Paternalism in the Medical Profession Philosophy 235 EC: Biomedical Ethics “The only appropriate and realistic model of the Dr.? patient relationship is paternalism. Doctors are the medical experts; most patients have little, if any, reliable medical knowledge; implicit trust in one’s physician is essential to the healing process; and doctors have the responsibility for our health and therefore have the duty to make all the important medical decisions. ” Critically assess that claim. The issue of doctor patient relationships has become more and more prevalent in our world today.
It is hard to draw a clear line in deciding what the appropriate roles are of both the patient and the medical professional. The claim that the paternalistic model is the appropriate and most realistic model will be argued in this paper. This model states that the doctor is the one in complete control, making all decisions on behalf of the patient, and the patient grants the doctor this responsibility, obeying any orders. In this model, patients act as children, who are ignorant and unknowledgeable, and doctors act as parents, not only guiding the child in the right direction, but also, actually telling them what to do.
Should doctors really hold complete responsibility for our health? Should they be the ones to make all the important medical decisions without patients having any say? This model will be argued in this paper in order to critically assess whether it should be dominant in our present society. “The traditional view held by physicians themselves was that the physician is the captain of the ship, and that the patient has to follow orders. ” This view has only been strongly believed since the 19th and 20th century, when medical professionals were granted almost complete control over all decision making by their patients.
Before that time, going to see a doctor was perceived as a last resort, and many would ignore their doctor’s advice altogether. Over time, this view has shifted and society began to believe that physicians “knew best, and therefore had not only the right but also the duty to make the decision. ” Today, less and less citizens are continuing to agree with this point of view, and instead other doctor patient relationship models have emerged and been identified by Robert Veatch: the engineering model, the priestly model, the collegial, and the contractual model.
The three alternative models to the priestly (paternalistic) model have emerged from a more contemporary perspective. The engineering model states that the relationship between the two parties would be nothing more than the doctor simply presenting the patient with the diagnosis, prognosis, and treatment options. Any decision as to which route to take is left entirely up to the patient. As the textbook explains, the doctor is nothing more than an “applied scientist”, or a “plumber without any moral integrity”, since ethics and values do not come into play in this relationship.
Although I do not entirely agree with this model, the responsibility is lifted off of the physician, and the patient is given freedom to decide. This would follow the argument of self-determination, as said by Dr. Ornstein. This is the belief that all people who are competent should be the ones in control of determining their own fate. Society has not always believed or relied on medical professionals. In fact “until well into the nineteenth century, the physician was seen as a figure of last resort. ” They were deemed useless and even harmful.
With this in mind, I wonder why in our day and age, we would rely even more on physicians than we did in the past? Today, we have the privilege of finding out almost anything we need to know within minutes via the Internet, and that is why sometimes, it is the patient that knows more than his own doctor. It is important that patients assume some level of responsibility for their own health, instead of relying on doctors, and the engineering model would display that type of behavior. That is another reason why I oppose the claim that paternalism is the ideal relationship between doctor and patient.
Another alternative model identified by Robert Veatch, is the collegial model. This theory emphasizes that both parties are connected through common goals and interests, and that each acts as an independent equal. This model would suggest that the parties work together, and therefore the responsibility is divided equally amongst the patient and physician. There is collaboration here, engaging in activities, which are satisfying to both, and demonstrating an adult-adult relationship, because no one party has greater control over the other.
This model goes hand in hand with the partnership model, which expresses that health care professionals and their patients act as partners or colleagues in the pursuit of the shared value of health. There is mutual participation in this model, which demonstrates that, unlike the paternalistic model, the patient can help come to a medical decision. This model stresses, “the patient uses expert help to realize his ends. ” This expert help can come in many forms, and as I have previously mentioned, today society is exposed to numerous modes of gathering any type of information that is of interest.
It is of course obvious that the physician has a stronger medical background and is more competent in that field, but that does not diminish the participation or contribution of the patient. With that being said, it is my opinion that the paternalistic model has clearly outgrown our culture, when there are models such as the partnership or collegial model, which are more in sync with our world today. Finally, the third alternative to the paternalistic model is the contractual model.
This model is similar to paternalism, in that it questions the assumptions of equality, however it differs in that there is a “contract” between both parties, leaving each with their own dignity and moral authority. What is crucial about this model is that it does not neglect the fact that there is an obvious difference in the degree of knowledge between the patient and the physician. Instead of focusing on that discrepancy, the model concentrates on the agreement between the two parties to exchange goods and services and the enforcement of that by government sanctions.
In other words, this model compromises between partnership and the reality of medical care, and according to Veatch, is the only realistic way to share all responsibility, while protecting various parties in health care. For example, both parties are freely entering this contract, and therefore are both given the right to leave it, given proper notice. However, while partaking in the contract, there are duties and obligations of each, which may neglect virtues of benevolence, care and compassion, which we do see stressed in other models.
