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Paternalism: Does it still have a place in modern medical practice?
"The paternalistic model assumes that there are shared objective criteria for determining what is best. Hence the physician can discern what is in the patient's best interest with limited patient participation . . . the physician acts as the patient's guardian, articulating and implementing what is best for the patient...The conception of patient autonomy is patient assent, either at the time or later, to the physician's determinations of what is best.""Four Models of the Physician-Patient Relationship." JAMA. April 22/29, 1992 Vol 267, No. 16.1
While some suggest that paternalism is part of a bygone era, a label with a negative connotation harkening back to a time when many physicians thought it appropriate, for example, not to burden their patients with a cancer diagnosis, others think some aspects of this model of the physician-patient relationship still have merit in today's practice of medicine.
This model of the physician-patient relationship is sometimes called the "parental or priestly model."1
"The term 'paternalism' has, I think, been forever sullied to such an extent that it's never going to be put forth as an ideal. And strong paternalism what has been described as strong paternalism which is doing things to patients without their consent and without regard to their wishes is, I think, properly discarded," says Farr Curlin, MD, associate professor of medicine at the Pritzker School of Medicine, University of Chicago.
"But paternalism in the more limited sense of relating to the patient as one who makes it his responsibility to care for the patient, according to one's own judgment, will always be alive, because it is a necessary component of good clinical practice. So, it is never going to be sufficient, and I think there is a growing appreciation for this across the board . . . to suggest that a good physician merely presents options to patients and provides them technically competent health care services," Curlin says.
"That's never going to be sufficient," he notes, "in part because patients are not like other consumers; they are, by virtue of being sick, or having their health threatened, they need someone to care for them not just to provide them with what they think they might want."
Others think paternalism is more appropriate to a bygone era of medicine, and that the word has a decidedly negative connotation today. Still, its vestiges may be alive and well, in some of its aspects of seeking to care for and protect the patient.
"Well, I don't think anybody will admit to [paternalism], but I think physicians and how they approach their patients in terms of their decision-making fall along a continuum, and I suspect some are more towards the shared decision-making, equal-level-with-the patient end of the spectrum, and others might be more, 'I'm in charge,'" says Joseph A. Carrese, MD, MPH, associate professor of medicine at Johns Hopkins School of Medicine in Baltimore; chair of the ethics committee at Johns Hopkins Bayview Medical Center; and a core faculty member of the Johns Hopkins Berman Institute of Bioethics.
Carrese notes that "as recently as 50 to 60 years ago, doctors' approach to their relationship with patients was very much one of doctors were in control and doctors limited the amount of information they gave patients in order to limit the patient's role in the decision-making process. It was very much one-sided, and that's what we're referring to that's what we have in mind when we think of the term, 'paternalism,' [i.e.,] that it's very much doctor-centered and doctors in control," Carrese explains.
With the paternalistic model, the physician still has obligations to the patient, "including that of placing the patient's interest above his or her own and soliciting the views of others when lacking adequate knowledge.1
Selecting relevant information
One of the challenges in communicating with a patient is knowing how much information to share with him or her and how much might be simply more than the patient can comprehend.
"How do you as a clinician select what information is relevant? How do you know if information is likely to be overwhelming?" says Ronald M. Epstein, MD, professor of family medicine, psychiatry, and oncology, and director, Center for Communication and Disparities Research, University of Rochester (NY) Medical Center.
Epstein suggests that paternalism and this approach to the physician-patient relationship is a relevant topic.
"Absolutely, because sometimes, you're in a position where you do have to make a decision on the patient's behalf. Consider an extreme situation for a patient who is suicidal; you won't just listen to what they say they want. Rather, you're going to make a decision; you may have to hospitalize them involuntarily. And if that isn't a paternalistic decision, what is?" Epstein asks.
But how a physician may or may not employ a paternalistic approach depends on the situation of a particular patient.
"Importantly, most of us do act paternalistically in ways that we often don't realize, and we have to examine whether we want to do that or not," Epstein explains. "For example, even the tone of voice you use to describe each option, or order in which you present a choice to a patient, may influence a patient's decision. We know that from psychological research. So, if you present A and B, patients may be more likely to choose A simply because it was offered as the first choice. And so, I think we are unwittingly paternalistic some of the time. . . If you favor a certain option, you'll present it and frame it a bit differently."
"Paternalism may not be all bad. Sometimes we need help knowing what the best thing is for us, but patients almost always should still be offered a choice."
Unbridled paternalism not an option
"Unbridled paternalism is a terrible idea," Esptein says. "But, if you think about the positive side of it, that is, acting as an agent for the patient with a deep knowledge of the patient's values, I think there's a place for it.
"Paternalistic actions have to be conscious; they have to be aware; and they have to be concordant with the patient's values. Sometimes, patients say they value something, and then their actions speak otherwise," he notes.
When he believes that patients are making a decision that may not be in their best interests, he will "try to cajole and nudge and convince patients" of this, i.e., that it may not be the best approach.
"That's different from forcing people to do things; generally, patients should be offered choices and options. Making recommendations and sometimes even making strong recommendations is part of our job."