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Paternalism Revisited

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.

Posted in: Medical Ethics

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27 thoughts on “Paternalism Revisited

  1. twidmer says:

    As argument for against consent you/Jauhar mentioned “Informed consent often used to … bully patients into making decisions they’re not equipped to make.” This IS parternalism! You can not argue for paternalism because informed consent is used in a paternalistic way.

    Paternalism is absolutely the wrong way to go. However I agree that there is room for improvement in decision support provided to patients.
    A separate issue is if the patient demands unnecessary or very expensive treatment, this is much more the question of who carries the cost, than how paternalistic the doctor is.

  2. Michelle B says:

    If ‘ paternalism’ is to be re-visited in Medicine (and Harriet did make many excellent points), please find a better coinage than paternalism.

    How about medical doctor? Medical doctor needs to be a term that includes the recognition of and deference to the expertise/knowledge/experience of such a professional at the same time connoting the appreciation/receptivity of continuing patient feedback by the medical doctor.

  3. weing says:

    I think informed consent should be preceded by a test of knowledge of the condition and its natural history, the differential diagnoses and the procedure and what it intends to accomplish. It can be done in multiple choice format and the patient can take it over and over until he/she scores 100%. They can then agree or not to the procedure.

  4. Dacks says:

    The question here seems to be “Does the patient understand rationally the full consequences of the decision he or she is making?” And, of course, the answer is often, no. But that extends to all areas of life – I’m thinking of how our politicians are making decisions at this moment based on argument, belief, pressure in which they have not fully anticipated the effects of their actions. I’m not sure what the cure for this is except continual probing for better information.

    One thing I would want from my doc is candor, which may be getting lost behind the informed consent issue. While I don’t think a doctor can choose for me, his or her opinion is valuable because of what lies behind it. I imagine it might be difficult at times for the doctor to differentiate between “what would you do if you were in my shoes?” and “what do you think is best for me?” These are not the same questions.

  5. weing says:

    “I imagine it might be difficult at times for the doctor to differentiate between “what would you do if you were in my shoes?” and “what do you think is best for me?” These are not the same questions.”

    That’s right. As someone once pointed out, a sadist is a masochist following the golden rule.

  6. Fifi says:

    Michelle B makes an excellent point. Is it really “paternalism” that needs to be revived? Or is that just nostalgia for a time when doctors tended to have unquestioned power? Shouldn’t we perhaps be talking about how to nurture a variety of relationships with patients (since not all patients are the same) and find a way to restore or create trust between doctor and patient? I guess the question becomes, are you simply seeking to re-establish unquestioned authority and more power over patients for doctors to be able to enforce compliance OR is it a desire for doctor/patient relationships that involves trust and cooperation? This is a power and trust issue, do all doctors really deserve unquestioning trust?

    It’s worth considering that the dark side of paternalism (and there wasn’t much light side for some patients) has been responsible for some of the more horrific experiments and treatments in the history of medicine, some so not very long ago. There’s a poor historical record for paternalism in medicine – particularly regarding women’s health (men suffered too but it was often those with less power like children, women, the poor and non-whites who bore the brunt of paternalist “Father Knows Best” attitudes and systems of authority).

    I’d also point out that the “maternalism” of woo seems to get quite a bit of traction from being the opposite of medical paternalism. I’d also wager that how poorly doctors have treated nurses historically – who often do more frontline work and know the patients better – also plays into why woo is attractive to nurses and others who work in medicine but have historically been treated poorly by doctors. (Growing up around hospitals as a kid, I saw a lot of this kind of arrogance and sense of entitlement, it’s really not something that needs to be encouraged!)