Leaving aside the three alternatives to the paternalistic model, there are several other arguments, which come to surface, when critically assessing the above-mentioned claim. The first is that doctors must act like parents because patients know much less than doctors do. This emphasizes the idea that the doctor patient relationship should be one of paternalism. This argument takes into account two different prototypes. The first is the parent-infant relationship, where the parent is the doctor, taking on an active role and the infant is the patient, taking on a passive role.
In this case the patient is extremely dependent on the medical professional. The second is the parent-adolescent child relationship, where the physician guides the patient in the right direction, and the patient co-operates to the degree of obeying. Both suggest that the patient has no responsibility, and that the duty and obligation of all decisions rest on the shoulders of the physician. This proposes that patients are ignorant and unknowledgeable and given the opportunity to make their own decision, they would not be able to.
It is likely that doctors know more than the average member of society, however, this is not to say that they are infallible, mistakes can happen. As Professor Ornstein has stated, we cannot choose our fathers, but we can choose our doctors, and in my opinion there is no connection where the two should be related. If a patient feels they should seek out a second, third or fourth opinion, that is their own right. Unlike the ability to seek out a second, third or fourth father. We do not have this option.
It is possible and even probable that doctors will differ in their views, and each may guide their patient down a different path. Although a relationship between a physician and a patient should be based on a degree of trust and loyalty, if there is any sort of uncertainty, patients should not feel the pressure of following a path they do not believe in. Getting another opinion is not disloyal or disrespectful; it is a patient’s right. Additionally, today more patients recognize that it is unfair for doctors to take complete responsibility for our welfare, as we are exposed to so much free medical information.
It is my opinion that it is the patient’s duty to also act responsible for his or her own welfare. Another argument that I have come across to oppose this claim is that doctors may be experts in medical matters but there may be other factors to take into account, such as ethical issues, when making a decision. Each doctor has taken an oath, to save lives. This is their main concern, and their main goal for each patient. One must wonder, whether or not this is always ethical. As Professor Ornstein has suggested, do we save someone who as a result must live the rest of his or her life in agonizing pain?
Or do we relieve them of that pain, and simply allow them to pass away? This is an ethical issue where many doctors may have opposing points of view, and may decide that their job would be to save the patient. That would be a paternalistic instinct however; medical decisions should not be purely medical all the time. There are always other factors to consider such as the medical conditions of the patient, their preferences, the quality of life and the socio economic conditions. Each, of course, is given a weight dependent on the specifics and circumstances of the case.
In the case of a patient who is experiencing excruciating pain, the doctor may come to the conclusion that the best option would be to remedy that pain with medication. It is important to note, that this paternalistic act is ignoring all ethical issues and only taking medicine into account. Opposing this notion would be to consider how this medication might cloud the patient’s judgment, or recognizing the patient’s preferences prior to formulating a medical decision. Doctors might be experts in medical matters, but the other factors, which are necessary to take into consideration, deem the paternalistic view inadequate.
A final argument against the paternalistic view is that physician-patient interactions are negotiations. Viewing the interactions as negotiations, is in itself opposing paternalism because the patient is given some level of autonomy to take part in the decision making process. The goal is to reach a mutual agreement. In order to do so, there are certain steps that must be followed. Firstly, the negotiation should involve adequate disclosures by both parties. This is necessary, so that values and objectives are clear, and a fair negotiation can take place. Secondly, the negotiation should be voluntary, meaning uncoerced.
Neither party should feel threatened while entering into the negotiation process. And finally, the solution should be one of mutual acceptance. Of course there are occasions where negotiation is not possible, and that would be for example in the case of an emergency, when the physician needs to save the patient without negotiating beforehand. In that case, the medical professional may act in a paternalistic way, however if there is a competent patient, negotiation is possible and can often be characterized in terms of any of the above-mentioned models (parent-child, friends, partners, etc. ).
The aspect that the relationship is seen as a negotiation counters the paternalistic view, in that the patient is given choice. If the patient chooses to give up his autonomy, and lay his destiny in the hands of his physician, that is his preference, unlike the paternalistic model, where that is not a choice, but the only way. The paternalistic model is not the only realistic relationship between doctor and patient. “As a normative model, paternalism tends to concentrate on care rather than respect, patients’ needs rather than their rights, and physicians’ discretion rather than patients’ autonomy or self determination. As I have mentioned previously, there are many other factors that must always be taken into consideration when dealing with a patient. Autonomy, self-determination, and respect, are surely incredibly important when dealing with a patient, and paternalism ignores those factors. The above-mentioned arguments, and alternative relationship models, clearly oppose the claim that paternalism is the only appropriate relationship. As I had asked the questions: Should doctors really hold complete responsibility for our health?
Should they be the ones to make all the important medical decisions without patients having any say? I believe the answer to both questions is quite clear, that the responsibility should be shared, and the patient, if capable, should take part in the decision making process. That being said, paternalism is not the most appropriate model and no one relationship trumps another. Instead, all must be taken into account depending on circumstance.