Watching a pendulum swing can be a monotonous activity, unless it is the ideological pendulum in which case it is both fascinating and humbling. From fashion to politics our ideologies swing wildly from one extreme to the other, never coming to rest in a moderate position. The pendulum is apparently still in motion with regard to our understanding of the physician-patient relationship and informed consent, having swung from an understanding of that relationship as one dominated by absolute paternalism (paternalism-run-amok) to one dominated by absolute patient autonomy (autonomy-run-amok). Recent articles advocating the benefit and necessity of some degree of paternalism in the physician-patient relationship are evidence that the pendulum is still in motion. This indeed coincides with what many have understood to be true of the professional relationship all along: those who present for care are often suffering and vulnerable, consequently lacking full autonomy and control—and what they seek, in part, is someone to assist them in the relief of their suffering and restoration of their health. Two recent essays have approached the problem of medical decision-making within the physician-patient relationship from the perspective of a “means-end” evaluation. In an article entitled “What Health Care Providers Know: A Taxonomy of Clinical Disagreements,” Daniel Groll explores the nexus of paternalism and autonomy in the context of disagreements over medical care by developing a “means-end” taxonomy in the form of a binary matrix for the evaluation of such disagreements between physicians and patients.[1] His taxonomy includes the concept of “medical accessibility”— nonmedical issues to which the medical resources and reasoning of the physician can be applied, at least indirectly if not directly. By means of this model, he demonstrates that physicians, by virtue of their knowledge and experience beyond “medical knowledge,” have a significant contribution to make to the medical decision-making process. While such nonmedical guidance carries no medical authority, it can be legitimately offered even if it is not with the authority of a clinician. He grounds this perspective in the unique responsibility that physicians as professionals have to the patient and their well-being, a responsibility that is often ignored.[2] What Groll is implicitly acknowledging, however, is the truth of our common humanity, a truth grounded in our shared nature, our mutual embodiment, and our communal environment, a truth that resonates with the plight of the other, enabling our mutual compassion and concern.
Similarly, Steven Joffe and Robert D. Truog in “Consent to Medical Care: The Importance of Fiduciary Context,” examine the issue of informed consent in the context of the fiduciary physician-patient relationship.[3] Defining “fiduciary” as one “entrusted with power…to be used for the benefit of another and legally held to the highest standard of conduct,”[4] they then distinguish two fiduciary models that are pertinent to the physician- patient relationship: fiduciary as agent and fiduciary as advisor. In the agency model the fiduciary acts paternalistically on the patient’s behalf, serving their welfare on the basis of an overarching authorization.[5] In the more deliberative advisor model, the fiduciary offers information and guidance to patients but lacks authorization to act on their behalf without their specific consent. In an attempt to capture the ambiguities surrounding the responsibility for decision-making between physicians and patients, Joffe and Truog have also drawn a distinction between choices concerning “means” and those concerning “ends.” They conceptualize shared decision-making as occurring along an inextricable means-ends continuum (as opposed to the matrix used by Groll) in which the patient is primarily responsible for determining the value-laden decisions about ends or subsidiary ends of their care while the physician has presumptive responsibility for determining the means to those ends. They also extend to the physician the responsibility of framing the decisions so that patients are able to appreciate the values and ends that are consequent upon their decision.[6] Moreover, this shared decision-making transpires in the thicker context of the fiduciary relationship that exists between the physician and patient, which, despite the relational asymmetry, entails a two-way flow of information and deliberation. Joffe and Truog contend that an agency-advisor interface is involved in every physician-patient interaction to some degree; it, too, is best understood as a continuum that changes over time and according to the medical circumstances, thus illustrating the dynamic complexity of the physician-patient interaction.
Both articles not only provide balance and clarity to the issue, but also refreshingly acknowledge the moral agency of the physician, an agency denied in the model of absolute autonomy. A physician is not merely an automaton, but a moral agent involved in a moral encounter, who must balance fiduciary responsibilities to the individual patient who has presented for care with contractual responsibilities for the health of the society they are called to serve.
Yet means-ends determinations are not without their limitations, for means frequently become the object of choice in medical care. If the desired end of a medical encounter is to postpone pregnancy, there are many means available to that end which are largely a matter of patient preference, and not the prerogative of the physician. Alternative categories for distinguishing areas of responsibility within the professional encounter, whether one chooses “elective/non-elective,” or “preventive/therapeutic,” are subject to the same difficulty: they can provide only a vague sphere in which to mold our interactions. Relationships resist rigid taxonomies.