    Doctors are experts but they’re certainly not gods, nor am I looking for a parent when I go to the doctor. I’m looking for an expert opinion and treatment when I go to a doctor, not someone who can’t say ‘I don’t know’ when they don’t know. I may even seek another expert’s opinion if you don’t seem to be as much of an expert as you claim, and a professional should be able to deal with that and not get their feather’s ruffled. Doctors shouldn’t be encouraging their patients to look at them like mommy and daddy, no matter how much easier it seems. Most MDs don’t have the training to play psychotherapist, nor to be aware of and navigate their own transference and counter-transference in a parent/child relationship. Though, of course, the vast majority of doctors will deal with patients who do treat them like mommy or daddy at some point during their career – there’s no reason to dive into that pathology head first. It would seem more sensible to equip physicians with enough understanding of psychology so as to be able to better communicate and build trust.

    Dr Hall wrote – “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.”

    Of course they have a responsibility to use their knowledge and experience to not only *help* patients make the best decision (for the patient’s needs, not the doctor’s) but also provide treatment. It’s what doctors are paid to do, it’s their job. However, helping someone make the best decision for themselves isn’t the same as forcing a treatment on someone. If someone isn’t legally competent to be making their own decisions, that’s another matter all together. People have the right to disregard experts, even if it kills them.

  7. hatch_xanadu says:

    One of the pitfalls I’ve seen in a culture of patients who reject paternalism and are becoming more autonomous in their own treatment decisions is the presumption—and increasingly this seems to be more often the rule than the exception—that the doctor is a lousy doctor, “he doesn’t know what he’s doing”.

    Many more people have tales of horror in the hospital than of positive experiences—and understandably so, since the receiving end of a hospital is the last place most of us want to be. But I fear that the tendency of folks to discuss their unpleasant experiences as though they were as a rule the result of “medical establishment” screwups is opening the culture up to ill-informed decisions and making folks more susceptible to claims that medicine is all a big conspiracy (and to quacks who feed on that notion: “The medical establishment just wants to take your money—give your money to me instead!”). Making informed decisions with one’s physician in the manner of two adults is certainly the ideal arrangement and deserves celebration—but often people tend to confuse “we’re both rational adults” with “I know just as much as the doctor does and I don’t need him to tell me what to do”.

  8. Fifi says:

    “I imagine it might be difficult at times for the doctor to differentiate between “what would you do if you were in my shoes?” and “what do you think is best for me?” These are not the same questions.”

    “That’s right. As someone once pointed out, a sadist is a masochist following the golden rule.”

    Well said! As was the comment about wanting candor, I want honesty from a doctor and awareness of the difference between personal opinion and evidence-based expert opinion. However, I think there’s no one-size-fits-all solution since this is about relationships between people and trust/authority and we ALL have unique experiences and intimate relationships with these that can bias our ideas about both. Certainly doctors (or SCAMMers for that matter) being parental feeds into some people’s neurotic need to hand over responsibility for themselves and not make choices themselves – SCAM artists take advantage of this a lot – but it will also create more problems with some other patients. Particularly ones who know medicine’s rather sordid history of abuses of power, arrogant mistakes and the other rather bitter fruits of paternalism. Besides, it ignores the fact that nostalgic “solutions” are trying to hold back change rather than direct change in constructive directions – it’s clinging on to old systems rather than dealing with contemporary reality and engaging in creating new ones based on integrity and trust rather than authoritarian power. People with true authority are trustworthy (authority is given to them because people trust them to be an authority and act with integrity, it’s earned through actions, they become authorities through their actions). People with mandated authority may feel entitled to authority (aka power over others) and respect simply for achieving a piece of paper (yes, I know med school can be hard) – these people are often dangerous since they are seeking power over others rather than a sharing of their power (their knowledge, experience and expertize) with the patient to serve the patient’s best interests.

  9. tarran says:

    A doctor’s job is very much like that of an auto mechanic – they are hired improve the operation of a complicated piece of machinery by owners who are dissatisfied with its operation.

    Would you like a mechanic making unilateral decisions as to what is done to your car? Would you like a mechanic who puts a temporary low-cost fix in place where you would like a long term fix, or unilaterally makes a high cost permanent repair, when you are looking for a low cost fix?

    Most car owners are absolutely opposed to such an idea. Yet, a car is far less important to us than or bodies. A broken car can be replaced. A broken body gets buried in a box 6 feet under ground.

