Medical Paternalism, Autonomy and Shared Decision Making

In the olden days, physicians had the dominant role in the doctor-patient relationship.  During this era of medical paternalism, physicians gave their best medical advice and patients accepted it.  If the gastroenterologist felt that his patient’s gallbladder had to go, for example, then surgery was sure to follow.  Informed consent – as we now understand its meaning – was not fully practiced.  Patients provided consent but were only partially informed.

While medical paternalism has largely become extinct, and is inconsistent with today’s societal and medical mores, it was the template for medical practice until only decades ago.  And while we regard the subjugation of patient autonomy to be a fundamental ethical breach, both physicians and patients during that era were perfectly satisfied with the arrangement.  A patient came to the doctor with medical issues.  The doctor -the medical professional - offered advice that the patient accepted.  The patient’s condition improved, as usually occurs, and all was good in the world.

The relationship was inherently unequal because only one of the two parties had medical knowledge and experience.  A similar construct might be present if a person consulted an attorney, an accountant or an electrician.  Many folks defer to the professionals they hire.  I certainly do so in many instances.

Medical paternalism was prime TV viewing in the 1970's.

I have only practiced medicine in the era where patient autonomy is sacrosanct.  While no system is perfect, I agree that the current system is ethically preferable and now designates that an informed patient is the decision maker.  We are also now more aware and sensitive that patients may consider cultural, financial and religious beliefs and realities in addition to the medical facts when making medical decisions.   In a stark example of this, a physician may strenuously advise a patient to accept blood transfusions because his life is at risk.  The patient, who is a Jehovah’s Witness, calculates the issue differently.

A common term used to describe today’s dynamic between doctors and patients is ‘shared decision making’.  The office visit is a brainstorming session, a collaboration between two parties.

I have found that many patients today aren’t satisfied just to share authority.  They have taken a lesson from the doctors of yesteryear and are practicing Patient Paternalism.  The patient dictates the medical advice.  We doctors hear this all the time.  A patient will tell me directly, or communicate to me via the electronic portal, statements such as these:

I need a CAT scan.  Please order it.

I need antibiotics.  My diverticulitis is acting up.

I think my pancreas is underactive.  I need that test I saw on a TV commercial.

I need to have my stomach scoped again.  I’m sure my ulcer is back.

As in any successful relationship, I think it works best if neither party dictates to the other.

I wholly support patient autonomy and have great respect for the doctrine of informed consent.  The irony is there are many patients today who eschew their right to autonomy.  They just want their doctors to tell them what to do.