correct treatment; for example, the correct drug in the correct dose); the human good (the good of the patient as a person); the perceptual good (the good as the patient perceives it); and the summum bonum (the greatest good, however defined) (see Edmund Pellegrino, ‘Moral Choice, the Good of the Patient, and the Patient’s Good’, in John C. Moskop & L. Kopelman (Eds.), Ethics and Critical Care Medicine, 1985).
The Shared Decision-Making Model
Awareness of these four very different goods of the patient allows us to look at a model midway between these two extremes – the ‘shared decision-making model’, also known as the ‘reciprocal model’, or the ‘negotiated contract model’. This model involves a joint approach, where health professionals are allied with patients and their family, the aim being to help each other identify the best course of action for the patient. It is based upon recognising the shared humanity of doctors and patients as well as the importance of ownership by the patient of their own body. In this model, information is offered freely by patients, and advice about likely diagnoses and treatment options is provided by the doctor, communicated in such a way that a joint decision can be made about what the patient might allow. Within this model, the ‘doctor-patient’ relationship is distinguished from the ‘doctor-disease’ relationship.
This model is that of a ‘bilateral covenant’, implying mutual respect, truthfulness, dignity, and justice. For example, the doctor offers informed percentages for five-year survival following radical mastectomy, versus that for lumpectomy plus radiotherapy. The patient decides whether sacrificing her breast is worth that statistical improvement in her prospects. In this model the values of the patient and of the doctor with regard to both health care and morality are discussed by the two autonomous parties. The shared decision-making model also allows that the patient may not clearly recognise their own values, so the virtuous clinician should guide them towards understanding and making coherent their value structure, in order to help them to make their own decisions. Education about how to engage in a moral discourse, and how to avoid prioritising health-care values over other values, is often necessary for this to be within the skill-set of the doctor.
Clinician empathy and wisdom are important here; as is patient reevaluation after reflection. The caring clinician should properly attempt to show the patient which path is likely to maximise their well-being, without coercing them. In other words, while patients are (generally) best at knowing what maximises their own good, doctors are (generally) best-placed to know what options are available to bring this about (see M.A. Kekewich, ‘Market Liberalism in Health Care: A Dysfunctional View of Respecting “Consumer” Autonomy’, Journal of Bioethical Inquiry, 11(1), 2014, p.25). Put another way, the shared decision-making model depends upon exploring and respecting what matters most to the individual patient. It aims to develop informed patient preferences, and it respects autonomy in a way that is aware of the necessary interdependence between the doctor and the patient (and their family) in the decision-making process. This involves a conversation which is inclusive, non-coercive, and reflective, seeking unforced consensual agreement about which treatment path to follow (see P. Walker & T. Lovat, ‘Dialogic Consensus in Clinical Decision Making’, Journal of Bioethical Inquiry, 2016). It requires mutual understanding of the values held by the patient, those who care for them, and doctors, in order to maximise the good of the patient in their actual situation. Factors that may confound this process include poor health literacy, cultural disinclinations to make autonomous decisions, and time-constraints during a consultation, amongst others.
Putting the shared decision-making model into clinical practice requires empathy, compassion, and a dialogue to determine what matters most to the patient. Therefore developing skills in how to have a real dialogue with patients, despite different socio-cultural backgrounds, should be a key part of medical training.
© Dr Paul Walker 2017
Paul Walker is a surgeon in Newcastle, New South Wales, and Conjoint Associate Professor in the School of Medicine and Public Health, University of Newcastle. He received his PhD in 2015.