    Dr Jauhar complains that sometimes patients make what he thinks are bad choices. So what? His job as a mechanic who fixes human bodies, is to do whatever the body’s owner asks of him. He confuses what doing no harm means. He probably recognizes that if he were to strap a patient down on a table and forcibly administer a treatment against the patient’s wishes that is harm.

    He seems to not recognize that tricking a patient into acceding to some treatment is in fact a sort of harm – the very same harm as when a mechanic tricks a car owner into paying for an unwanted, expensive, engine rebuild.

  10. Fifi says:

    Someone saying “you’re the doctor, you decide” is making a treatment choice – their choice is to let the expert decide (for whatever reason). This is a valid choice, probably the one in the patient’s best interest at times (and at others, not so much – so sometimes it’s a resonsible choice and sometimes it’s avoidance behavior, it would be the second set of patients that are also likely to not take responsibility for their choice and launch malpractice suits). The patient chooses to hand over their power to the doctor. While I’m sure the laws and rules around emergency room treatment change from place to place, clearly doctors authority over a patient in a medical authority when the patient *can’t* help themselves is a bit of a different matter. While clearly this is connected to other kinds of situations regarding a doctor’s authority over a patient and patient choice, it’s hardly the same context as a patient making a choice regarding chemotherapy or some issue which isn’t quite as urgent/immediate.

  11. Harriet Hall says:

    tarran,

    No, the doctor’s job is not to do whatever the owner of the body asks. And the job of a car mechanic is not to do whatever the car owner asks. If the owner tells him to take the carburetor out and not replace it, any ethical mechanic would refuse.

    What if the mechanic offers me a choice between an expensive new part and a less expensive rebuilt or remanufactured part? What if there aren’t any good statistics to show whether the rebuilt part is as reliable as the new part? I have no experience with rebuilt parts and no ability to judge the relative merits. The mechanic is probably a better judge than I am, and I would feel comfortable asking him “What would you do?” and following his advice.

    fifi,

    Yes, patients often do say “You’re the doctor, you decide” and I agree that that’s a valid choice. The current anti-paternalistic culture has tried to invalidate that choice, and I’m asking that that knee-jerk reaction be reconsidered.

  12. skeptyk says:

    Fifi: “I’d also point out that the “maternalism” of woo seems to get quite a bit of traction from being the opposite of medical paternalism.”

    Indeed, you’re right on. SCAM is riddled with old-fashioned paternalism. Altmedders exploit, consciously or not, the juvenile desires of people in distress.

    Think about it: my generation has been fed for years on suspicions of physicians, whom, per conventional wisdom, are paternalistic know-it-alls who spend little time with patients. Maybe we, as individuals, have been fortunate, in our rare encounters with medicine, to have had only genuine, caring doctors and nurses, but we all just know that such doctors are exceptions to the rule of rich, cold pill pushers that define the profession. This is a very common attitude.

    We assert that we want more say in our care, to be listened to and respected as adults, to be able to ask questions about proposed treatments, et cetera. These are the natural desires of grown ups.

    Along comes the chiropractor (naturopath, acupuncturist, herbalist, homeopath…) telling us she knows just how we feel, assuring us that she will take an hour or more at our first visit, that she will listen, will treat us as an adult, will care for and respect us as whole person, et cetera. In other words, even though the treatments these various providers offer differ a lot, they are the same in saying they are different from the orthodoxy (medicine) in this.

    SCAMmers appeal to our stated desire for respect and choice, but do they actually deliver on this, which is perhaps their primary selling point?

    I would suggest that they simply substitute a different kind of paternalism, and one harder to fight. Once one is cocooned in the safe place, (the altmed provider’s office) it is actually all the harder to question the “healer”, this kind, new friend. Unlike your MD, with whom you have a professional, dissatisfying, relationship, you have a more personal relationship with this alt doc. While it is encouraged that you question her so you may learn more about the therapy, you feel it would be impertinent to question the underlying philosophy of her profession, gauche behavior for a guest.

