FOUR MODELS OF THE PHYSICIAN-PATIENT
RELATIONSHIP
Ezekiel J. Emanuel MD, Ph.D., and Linda L. Emanuel MD, Ph.D.
During the last two decades or so, there has been a struggle over the patient's
role in medical decision-making that is often characterized as a conflict between
autonomy and health, between the values of the patient and the values of the
physician. Seeking to curtail physician dominance, many have advocated an ideal
of greater patient control.',' Others question this ideal because it fails to
acknowledge the potentially imbalanced nature of this interaction when one party
is sick and searching for security, and when judgments entail the interpretation
of technical information.14 Still others are trying to delineate a more mutual
relationship.5,6 This struggle shapes the expectations of physicians and patients
as well as the ethical and legal standards for the physician's duties, informed
consent, and medical malpractice. This struggle forces us to ask, What should
be the ideal physician-patient relationship?
We shall outline four models of the physicianpatient interaction, emphasizing
the different understandings of (1) the goals of the physicianpatient interaction,
(2) the physician's obligations, (3) the role of patient values, and (4) the
conception of patient autonomy. To elaborate the abstract description of these
four models, we shall indicate the types of response the models might suggest
in a clinical situation. Third, we shall also indicate how these models inform
the current debate about the ideal physician-patient relationship. Finally,
we shall evaluate these models and recommend one as the preferred model.
As outlined, the models are Weberian ideal types. They may not describe any
particular physician-patient interactions but highlight, free from complicating
details, different visions of the essential characteristics of the physician-patient
interaction.7 Consequently, they do not embody minimum ethical or legal standards,
but rather constitute regulative ideals that are "higher than the law" but not
"above the law."'
THE PATERNALISTIC MODEL
First is the paternalistic model, sometimes called the parental 9 or priestly
model. In this model, the physician-patient interaction ensures that patients
receive the interventions that best promote their health and well-being. To
this end, physicians use their skills to determine the patient's medical condition
and his or her stage in the disease process and to identify the medical tests
and treatments most likely to restore the patient's health or ameliorate pain.
Then the physician presents the patient with selected information that will
encourage the patient to consent to the intervention the physician considers
best. At the extreme, the physician authoritatively informs the patient when
the intervention will be initiated.
The paternalistic model assumes that there are shared objective criteria for
determining what is best. Hence the physician can discern what is in the patient's
best interest with limited patient participation. Ultimately, it is assumed
that the patient will be thankful for decisions made by the physician even if
he or she would not agree to them at the time." In the tension between the patient's
autonomy and well-being, between choice and health, the paternalistic physician's
main emphasis is toward the latter.
In the paternalistic model, the physician acts as the patient's guardian, articulating
and implementing what is best for the patient. As such, the physician has obligations,
including that of placing the patient's interest above his or her own and soliciting
the views of others when lacking adequate knowledge. The conception of patient
autonomy is patient assent, either at the time or later, to the physician's
determinations of what is best.
THE INFORMATIVE MODEL
Second is the informative model, sometimes called the scientific,9 engineering,10
or consumer model. In this model, the objective of the physician patient interaction
is for the physician to provide the patient with all relevant information, for
the patient to select the medical interventions he or she wants, and for the
physician to execute the selected interventions. To this end, the physician
informs the patient of his or her disease state, the nature of possible diagnostic
and therapeutic interventions, the nature and probability of risks and benefits
associated with the interventions, and any uncertainties of knowledge. At the
extreme, patients could come to know all medical information relevant to their
disease and available interventions and select the interventions that best realize
their values.
The informative model assumes a fairly clear distinction between facts and values.
The patient's values are well defined and known; what the patient lacks is facts.
It is the physician's obligation to provide all the available facts, and the
patient's values then determine what treatments are to be given. There is no
role for the physician's values, the physician's understanding of the patient's
values, or his or her judgment of the worth of the patient's values. In the
informative model, the physician is a purveyor of technical expertise, providing
the patient with the means to exercise control. As technical experts, physicians
have important obligations to provide truthful information, to maintain competence
in their area of expertise, and to consult others when their knowledge or skills
are lacking. The conception of patient autonomy is patient control over medical
decision-making.
