“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.
In this very permissible society, in the context of a global village and advanced technologies, there are always exceptions to the rules. Knowledge and information abound. We all know in a glance, because the technologies, such as the Internet, allow us to learn so many things in just one click of a mouse.
Paternalism, as a very broad social and economic concept, seems to be outdated. I consider it very traditional since it pertains to the traditional parent (father) child relationship, wherein the desires and wishes and the command of the father always rule. Historically, fathers are always the law inside the house. In other similar relationships such as teacher and student, proprietor and clients, paternal relationship can be described as the more powerful party taking charge of the other. This is not the case in present times.
In schools, teachers are now considered as facilitators, not gurus per se. They facilitate or assist the learners to learn whatever the learners decide to learn. In commerce and trading, it is the buyer’s feedbacks that rule, not the owners or managers’ voices. Businesses are more market oriented. They listen intently to their buyers or customers because if they do not, the precious clientele will certainly patronize all the other substitutes in the markets. It seems to be that with the technological advancements and the more expansive world view of the people, experts are not constantly as they are. They can be knowledgeable to a certain extent, but they may also miss some important points. Hence, it is best to listen and let the stakeholders decide, precisely because they will decide on their own terms, according to their own beliefs and their gut feel or their mere will.
In this line, I want to state my position that in the fields of medicine as well, the context of paternalism has leveled down. Doctors must not have a paternal relationship with their clients anymore because the present time renders it impractical and disadvantageous, at worst, even detrimental.
The doctor patient relationship should be more collaborative because medical knowledge is not exclusive to the doctors alone. Even when a simple mother does not know how to cure a simple fever, by merely searching the Internet for the child’s apparent symptom may lead her to various choices, such as letting the child drink over the counter relief, applying various natural and herbal medical practices or it may also lead her, eventually, to further consulting a doctor, and “conferring” with him the knowledge about the disease which she has already initiated.
The point of this discussion is that, doctors are not gods. A paternalistic relationship between doctor and a patient is not the most appropriate and realistic model of the doctor patient relationship. At this age, I assume that a more collaborative relationship should emerge and be encouraged. Our trust to them does not directly pave the way towards healing. This belief is further strengthened by the concept of wholeness which healing and medical practice has also come to recognize nowadays. Healing is a total process and medical treatment may just be one aspect of it.
The Limiting Nature of a Paternalistic Approach
The paternalistic approach is illustrated by a doctor-centered approach to medical treatment. It depends mostly on closed questions made to elicit a simple yes or no answer. The doctor’s diagnosis is modeled out of the symptoms and signs of a particular illness. However, this is not centered on the patient’s unique experience of the said illness. This must not be an absolute case in each patient-doctor encounter.
Doctors do not know everything. Also, they are not infallible and they may mistakes to the detriment of their patients. Even when the patient has objectively and succinctly articulated the symptoms and the illness he has encountered, the doctor may unwittingly direct his conclusion to a similar disease or condition which does not full address the ills of the patient. In this case, the patient also has the right and the responsibility to initiate personal efforts to know more about what he is feeling, especially the symptoms and signs he has experienced and its duration, etc.
In this regard, the sole responsibility is not in the doctor. People are supposed to be the main managers of their health and not the doctors. Individuals must be responsible for their own health and medicine is responsible for illness (provided that the doctor has diagnosed it accurately).
In one example, the child has been initially diagnosed for dengue and he has been given all the medicines and tests for the said disease. The mother, a researcher, tried to differentiate the symptoms of the disease to what he actually noticed in her child during the last five days in their stay at the hospital. She was led to the conclusion that the disease may be a pulmonary infection and it has the same symptoms of high fevers and some more similarities with blood counts. She talked to the doctor and insisted that her child be scheduled for a chest x-ray. She was right; it was a form of a pneumonia and not dengue.
If the doctor is all knowing, how could it escape him? If the patient is to be blamed for not explicitly telling the doctor all the symptoms or what he actually feels, then can we blame the child? If we are to consider the instincts of “paternalistic” and maternal in this case, we could say that the mother’s instinct was more infallible. The mother instinctively resorted to actually finding the precise symptoms as she sees fit in the doctor’s diagnosed disease and she ruled out the difference with her child’s case. What actually urged her was the sight of seeing her helpless son being extracted of blood morning and night for the last five days.
Another solid argument about the paternal nature of the doctor patient relationship is the trust factor which patients often “submit” to their health practitioners. A paternalistic nature may be acceptable during those times when someone’s doctor has been the family’s very own doctor. Another segment of trust is that the doctor is a relative or has lived in one’s community for a long time. Hence, as we see it in movies, when a family member gets ill, the doctor is called as if he is surrogate father or an uncle. Often, this family doctor knows about the family history, the members of the family, their congenital and genetic diseases, etc.