    She has invoked the buzz words like “natural” and “gentle” and “immune-boosting” and “holistic”, and you are lulled and comforted because you have found someone who understands, who will take care of you. You submit in a manner more complete than any time you ever “followed doctor’s orders” You submit to your new caregiver and her bizarre tests and her odd treatments.

    The atmosphere is of a soft cult. While we boomers like to question authority, we are hesitant to question religious beliefs, and SCAM has a strong fragrance of faith-based. (I call it make-believe medicine.) Our cultivated multicultural sensitivity (a good thing) can lead us to let absurd ideas and treatments stand without challenge. SCAM is like a soft cult: there is no single guru or text, but there are social pressures to adhere to a party line.

    I do not want to hang out with my MD. Really. He’s a decent guy, AFAIK, but my interest is that he is a well-respected (by his preofessional peers) internist. And once a year is plenty often enough to see him, thank you.

  13. Fifi says:

    Dr Hall – What culture are you referring to? Medical culture in the US? Or culture in general in the US? People are still perfectly able to ask their doctor to “make the choice” or simply follow whatever their doctor recommends as the “best” choice, it’s hardly as if this ability has been taken away from patients! Now, more patients may choose not to do this these days, that’s just as valid a choice even though it may be less appealing to doctors. I’m not sure how you believe the choice to hand over one’s responsibility for oneself is being “invalidated” by the current culture – sure it looks like a lack of self responsibility but it IS handing over one’s responsibility for oneself to one’s doctor.

    This still looks more like it’s a desire for authority being wrapped up in patient choic/freedom – that may be partially due to being expressed as a desire for a return to “paternalism” but whether that is the case or not, it’s not that different than the whole SCAM thing of trying to sell deregulation as “health freedom”. Both seem to be about having power over others, not sharing one’s power with others. Sharing requires two willing participants. This comes back to earning authority by earning trust – the medical profession has lost the trust of many people for some VERY good reasons based on evidence not just whimsy.

    You do realize that a parent/child relationship between adults – even in a professional context like medicine where it’s more likely to arise – is ultimately somewhat pathological on the part of both the doctor and patient? And the kind of doctor who enjoys this kind of relationship is exactly the kind of doctor who shouldn’t be engaging in them! (Complimentary neurosis and all that jazz.) Certainly it can’t be avoided in some situations with some very neurotic patients, but playing into it seems highly unethical to me and actually the source of some medical quackery!

  14. James Fox says:

    Paternalism can often just be a cover for an over inflated or fragile ego when it comes to any profession with intrinsic authoritarian aspects. Candor and honesty needs to include statements like, “I don’t know”, or “ Dr X knows more than me, you should have a consultation/second opinion with him/her” or “I’ll consult with Dr X and get back with you regarding the best options”.

    Sadly as mentioned by others the CAM practitioner often gives the patient more time and the illusion of collaboration and emotional support. It is no mystery why many folk prefer the warm and fuzzy atmosphere much of alternative medicine offers. My preference is optimal clinical excellence and good science. However if there is an unwillingness of a medical practitioner to have frank and open discussions regarding care and treatment options I would likely choose someone else and hopefully not have to sacrifice expertise to any significant degree.

  15. Fifi says:

    “SCAMmers appeal to our stated desire for respect and choice, but do they actually deliver on this, which is perhaps their primary selling point?
    I would suggest that they simply substitute a different kind of paternalism, and one harder to fight.”

    My point was that the “paternalism” of medicine compliments (and more than partially created and nourished) the “maternalism” of CAM – both are asking for our trust on false pretenses. Two side of the same coin, neither with much respect for the patient and both with a (from my perspective, undeserved) sense of entitlement when it comes to having authority over others. (Of course, I’m working with generalizations here, plenty of doctors and patients manage to have wonderful, constructive relationships that work well for all involved.)

  16. tarran says:

    What if the mechanic offers me a choice between an expensive new part and a less expensive rebuilt or remanufactured part? What if there aren’t any good statistics to show whether the rebuilt part is as reliable as the new part? I have no experience with rebuilt parts and no ability to judge the relative merits. The mechanic is probably a better judge than I am, and I would feel comfortable asking him “What would you do?” and following his advice.