THE INTERPRETIVE MODEL
The third model is the interpretive model. The aim of the physician-patient
interaction is to elucidate
the patient's values and what he or she actually wants, and to help the patient
select the available medical interventions that realize these values. Like the
informative physician, the interpretive physician provides the patient with
information on the nature of the condition and the risks and benefits of possible
interventions. Beyond this, however, the interpretive physician assists the
patient in elucidating and articulating his or her values and in determining
what medical interventions best realize the specified values, thus helping to
interpret the patient's values for the patient.
According to the interpretive model, the patient's values are not necessarily
fixed and known to the patient. They are often inchoate, and the patient may
only partially understand them; they may conflict when applied to specific situations.
Consequently, the physician working with the patient must elucidate and make
coherent these values. To do this, the physician works with the patient to reconstruct
the patient's goals and aspirations, commitments and character. At the extreme,
the physician must conceive the patient's life as a narrative whole, and from
this specify the patient's values and their priority."," Then the physician
determines which tests and treatments best realize these values. Importantly,
the physician does not dictate to the patient; it is the patient who ultimately
decides which values and course of action best fit who he or she is. Neither
is the physician judging the patient's values; he or she helps the patient to
understand and use them in the medical situation.
In the interpretive model, the physician is a counselor, analogous to a cabinet
minister's advisory role to a head of state, supplying relevant information,
helping to elucidate values and suggesting what medical interventions realize
these values. Thus the physician's obligations include those enumerated in the
informative model but also require engaging the patient in a joint process of
understanding. Accordingly, the conception of patient autonomy is self-understanding;
the patient comes to know more clearly who he or she is and how the various
medical options bear on his or her identity.
THE DELIBERATIVE MODEL
Fourth is the deliberative model. The aim of the physician-patient interaction
is to help the patient determine and choose the best health related values that
can be realized in the clinical situation. To this end, the physician must delineate
information on the patient's clinical situation and then help elucidate the
types of values embodied in the available options. The physician's objectives
include suggesting why certain health related values are more worthy and should
be aspired to. At the extreme, the physician and patient engage in deliberation
about what kind of health- related values the patient could and ultimately should
pursue. The physician discusses only health-related values, that is, values
that affect or are affected by the patient's disease and treatments; he or she
recognizes that many elements of morality are unrelated to the patient's disease
or treatment and beyond the scope of their professional relationship. Further,
the physician aims at no more than moral persuasion; ultimately, coercion is
avoided, and the patient must define his or her life and select the ordering
of values to be espoused. By engaging in moral deliberation, the physician and
patient judge the worthiness and importance of the health-related values.
In the deliberative model, the physician acts as a teacher or friend,14 engaging
the patient in dialogue on what course of action would be best. Not only does
the physician indicate what the patient could do, but, knowing the patient and
wishing what is best, the physician indicates what the patient should do, what
decision regarding medical therapy would be admirable. The conception of patient
autonomy is moral self-development; the patient is empowered not simply to follow
unexamined preferences or examined values, but to consider, through dialogue,
alternative health-related values, their worthiness, and their implications
for treatment. COMPARING THE FOUR MODELS
The Table compares the four models on essential points. Importantly, all models
have a role for patient autonomy; a main factor that differentiates the models
is their particular conceptions of patient autonomy. Therefore, no single model
can be endorsed because it alone promotes patient autonomy. Instead the models
must be compared and evaluated, at least in part, by evaluating the adequacy
of their particular conceptions of patient autonomy.
The four models are not exhaustive. At a minimum there might be added a fifth:
the instrumental model. In this model, the patient's values are irrelevant;
the physician aims for some goal independent of the patient, such as the good
of society or furtherance of scientific knowledge. The Tuskegee syphilis experiment5-17
and the Willowbrook hepatitis study180 are examples of this model. As the moral
condemnation of these cases reveals, this model is not an ideal but an aberration.
