Doctor Knows Best (Kind of): Different Models for Patient/Doctor Decision Making

    Even though I know how much of an over-eager premed it makes me sound like, I sometimes feel like I cannot stop recommending Being Mortal by Atul Gawande (2017). It's a powerful exploration of death and dying from a medical standpoint, and it provides both a patient and physician perspective on what that experience can be like. As soon as we started talking about our four main biomedical ethics values, I started thinking about that book again, and in particular its take on physician/patient decision making. In it, Gawande references an ethical paper that explores the four kinds of relationships that physicians and patients can have (he only mentions three of the four, so I shall also omit the deliberative relationship). The first is the paternalistic relationship: this is assumes that the patient's moral values are fixed, shared by the physician, and less important than the objective consequences to a patient. In other words, the physician decides what is best for the patient, regardless of what the patient might prefer, and communicates as such. The second model is the informative relationship: this assumes that the patient's values are fixed but unknown to the physician, and that the physician's main responsibility is to provide information (but not advice) in order to allow the patient to select options for their care. It's essentially a "customer is always right" mentality. The third model is the interpretive relationship: This recognizes the patient's values as developing and conflicting, and essentially combines the previous two relationships to allow for both information and advice from the physician. (Emanuel, 1992)

    In considering the ethics of these relationships, there are some obvious takeaways. Almost everyone has had the frustrating experience of seeing a doctor who thought they knew better; as such, most can agree that the paternalistic relationship is not an ideal one to foster trust and patient-centered communication. In general, physicians have been moving away from this kind of attitude, in favor of one of the other styles of communication listed above. That said, deciding between the models requires some ethical consideration. In a sense, the models exist on a spectrum between beneficence and autonomy; the paternalistic model prioritizes beneficence even when it may infringe on autonomy, while the informative model is the reverse. In Being Mortal, Gawande strongly advocates for the interpretative model, taking the position that it allows for the most benefit to the patient by first having the physician help the patient in determining their values, in order to make recommendations most in line with those values. Of course, this presents a concern from a justice perspective; if your treatment recommendations are guided by patient values (or at least your interpretation of them) how can you guarantee each patient is receiving the same standard of care? For that matter, how do you reconcile a desire to be non-malfeasant with respecting a patient's autonomy? 

    

    Like most good ethical questions, this one doesn't really have an "objective" right answer. But I'm curious what factors guide you in deciding how best to communicate with patients. Some people might strongly favor one model above all else, while others (like myself) might think that different approaches are warranted in different situations. But I think this is an important conversation that reflects our in-class discussions about biomedical ethics, and something that should be thought about by anyone who wants to become a physician. 

References

Emanuel, E. J. (1992). Four models of the physician-patient relationship. JAMA: The Journal of the American Medical Association, 267(16), 2221–2226. https://doi.org/10.1001/jama.267.16.2221

Gawande, A. (2017). Being Mortal Illness, Medicine, and What Matters in the End (1st ed.). Profile Books Ltd.