    Dr Hall, you and I agree. What you are describing is a proper relationship. Note, if your doctor answers your questions with some absurd thing saying something along the lines of “your chakras are aligned so the low cost option should be sufficient”, you’d probably fire the guy on the spot. Under paternalism, the doctor may conclude “Her chakras are aligned, we’ll do the low cost option and not tell her about her other options”, in which case you are getting the type of care you don’t want.

    The important thing to ask guys like Dr Jauhar us do you want an auto mechanic treating you the way you propose to treat your customers? I think the answer would be quite instructive (and it could be surprising, perhaps he does not want to be bothered with the care of his car, has no need to worry about money, so he just take sit to the dealership and agrees to whatever they recommend).

  17. wertys says:

    I would agree with Fifi’s point that medical ‘paternalism’ has been largely responsible for creating a cultural environment in which the ‘warm and fuzzy’ approach of SCAM can be seen as a desirable alternative. I would contend however that even these days, when doctors are tempted to be paternalistic (or perhaps I should say directive and noncollaborative ) in planning treatment, they are not nearly as bad as once they were. In part this is because newer generations of doctors are part of a modern culture where paternalism has been named and shamed.

    Speaking for myself, nothing makes me cringe more than a patient who says ‘You’re the doctor, you tell me what to do”. Even when I know they’re actually sincere and not trying to be passive voyeurs of their own treatment. My training has bred me to expect that patients want to be involved in decision-making, and I find it uncomfortable being any other way.

  18. daedalus2u says:

    I have been thinking about this in the context of what is a “good parent”, and how would a “good parent” be “paternalistic”. Paternalism does have the connotation of being infantilizing and between adults of being a type co-dependency, which as fifi points out is quite unhealthy for both parties.

    Being paternalistic does not necessarily result in a co-dependency. The essence of good parenting (in my opinion), is to allow the child as much agency as the child is capable of handling. The good parent does not substitute their wants for the child, they use their adult reasoning capacities to emulate the child’s desires and make the choice that the child would make if the child had adult reasoning and applied it to the task at hand (within limits).

    For example in choosing a gift for a child, a good parent does not choose what the parent wants and which the child has no interest in, but rather what the child would want and which is ultimately in the child’s “best interests”. Many parents do not achieve this level of parenting but instead simply impose their values on their children (this is a cartoonish simplification of parenting).

    To emulate a person’s thinking sufficiently well to be able to make treatment decisions on their behalf requires a great degree of personal knowledge, a degree of personal knowledge that most doctors lack.

    In the context of a health care provider and patient, only when the health care provider knows the patient’s wishes sufficiently well is the health care provider able to act on them. Virtually always the only way this can happen is by the patient telling the health care provider what they want.

    To do otherwise is to exploit the patient. It is exploitive to assume and make value judgments. It is exploitive for the car mechanic too, but they do it all the time.

  19. mckenzievmd says:

    I see the paternalism question from a slightly different angle. Since I’m a vet, my patients are literally property, and within very minimal limits the owners can do what they like with them. For a long time, the auto-mechinic model was much more applicable than the medical model to my profession. What the owner wanted we did, and while that usually was in the best interests of the patient, it often wasn’t. And if care got too expensive, the pet was disposed of no questions asked regardless of the medical facts.

    Yet vets of my generation are now trained as doctors in the same medical model as MDs, and many of my clients view their pets as members of the family, so in a general sense the pediatric model fits better than the mechanic model these days, at least in my area of practice. And that means that if I take the patient’s interests seriously, I have to deal with conflicts not just between what the patient wants (often to run away) and what I think is best (that it receive the treatment I’m trying to give), but also between what the owner wants or can afford and what I think is best. Lots of interesting negotiating and room for degrees of paternalism in there, which has led me to a compromise position.

    (FWIW, I also get sued less than most MDs, though often enough that informed consent as litigation prophylaxis is still a consideration.)