Thus we have not elaborated it herein.
A CLINICAL CASE
To make tangible these abstract descriptions and to crystallize essential differences
among the models, we will illustrate the responses they suggest in a clinical
situation, that of a 43-year-old premenopausal woman who has recently discovered
a breast mass. Surgery reveals a 3.5-cm ductal carcinoma with no lymph node
involvement that is estrogen receptor positive. Chest roentgenogram, bone scan,
and liver function tests reveal no evidence of metastatic disease. The patient
was recently divorced and has gone back to work as a legal aide to support herself.
What should the physician say to this patient?
In the paternalistic model a physician might say, "There are two alternative
therapies to protect against recurrence of cancer in your breast: mastectomy
or radiation. We now know that the survival with lumpectomy combined with radiation
therapy is equal to that with mastectomy. Because lumpectomy and radiation offers
the best
survival and the best cosmetic result, it is to be preferred. I have asked the
radiation therapist to come and discuss radiation treatment with you. We also
need to protect you against the spread of the cancer to other parts of your
body. Even though the chance of recurrence is low, you are young, and we should
not leave any therapeutic possibilities untried. Recent studies involving chemotherapy
suggest improvements in survival without recurrence of breast cancer. Indeed,
the National Cancer Institute recommends chemotherapy for women with your type
of breast cancer. Chemotherapy has side effects. Nevertheless, a few months
of hardship now are worth the potential added years of life without cancer."
In the informative model a physician might say, "With node-negative breast cancer
there are two issues before you: local control and systemic control. For local
control, the options are mastectomy or lumpectomy with or without radiation.
From many studies we know that mastectomy and lumpectomy with radiation result
in identical overall survival, about 80% 10-year survival. Lumpectomy without
radiation results in a 30% to 40% chance of tumor recurrence in the breast.
The second issue relates to ,systemic control. We know that chemotherapy prolongs
survival for premenopausal women who have axillary nodes involved with tumor.
The role for women with node-negative breast cancer is less clear. Individual
studies suggest that chemotherapy is of no benefit in terms of improving overall
survival, but a comprehensive review of all studies suggests that there is a
survival benefit. Several years ago, the NCI suggested that for women like yourself,
chemotherapy can have a positive therapeutic impact. Finally, let me inform
you that there are clinical trials, for which you are eligible, to evaluate
the benefits of chemotherapy for patients with node-negative breast cancer.
I can enroll you in a study if you want. I will be happy to give you any further
information you feet you need."
The interpretive physician might outline much of the same information as the
informative physician, then engage in discussion to elucidate the patient's
wishes, -and conclude, "It sounds to me as if you have conflicting wishes. Understandably,
you seem uncertain how to balance the demands required for receiving additional
treatment, rejuvenating your personal affairs, and maintaining your psychological
equilibrium. Let me try to express a perspective that fits your position. Fighting
your cancer is important, but it must leave you with a healthy self-image and
quality time outside the hospital. This view seems compatible with undergoing
radiation therapy but not chemotherapy. A lumpectomy with radiation maximizes
your chance of surviving while preserving your breast. Radiotherapy fights your
breast cancer without disfigurement. Conversely, chemotherapy would prolong
the duration of therapy by many months. Further, the benefits of chemotherapy
in terms of survival are smaller and more controversial. Given the recent changes
in your life, you have too many new preoccupations to undergo months of chemotherapy
for a questionable benefit. Do I understand you? We can talk again in a few
days."
The deliberative physician might begin by outlining the same factual information,
engage in a conversation to elucidate the patient's values, but continue, "It
seems clear that you should undergo radiation therapy. It offers maximal survival
with minimal risk, disfigurement, and disruption of your life. The issue of
chemotherapy is different, fraught with conflicting data. Balancing all the
options, I think the best one for you is to enter a trial that is investigating
the potential benefit of chemotherapy for women with node-negative breast cancer.
