Doctor vs. Patient: Who Gets the Final Say?
Summary Sentence: Exploring different models of the doctor-patient relationship.
Doctor vs. Patient: Who Gets the Final Say?
For centuries doctors had one primary job: to restore the health of the patient in front of them. They were expected to do so using the skills and knowledge obtained throughout their careers and patients were expected to quietly comply with those decisions made by the physician regarding their treatments. Information was only shared with the patient if the physician deemed that sharing information would not jeopardize the decided-upon treatment; consent was in many ways nothing more than a legal formality. The language of the American Medical Association’s Code of Medical Ethics in 1847 even read:
“The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them (Monya 1).”
The movement away from this model can be traced back to the work of early psychologists, among them Sigmund Freud and Josef Breuer, who advocated the importance of informed patients– a view that sharply contrasted practices at the very core of paternalism. Despite their best efforts, the vast majority of medical professionals still openly supported the paternalistic model as late as the 1960’s. The movement away from paternalism (and thus towards patient autonomy) took place largely in the last few decades of the 20th century. While the reasons for this shift are fascinating, they are not what I will be exploring in this piece; rather I will examine what an ideal doctor-patient relationship looks like– what responsibilities doctors have for the patients, and to what degree patients are required to listen to them.
In their 1992 paper, Emanuel and Emanuel break the relationship down into 4 potential models, each with a different level of interference on the part of the physician. These models are, put in order from low to high levels of doctor control, referred to as the informative, interpretive, deliberative, and paternalist models. The first model I will discuss is the informative model. There are two components to this model; first, the physician is required to disclose all relevant clinical information to the patient, regardless of how the information will affect the patient’s decisions. Second, the patient must be free from any interference (including any personal opinions or suggestions from the doctor) while making decisions regarding their treatments. The goal of this model is to allow fully informed patients to exercise the greatest levels of autonomy possible. Perhaps the most traditional argument against this model is that it gives patients the ability to make decisions that negatively affect their health or are not optimal in the eyes of medical professionals. While this model does allow for such situations, that is not my main concern with it– after all, we use our individual autonomy to make suboptimal decisions regarding our health nearly every day (e.g. eating dessert, not exercising, etc.). If creating a perfectly healthy society was our ultimate goal, policies meant to promote individual health and welfare would override all individual autonomy. The more problematic piece of this model is the inability for doctors to express their recommendations to the patient. Given the extensive medical expertise physicians work to acquire in medical school and residency, it would be unreasonable to force them to withhold personal recommendations. The same could be said of a car mechanic– given their extensive expertise in the inner workings of motor vehicles, it would be unreasonable to ask them to withhold recommendations on how to fix a run-down car. The potential to help patients or customers make well-informed decisions is too high to justify withholding recommendations from experts. In both cases, the recommendations of the experienced professional are of value, and the final decision would be best left to the customer.
In the interpretive model, the role of the doctor is greater. Physicians are still required to disclose all relevant information to the patient, but they are also tasked with helping the patient understand how different treatments align with their values. As Emanuel & Emanuel describe it, the physician takes more of a counselor/advisor role in this view, with final decisions being left to the patient. The role of the doctor is limited in the sense that the physician is still not permitted to make true recommendations on treatment– they are only allowed to discuss how treatments fit in with the personal values of the patient. Because of this limitation, I would argue that the interpretive model suffers from the same problem as the informative model. Forcing physicians to withhold professional recommendations remains unreasonable for the same reasons outlined above in the informative model.
Contrary to the previous two models, the paternalistic view exists on the polar opposite side of the doctor-patient relationship spectrum. Of the four models, the paternalistic model has by-far the highest level of doctor involvement. The model is relatively simple in theory; it is composed of a physician who both diagnoses conditions and makes all treatment decisions, and a patient whose sole responsibility is to listen to and follow the instructions of the physician. This model does have some advantages– perhaps the biggest being that it streamlines the healthcare process while still prioritizing patient health. Despite its overall efficiency, putting all responsibility in the hands of the doctor raises problems of its own. One issue that could be particularly prevalent in the U.S. is the issue of discrimination. While by law doctors must treat all patients the same, this is not always true in practice. Physicians would, for instance, have the power to decide on less-effective treatment for people of color. The same could be said for people who live in poverty and are unlikely to pay back their medical expenses. Even from a moral standpoint, however, paternalist models fail on important grounds. Jay Katz argues that physicians have always put more emphasis on longevity of life than on quality of life and goes on to emphasize that duration is not always more important than quality of life; in many cases, the opposite may even be true. Take, for example, a patient with late-stage cancer who has exhausted traditional treatment options. They have been through numerous different treatments over several years and nothing has successfully eradicated the cancer. At this late stage, the patient has two real options; the first is to live, for example, the remaining 12 months of their life free of treatment and making the most of it– whatever that means to the given person. The second option would be to enroll in long experimental treatments that could extend life by as much as a year, but there is no guarantee. The choice is now between one year of high-quality[1] life and 1-2 years of lower-quality life enrolled in extensive treatments. No amount of medical expertise can give an objectively “correct” answer to this question– only the patient can determine what the best way to spend their remaining time is. For these reasons, I cannot endorse a pure paternalistic model.