    My patient’s interests are pretty simple. The opportunity for expression of species-typical behaviors, freedom from significant pain and other forms of suffering, and so on. There is still an issue of conflict since what the owner wants to do isn’t always what I think is in the pateint’s best interests, but at least I’m comfortable behaving paternalistic towards the actual patient, if not the client. However, the client also has an interest in the situation that has to be respected, and they are the ones with the primary relationship with the pet. So I still have to respect their autonomy and interests while advocating for the patient and considering my own perspective. Tricky.

    For human patients and MDs, the situation is obviously even more complex since the interests of humans are more complex (or at least their species-typical behaviors are).

    It seems to me there is no perfect solution. Doctors don’t, or shouldn’t, let patients micromanage their care, so in practice they make a lot of crucial decisions without clear knowledge or consent of the patient. And I absolutely agree that how one presents a case controls the patient’s choice to a greater extent than most of us would admit. So to a certain degree, informed consent can be an illusion.

    But I think it is critical that doctors take seriously, as a framework for what they do, that patients do have complex and powerful interests in their own health and healthcare. These interests are informed by personality, culture, ontogeny, and many complex factors. It is impossble for doctors to truly be present inside a pateint’s perspective, and this should engender great caution in projecting one’s values or taking decisions away from the patient. Perhaps the absurd extremes of doctor as technician and patients as thoroughly autonomous and in charge is undesirable and unachievable. But beginning with a foundation of great respect for the patient’s interest may be a check against forcing our values upon others.

    Paternalism seems a slippery slope. Lots of scenarios can be concocted to show how it can be a justification for abuse. What about denying care that the doctor feels is morally wrong? What about forcing care on a patient for their own good against their vehement objections? Not situations most doctors would probably be totally comfortable with, yet common under a pure paternalistic model. So which I agree that the balance between doctor and patient isn’t equal in terms of decision-making, and probably shouldn’t be, I think the advantage we have in terms of knowlege, a certain objectivity or distance from the emotions of the patient, and our “Aesculapian authority,” imposes on us a duty to be respectful of the patient and their values, and the modern model does that better than the paternalistic model.

  20. Fifi says:

    wertys – “I would contend however that even these days, when doctors are tempted to be paternalistic (or perhaps I should say directive and noncollaborative ) in planning treatment, they are not nearly as bad as once they were. In part this is because newer generations of doctors are part of a modern culture where paternalism has been named and shamed.”

    True and a good point. I’d add that the younger generation of patients have different expectations as well. We have 3 quite different generational experiences of the world going on right now – and ones that can be very different! We have the pre-TV/computer generation who have learned to use these technologies but don’t think like them (so to speak, who haven’t been shaped by them…so Boomers and earlier, generally speaking, though there are all kinds of individual variations, of course, and I’m not excluding this generation from innovation in any way!); we have the Gap Generation (my generation who straddle the digital divide and saw the introduction of home PCs, video, timeshifting, etc); and the GenX/Y generations that grew up within a highly technological environment with a very different concept of communication (though hardly alien, a lot of predictable youthful behavior gets contextualized and dramatized by older generations who don’t understand, as always ;-) ).

    I’m curious, do you feel you have lost something by not feeling comfortable with being paternalistic even when a patient asks you to make their choice for them? Do you know why you feel this way? Is it the weight of the responsibility? It just feels “unnatural”? Or is it because the patients who insist upon you doing this are actually trying to manipulate you and avoid their own personal responsibility for their life choices and THIS feels uncomfortable?

    I’m extremely fascinated by the cultural aspects of medicine and communication (um, if that wasn’t obviously one of my hobbyhorses! ;-) ), and I suspect that some doctors who are not naturally good communicators may be greatly helped out in their training by having some understanding of the psychology of treatment (for lack of a better term!). Does this now exist as part of medical training? I know there’s been some research into the cultural aspects of the expression of pain across cultures but this seems to be an area that’s only starting to be investigated. Though I could well be wrong and would welcome anyone pointing me in the direction of any resources regarding medicine, culture and communication.