First, it ensures that you receive excellent medical care. At this point, we
do not know which therapy maximizes survival. In a clinical study the schedule
of follow-up visits, tests, and decisions is specified by leading breast cancer
experts to ensure that all the women receive care that is the best available
anywhere. A second reason to participate in a trial is altruistic; it allows
you to contribute something to women with breast cancer in the future
who will face difficult choices. Over decades, thousands of women have participated
in studies that inform our current treatment practices. Without those women,
and the knowledge they made possible, we would probably still be giving you
and all other women with breast cancer mastectomies. By enrolling in a trial
you participate in a tradition in which women of one generation receive the
highest standard of care available but also enhance the care of women in future
generations because medicine has learned something about which interventions
are better. I must tell you that I am not involved in the study; if you elect
to enroll in this trial, you will initially see another breast cancer expert
to plan your therapy. I have sought to explain our current knowledge and offer
my recommendation so you can make the best possible decision."
Lacking the normal interchange with patients, these statements may seem contrived,
even caricatures. Nevertheless, they highlight the essence of each model and
suggest how the objectives and assumptions of each inform a physician's approach
to his or her patients. Similar statements can be imagined for other clinical
situations such as an obstetrician discussing prenatal testing or a cardiologist
discussing cholesterol reducing interventions.
THE CURRENT DEBATE AND THE FOUR MODELS
In recent decades there has been a call for greater patient autonomy or, as
some have called it, "patient sovereignty,"2' conceived as patient choice and
control over medical decisions. This shift toward the informative model is embodied
in the adoption of business terms for medicine, as when physicians are described
as health care providers and patients as consumers. It can also be found in
the propagation of patient rights statements, 21 in the promotion of living
will laws, and in rules regarding human experimentation. For instance, the opening
sentences of one law state: "The Rights of the Terminally III Act authorizes
an adult person to control decisions regarding administration of life-sustaining
treatment.... The Act merely provides one way by which a terminally-ill patient's
desires regarding the use of life, sustaining procedures can be legally implemented"
(emphasis added).22 Indeed, living will laws do not require or encourage patients
to discuss the issue of terminating care with their physicians before signing
such documents. Similarly, decisions in "right-to die" cases emphasize patient
control over medical decisions. As one court put it":
The right to refuse medical treatment is basic and fundamental.... Its exercise
requires no one's approval.... [The controlling decision belongs to a competent
informed patient.... It is not a medical decision for her physicians to make....
It is a moral and philosophical decision that, being a competent adult, is [the
patients] alone. (emphasis added)
Probably the most forceful endorsement of the informative model as the ideal
inheres in informed consent standards. Prior to the 1970s, the standard for
informed consent was "physician based."14-26 Since 1972 and the Canterbury case,
however, the emphasis has been on a "patient oriented" standard of informed
consent in which the physician has a "duty" to provide appropriate medical facts
to empower the patient to use his or her values to determine what interventions
should be implemented.2'-27
True consent to what happens to one's self is the informed exercise of a choice,
and that entails an opportunity to evaluate knowledgeably the options available
and the risks attendant upon each.... [11t is the prerogative of the patient,
not the physician, to determine for himself the direction in which his interests
seem to lie. To enable the patient to chart his course understandably, some
familiarity with the therapeutic alternatives and their hazards becomes essential.27
(emphasis added)
SHARED DECISION MAKING
Despite its dominance, many have found the informative model "arid.1120 The
President's Commission and others contend that the ideal relationship does not
vest moral authority and medical decision-making power exclusively in the patient
but must be a process of shared decision making constructed around "mutual participation
and respect."20," The President's Commission argues that the physician's role
is "to help the patient understand the medical situation and available courses
of action, and the patient conveys his or her concerns and wishes."' O Brock
and Wartman29 stress this fact-value "division of labor"-having the physician
provide information while the patient makes value decisions-by describing "shared
decision making" as a collaborative process
in which both physicians and patients make active and essential contributions.