I do believe that in general practice, this is not the norms nowadays. Because of global mobility, people extensively travel. They live from one place to another, within their own locality or country and in their own region or internationally. The issue of trust is dissolved into the consumerist nature of the transaction, which is the doctor having to dispel the ailments or illness at a price which the patient often succumb to, in exchange for his good health.
To establish trust, people nowadays search for various doctors online. They also call their most trusted family members and friends to heed their references. They try to study the doctor’s abilities and gauge for themselves if the doctor is okay before setting up a medical appointment. Patients unwittingly presume their own role in their own healing or treatment the moment they decide or willfully select whose medical expertise they are going to seek. I think this is not being paternal since the patients are trying to select their own fathers.
The Persisting Side of Paternalism
While modern patients are now very selective on their health care and the treatments they want for themselves, there also exists a public condition in medical care. Most people do not have access to quality healthcare because they could not afford it. Poor people do not have several choices and for them, being taken care of by a doctor is a glory by itself. This situation sustains the paternalistic relationship where the doctors act like second parent (if not god) to the patients.
Imagine a community which has not been visited by a doctor in the last three to five years. The arrival of the medical expert is for them the cure in itself. Hence, they line up to be diagnosed for all the ills they have long experienced. They have no other access to medical or health knowledge except when they are visited by health professionals. They have no means of applying technological advancements and practically applying it to ease their pains. They also do not have the money to go to other medical clinics or centers nearby.
In such cases, when the doctor tell a patient that he has a lump in his throat and this could be thyroid cancer, the advice of surgery seems to be absolute medical decision for the patient. The patient assumes that the doctor knows it all and that he knows best. The patient also considers that the doctor also see fit as to how this operation, which he proposed, is to be conducted, given his social and economic conditions.
In this context, the doctor is not also a medical experts, he is also the father since the patient lacks the knowledge and the resources to take care of his own medical conditions. I suppose that the doctor will also be the one to arrange for a free medical surgery for the patient.
In a different scenario, an informed and economically independent patient may be diagnosed by the same doctor the same case but the patient may have various options. He may opt for a second opinion. He may instantly request his doctor for a biopsy. If the lump is not cancerous, he may also resort to nuclear treatment. He may resort to natural healing and go to a naturopathic doctor to dissolve the lump without any surgery or any interventionist approach. In sum, the patient with greater knowledge and greater fortune has the greater options. All his options lead to his general well being.
Another persisting situation which warrants a paternalistic relationship is that the doctor presupposes the full responsibility of his utmost commitment to his patient. By setting out what the patient must do, the doctor is reducing his liability in any case that something goes wrong with the medical treatment or procedure. Hence, we often hear them become more authoritative, decisive and insistent when there is a pressing medical need or condition that warrants immediate medical concern.
They just actually fear that they may be blamed or even held responsible when something bad happens to the patient. Thus, while they are a position to authorize any medical procedure, they sometimes urgently admonish the patient to submit to their decision. This is a good oversight of the whole situation since we presume that the doctor is acting on the best interest of the patients. The only problem is that when he is at fault or all the other angles were not keenly observed.
There are negative and positive sides to the paternalistic relationship between patients and doctors. However, there is also a best alternative or a middle ground to this – collaborative participatory model. There must be a synergy of medical information and knowledge which does not only comes from the doctors but also from the patients and even the third party resources as well (these may include the relatives of the patient, the community health workers, the nurses, among others). If this type of a relationship is strengthened, this will be a better collaboration between the doctors and the patients and this guarantees better medical diagnosis and prognosis.
A collaborative arrangeemtn ensures the totality of the medical care. This entails that there is flexibility in the process. For instance, at one point, the doctor may become more paternal as the case warrants it. At other times, he may leave the patient to more freedom and choices when it comes to his medical services. The best thing about this model is that it does not really absolute powers and authority over one single stakeholder in the health or medical process. The patients and the doctors often discuss the options, the negative and the positive aspects of it. It is interesting to note that when the burden of health is shared between the patient and the doctor, a more meaningful healing process occurs. This is very much different from the traditional process that when a doctor rules out the conditions and what needs to be done, the patinets meekly submits. The new concept of wholeness and healing is very congruent to this model because it assumes that the patient takes an active role in his own healing.
I firmly believe that the body has natural processes and it takes the union of the body and the mind and spirit to attain good health or wellness. This is also the ebst way to be cured or treated. Healing cannot come when the person is at peace with himself and with the process that he will undergo.
Dr. O’s Lesson 3 Notes: Why Paternalism Is Necessary in the Medical Profession. n.d. 22 pp.
Kluge, Eike-Henner W. Readings in Biomedical Ethics: A Canadian Focus, 3rd ed. Toronto: Pearson Education Canada, 544 pp.