  21. Kimbo Jones says:

    I wonder how much paternalism (or similar attitudes) contributes to CAM, if at all. Patients may not confront their doctors with “hey I’m not a child”, but they may instead give up and seek the more “holistic” and “client-centered” approaches of CAM “doctors”. Does anyone know of any studies on this topic?

  22. Kimbo Jones says:

    To clarify my comment above: If doctors are being paternalistic to clients who find that off-putting but are too shy to stand up for themselves, are they likely to find comfort in CAM which promotes itself with “it’s all about you” buzz words but is just another form of paternalism in disguise (i.e., doctors don’t know what they’re talking about but we do so do what we say instead).

    Would a patient find CAM more appealing due to the greater (albeit artificial) simplicity of the “doctor”-patient relationship? Is it likely that paternalism in medicine could be accidentally turning people on to the masked and more simple paternalism of CAM?

    There’s a lot of hearsay on this so far, but I’d like to see some evidence (if there is any).

  23. MedsVsTherapy says:

    From Hatch Xanadu:
    “But I fear that the tendency of folks to discuss their unpleasant experiences as though they were as a rule the result of “medical establishment” screwups…”

    Uh, Hatch – wake up. This is the rule.

    If you are a doctor, then, in social events this holiday season, if people do not know your profession, masquerade as a non-doctor. Get people talking about problems they have encountered with docs and the health care system. Try not to come to the defense of the docs, but evaluate whether the care really should have gone as it did, as best as you can tell from the person’s story. Lousy performance is the rule.

  24. Dacks says:

    MVsT:
    Just an anecdote, second-hand, but fresh – my mother had both hips replaced Monday. I talked to her yesterday: not only did the operation go uneventfully well, her aftercare was also excellent. She is in good spirits, talkative; the morphine (I think that’s what it was) pump had been removed and they had gotten her upright for a few moments. She is looking forward to progressing quickly and the hospital seems to be helping her move along.

    So here’s your first story in defense of the medical establishment!

  25. Fifi says:

    Kimbo Jones – It seems to me that different CAM practitioners use both paternalism and maternalism – depending on the personality of the CAM practitioner and the flavor of woo being served up. Reiki and homeopathy seem to tend very much towards the maternalistic – lots of comforting, listening, discussing with concern, gentle and soothing touch and hugs (not surprisingly, these are also less physically invasive types of woo). Both really have more in common with psychological therapeutic modalities. This stuff isn’t really trying to pass itself off as conventional medicine in any way shape or form in my experience. It also is more attractive to women than men and often ties in with specific women’s concerns (adn is popular with women going through transitions such as menopause since it offers the “wise woman” model of older women…quite a positive image if it’s substance actually was wisdom! :-)

    On the paternalistic side are the treatments that often try to pass themselves off as medicine and science based – chiropractice, fake cancer treatments, yoga healing stuff like 3HO (though there’s a great variety of schools of yoga that run from secular through religious, quite a few reflect the paternalism that is so prevalent in yoga’s land of origin). Interestingly, sometimes these paternalists try to claim they’re feminists and maternalists because they worship a goddess – though that’s silly since feminism is about seeing women as fellow humans deserving of equal rights, not being a “good” woman who stays in her place at the foot of the goddess cult run by a man!).

    There will always people who want freedom without responsibility, which seems to be a nostalgia for childhood more than anything else. Of course, “freedom” has become so prevalent in marketing and propaganda that I suspect many people have no real idea of what it means to themselves personally or in a larger context. Is it eating a certain brand of gum? Having an expensive car with seat warmers? Do you buy freedom? And, if you can, who do you buy it from and do you have to take someone else’s freedom to finance your own?

  26. daedalus2u says:

    The archetypal placebo effect is the parental “kiss it and make it better”, usually administered by the mother. Using a parental affect to administer a placebo while deferring to the patients’ autonomy in determining which choices to make is (I think) an appropriate use of a parental affect in a health care situation.

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