Physicians bring their medical training, knowledge, and expertise including
an understanding of the available treatment alternatives-to the diagnosis and
management of patients' condition. Patients bring knowledge of their own subjective
aims and values, through which risks and benefits of various treatment options
can be evaluated. With this approach, selecting the best treatment for a particular
patient requires the contribution of both parties.
Similarly, in discussing ideal medical decision making, Eddylo argues for this
fact-value division of labor between the physician and patient as the ideal:
It is important to separate the decision process into these two steps....
The first step is a question of facts, The anchor is empirical evidence....
[T]he second step is a question not of facts but of personal values or preferences.
The thought process is not analytic but personal and subjective.... [I]t is
the patient's preferences that should determine the decision.... Ideally, you
and I [the physicians] are not in the picture. What matters is what Mrs. Smith
thinks.
This view of shared decision making seems to vest the medical decision-making
authority with the patient while relegating physicians to technicians "transmitting
medical information and using their technical skills as the patient di rests."
Thus, while the advocates of "shared decision making" may aspire toward a mutual
dialogue between physician and patient, the substantive view informing their
ideal re-embodies the informative model under a different label.
Other commentators have articulated more mutual models of the physician-patient
interaction.5,1,25 Prominent among these efforts is Katz'31 The Silent World
of the Doctor and Patient. Relying on a Freudian view in which self- knowledge
and self-determination are inherently limited because of unconscious influences,
Katz views dialogue as a mechanism for greater self-understanding of one's values
and objectives. According to Katz, this view places a duty on physicians and
patients to reflect and communicate so that patients can gain a greater self-understanding
and self determination. Katz' insight is also available on grounds other than
Freudian psychological theory and is consistent with the interpretive modet.13
OBJECTIONS TO THE PATERNALISTIC MODEL
It is widely recognized that the paternalistic model is justified during emergencies
when the time taken to obtain informed consent might irreversibly harm the patient.
1,2,20 Beyond such limited circumstances, however, it is no longer tenable to
assume that the physician and patient espouse similar values and views of what
constitutes a benefit. Consequently, even physicians rarely advocate the paternalistic
model as an ideal for routine physician-patient interactions.32
OBJECTIONS TO THE INFORMATIVE MODEL
The informative model seems both descriptively and prescriptively inaccurate.
First, this model seems to have no place for essential qualities of the ideal
physician-patient relationship. The informative physician cares for the patient
in the sense of competently implementing the patient's selected interventions.
However, the informative physician lacks a caring approach that requires understanding
what the patient values or should value and how his or her illness impinges
on these values. Patients seem to expect their physician to have a caring approach;
they deem a technically proficient but detached physician as deficient, and
properly condemned. Further, the informative physician is proscribed from giving
a recommendation for fear of imposing his or her will on the patient and thereby
competing for the decision making control that has been given to the patient.'5
Yet, if one of the essential qualities of the ideal physician is the ability
to assimilate medical facts, prior experience of similar situations, and intimate
knowledge of the patient's view into a recommendation designed for the patient's
specific medical and personal condition,3-5,25 then the informative physician
cannot be ideal.
Second, in the informative model the ideal physician is a highly trained subspecialist
who provides detailed factual information and competently implements the patient's
preferred medical intervention. Hence, the informative model perpetuates and
accentuates the trend toward specialization and impersonalization within the
medical profession.
Most importantly, the informative model's conception of patient autonomy seems
philosophically untenable. The informative model presupposes that persons possess
known and fixed values, but this is inaccurate. People are often uncertain about
what they actually want. Further, unlike animals, people have what philosophers
call "second order desires , that is, the capacity to reflect on their wishes
and to revise their own desires and preferences. In fact, freedom of the will
and autonomy inhere in having "second order desires" and being able to change
our preferences and modify our identity. Self-reflection and the capacity to
change what we want often require a "process" of moral deliberation in which
we assess the value of what we want. And this is a process that occurs with
other people who know us well and can articulate a vision of who we ought to
be that we can assent to. 13 Even though changes in health-or implementation
of alternative interventions can have profound effects on what we desire and
how we realize our desires, self-reflection and deliberation play no essential
role in the informative physician-patient interaction. The informative model's
conception of autonomy is incompatible with a vision of autonomy that incorporates
second-order desires.
