Dec 16 2008
Paternalism is out of fashion. Doctors used to have a parent-child relationship with their patients: they concealed the truth if they thought it was in the patient’s best interest, they dictated the treatment and did not have to justify it to the patient. “You have to take this pill because I’m the expert and I know what’s best; don’t ask questions.” Sort of like “You have to go to bed now – because I said so and because I’m the mommy.”
Some time in the 20th century we evolved to a different doctor-patient relationship, an adult-adult one in which the doctor shared expert knowledge and information with the patient and they cooperated to decide on the best treatment plan. The principle of patient autonomy became paramount and the patient gave informed consent to the chosen treatment.
It is generally accepted that this is all for the good. But is it really? In his book Intern: A Doctor’s Initiation, Sandeep Jauhar says, “Over time, my views on informed consent have evolved. I no longer view paternalism as suspiciously as I once did. I now believe that it can be a core component of good medical care.”
He gives some vivid case examples from his training in the cardiac care unit to illustrate his thinking. Patients are frequently asked to make critical decisions when they’re at their worst – sick and frightened, and maybe not thinking as clearly as usual. The stakes are high and they are pressed to make immediate decisions.
How far should autonomy go? What do you do if a patient is DNR but you believe the current problem is transient? Is it justified to override the DNR order if you think the patient will recover and thank you?
Is there really any such thing as fair informed consent? The way the doctor presents the options can influence perceptions. “With treatment X, 50% of patients will survive” doesn’t sound the same as “Without treatment X, 50% will die a horrible death.” The patient may not fully understand the implications. He may be frightened of chemotherapy because a family member went through an unusually bad experience. He may reject intubation because of false beliefs. A surgeon may not be entirely objective when recommending surgery over medical treatment.
What if the patient refuses life-saving treatment? Jauhar asks, “When do the demands of beneficence outweigh those of patient autonomy? First, do no harm, I had been taught, but what about the harm a patient can inflict upon himself?”
Sometimes patients want autonomy, sometimes they want to be guided or even told what to do. We’ve all had them ask us “What’s best?” “What would you do if you were in my shoes?” Sometimes they even say, “You’re the doctor; you decide.”
Informed consent often used to ratify decisions that have already been made or bully patients into making decisions they’re not equipped to make. If they make a decision that we don’t agree with, we think they’re not in their right mind; but “as long as they agree with us, they’re not crazy.” This isn’t fair: most doctors would gladly accept a scar to save a life, but Jauhar points out that a scar may have a very different meaning for a fashion model than for a doctor. A model might be willing to accept a greater risk of death to avoid a scar. We have to respect differences of judgment and patient autonomy, but do we go too far?
Informed consent was intended to protect patients, but in practice it is often used to protect doctors from hard decisions or to abdicate responsibility. A signed consent form provides some protection from malpractice suits. If the outcome is poor, doctors can blame the patient for a poor decision.
Don’t doctors have a responsibility to use their knowledge, experience, and hard-earned judgment to help the patient make the best decision? Isn’t that what most patients really want? Maybe a little judicious beneficent paternalism is not such a bad thing after all. It’s something to think about.
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