The ideal model of the doctor-patient relationship lies somewhere in-between the paternalist and interpretive models. The closest of Emanuel and Emanuel’s four models to my ideal relationship is called the deliberative model. This model, like the informative and interpretive models (and contrary to the paternalistic model), establishes patient autonomy as the baseline of the relationship and requires that physicians disclose all relevant information to the patient, regardless of how it will affect their decisions. The key differentiator is that this model allows physicians to give professional opinions and other suggestions to the patient. The goal is a ‘deliberation’ between the physician and patient regarding what the best treatment option is and how to proceed. According to Emanuel and Emanuel, the physician aims to have the same effect of a close friend or teacher to the patient– nudging them in the direction they believe is best for them, but ultimately leaving the final decision up to the patient.
I would argue that the ideal model would be a variation of the deliberative model– specifically with one of Jay Katz’s modifications. The core structure of the model remains the same, however Katz adds one important aspect; the ‘deliberation’ component is not only available to the patient but required in its entirety. With this change, patients are given all relevant information regarding their diagnosis first. After disclosing all relevant information, they are required to engage in meaningful conversation regarding ideal treatment options. During this time the physician is required to give their professional recommendations and convey the reasons behind said recommendations. This added component forces all patients to consider options they may otherwise ignore or be ignorant of altogether. In the case of the cancer patient outlined above, this model would allow the physician present to convey their professional opinions on the “correct” decision, but ultimately leave the final decision up to the patient.
There are a number of opposing stances that could be taken in response to this view. One common idea is that patients will not be able to comprehend the intricacies of their conditions, and thus a doctor is the only one qualified to make treatment decisions. To this I would say that one of the key responsibilities of the physician in this model is ensuring patients understand their condition and all treatment options. This includes putting complex conditions into simpler terms or “dumbing it down” for many patients. If a physician is unable to explain the condition at hand, treatment options, and their recommendations for treatment, perhaps they were unfit to become a doctor in the first place. A second common counter argument to this model is one that has already been discussed above– that establishing patient autonomy as the baseline of the relationship gives people the ability to make suboptimal decisions regarding their health. As previously discussed, this is something we see every day– each time we eat dessert, fail to exercise, or stay up late we make a poor health decision. The list is nearly infinite. If a healthy society was the ultimate goal, policies promoting health and welfare would trump individual autonomy in many more areas than the doctor-patient relationship.
Perhaps the most glaring counter argument, however, would be whether the same model could be applied to mentally disturbed individuals. An example was recently brought to my attention regarding a patient with severe anorexia. If physicians do not interfere she will likely starve to death, but interference would undermine the most basic principle of the deliberative model– autonomous decision-making by the patient. This poses the question whether the model would allow interference in similar cases. In the case of mental illnesses, I would argue that the considerations when formulating an ideal doctor-patient relationship are entirely different, and thus the model outlined above cannot be applied. It is not uncommon that mentally ill patients are admitted to psychiatric hospitals against their will in the first place. Additionally, the model outlined above is built around the assumption that individuals are both seeking treatment/advice, and are capable of making concrete, rational decisions about their treatments. If individuals do not meet these qualifications, the model cannot apply to their case.
The relationship between patients and doctors has changed so much in such short periods of time. Less than a century ago patient autonomy was an afterthought in the name of restoring the health of patients as quickly and efficiently as possible. Today, patient autonomy is at the forefront of ethical debates, medical school textbooks, and even entire college classes. With the world of modern medicine continuing to evolve at unprecedented rates, it is not unreasonable to wonder if this debate will be a silly afterthought in 50 or 100 years. For now, however, the deliberative model (albeit with some modifications by Jay Katz) remains the ideal relationship our healthcare system should be striving for.
Citations:
PT;, Hershey. “A Definition for Paternalism.” The Journal of Medicine and Philosophy, U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/4009082/. Accessed 20 Oct. 2023.
P;, Kaba R;Sooriakumaran. “The Evolution of the Doctor-Patient Relationship.” International Journal of Surgery (London, England), U.S. National Library of Medicine, pubmed.ncbi.nlm.nih.gov/17386916/. Accessed 20 Oct. 2023.
De, Monya. “Towards Defining Paternalism in Medicine.” Journal of Ethics | American Medical Association, American Medical Association, 1 Feb. 2004, journalofethics.ama-assn.org/article/towards-defining-paternalism-medicine/2004-02.
“Medical Paternalism.” Wikipedia, Wikimedia Foundation, 1 Oct. 2023, en.wikipedia.org/wiki/Medical_paternalism#:~:text=By%20the%20end%20of%20the%2020th%20century%20and,Medical%20Council%20indicating%20that%20it%20is%20ethically%20unsupportable.
Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA. 1992 Apr 22-29;267(16):2221-6. PMID: 1556799.
[1] Here I say, “high-quality” life in a relative sense. It may be lower quality than that of a healthy individual, but is certainly higher than the quality of life when undergoing extensive and/or invasive treatments.