Over the past fifty years the concept of paternalism has developed very negative connotations, especially in medicine, despite the fact that the image of a father is not inherently a negative one. No doubt it is the converse image of the patient as a dependent, needy child to which many object; yet that is in fact the foundation of healthcare—caring for the vulnerable person in need. The challenge of the medical profession and professional relationships is to navigate this changing dynamic in the context of a prosperous society and a highly developed healthcare system. It entails recognition of the uniqueness of each encounter, a discernment of the degree of autonomy possessed by the person presenting for care, and the ability to alter one’s approach to that unique individual in order to adequately meet their physical, emotional, and spiritual needs. Formerly, with limited medical resources, less patient access to information, and a more homogenous culture resulting in greater cultural consensus, a paternalistic physician-patient relationship was not inappropriate. But as technology has exponentially expanded healthcare options, as patients have gained greater access to medical information, and as the explosion of options has necessarily resulted in less consensus, the relationship between physician and patient also has had to undergo change. Physicians have had to increasingly assume an advisory role, assisting patients in the translation, interpretation and application of the information that they have acquired.
Yet there are some who believe that this role is still inappropriate. According to Robert Veatch every medical choice requires a value perspective—and health professionals have no expertise in the value dimension of medical care.[7] He believes that they are incapable of making judgments about what is good for a patient; therefore, the patient must be in charge of making all decisions.[8] However, if medicine were to abandon all conceptions of the patient’s good, its moral telos would be replaced by the exigencies of a business transaction. While there have been many recent attempts to reimagine medicine according to a business model, the uniqueness of the fiduciary physician-patient relationship resists such reimagining. Interpersonal relationships based on a social contract theory result in a highly autonomous relational model that fails to acknowledge that human flourishing necessarily entails relationships with others. As relationships become contractual and decontextualized, the healing aspects of the relationship, dependent as they are on compassion, trust, and the experiences of our shared and vulnerable humanity, are irretrievably lost. Paternalism is replaced by disinterested depersonalization, dispassionate entrepreneurialism.
While the scope of medicine has been extended in recent years to include preventive care and enhancement, the primary focus of medicine is still healing and restoration. Consequently, patients present for care in various states of vulnerability, with limited knowledge, misinformation, misunderstood facts, fears, anxieties and denial, all of which coalesce to limit their autonomy. In this state of being, what they seek is expertise and care, not the exercise of their autonomy. The proper response to paternalistic indiscretions in professional relationships should be to correct those attitudes rather than restructure the entire relationship. The physician-patient relationship is a dynamic moral encounter between moral agents in which the relational parameters ought to be determined by the parties involved. Attempting to deconstruct and reconstruct the relationship through the imposition of unsolicited ideologies violates vital aspects of the professional relationship for it neglects the vulnerability of the patient as well as the obligations of the physician who is ultimately responsible for any choices made by patients that require physician participation. Furthermore, reconstructing the professional relationship on a framework of patient autonomy unjustly disadvantages the vulnerable who are most in need of care. The power differential inherent in the relationship needs to be acknowledged and respected, not denied or injudiciously abused. The terms of engagement should be determined from within the confines of the relationship, not dictated from without.
The swinging of this pendulum is a welcome event, for effective professional relationships are not located in the extremes of either autonomy or paternalism but in a dynamic equilibrium between these extremes, one that requires conscientious discernment and balancing. As a moral encounter, the physician-patient relationship varies over time with changes in age, maturity, experience, technology, and the extenuating circumstances of both parties. The respect for autonomy that is crucial to the physician-patient relationship is that which esteems the person who has presented for care in the midst of their compromised autonomy, and which seeks collaboratively to restore that person to autonomy and wholeness. The art of medicine is recognizing the role required in a given relational moment and shifting roles as needed to best accommodate the vulnerabilities of the person who has presented to you for care.
[1] Daniel Groll, “What Health Care Providers Know: A Taxonomy of Clinical Disagreements,” Hastings Center Report 41, no. 5 (2011): 27-36.
[2] Ibid., 34.
[3] Steven Joffe and Robert D. Truog, “Consent to Medical Care: The Importance of the fiduciary Context,” in The Ethics of Consent: Theory and Practice, eds. Franklin G. Miller and Alan Wertheimer (Oxford: Oxford University Press, 2010).
[4] Ibid., 352.
[5] Ibid., 353.
[6] Ibid., 360.
[7] Robert Veatch, Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge, (Oxford: Oxford University Press, 2009), vii-viii.
[8] Ibid., 3.
Susan Haack, "The Physician-Patient Relationship: Moral Agency in Balance,” Dignitas 18, no. 4 (2011): 8–10.