OBJECTIONS TO THE INTERPRETIVE MODEL
The interpretive model rectifies this deficiency by recognizing that persons
have second-order desires and dynamic value structures and placing the elucidation
of values in the context of the patient's medical condition at the center of
the physician-patient interaction. Nevertheless, there are objections to the
interpretive model.
Technical specialization militates against physicians cultivating the skills
necessary to the interpretive model. With limited interpretive talents and limited
time, physicians may unwittingly impose their own values under the guise of
articulating the patient's values. And patients, overwhelmed by their medical
condition and uncertain of their own views, may too easily accept this imposition.
Such circumstances may push the interpretive model toward the paternalistic
model in actual practice.
Further, autonomy viewed as self-understanding excludes evaluative judgment
of the patient's values or attempts to persuade the patient to adopt other values.
This constrains the guidance and recommendations the physician can offer. Yet
in practice, especially in preventive medicine and risk-reduction interventions,
physicians often attempt to persuade patients to adopt particular health-related
values. Physicians frequently urge patients with high cholesterol levels who
smoke to change their dietary habits, quit smoking, and begin exercise programs
before initiating drug therapy. The justification given for these changes is
that patients should value their health more than they do. Similarly, physicians
are encouraged to persuade their human immunodeficiency virus (HIV)-infected
patients who might be engaging in unsafe sexual practices either to abstain
or, realistically, to adopt "safer sex" practices. Such appeals are not made
to promote the HIV-infected patient's own health, but are grounded on an appeal
for the patient to assume responsibility for the good of others. Consequently,
by excluding evaluative judgments, the interpretive model seems to characterize
inaccurately ideal physician-patient interactions.
OBJECTIONS TO THE DELIBERATIVE MODEL
The fundamental obiections to the deliberative model focus on whether it is
proper for physicians to judge patients' values and promote particular health-related
values. First, physicians do not possess privileged knowledge of the priority
of health-related values relative to other values. Indeed, since ours is a pluralistic
society in which people espouse incommensurable values, it is likely that a
physician's values and view of which values are higher will conflict with those
of other physicians and those of his or her patients.
Second, the nature of the moral deliberation between physician and patient,
the physician's recommended interventions, and the actual treatments used will
depend on the values of the particular physician treating the patient. However,
recommendations and care provided to patients should not depend on the physician's
judgment of the worthiness of the patient's values or on the physician's particular
values. As one bioethicist put it:
The hand is broken; the physician can repair the hand; therefore the physician
must repair the hand-as well as possible-without regard to personal values that
might lead the physician to think ill of the patient or of the patient's values....
[Alt the level of clinical practice, medicine should be value-free in the sense
that the personal values of the physician should not distort the making of medical
decisions.
Third, it may be argued
that the deliberative model misconstrues the purpose of the physician patient
interaction. Patients see their physicians to receive health care, not to engage
in moral deliberation or to revise their values. Finally, like the interpretive
model, the deliberative model may easily metamorphose into unintended paternalism,
the very practice that generated the public debate over the proper physician-patient
interaction.
THE PREFERRED MODEL AND THE PRACTICAL IMPLICATIONS
Clearly, under different clinical circumstances different models may be appropriate.
Indeed, at different times all four models may justifiably guide physicians
and patients. Nevertheless, it is important to specify one model as the shared,
paradigmatic reference; exceptions to use other models would not be automatically
condemned, but would require justification based on the circumstances of a particular
situation. Thus, it is widely agreed that in an emergency where delays in treatment
to obtain informed consent might irreversibly harm the patient, the paternalistic
model correctly guides physician-patient interactions. Conversely, for patients
who have clear but conflicting values, the interpretive model is probably justified.
For instance, a 65-year-old woman who has been treated for acute leukemia may
have clearly decided against reinduction chemotherapy if she relapses. Several
months before the anticipated birth of her first grandchild, the patient relapses.
The patient becomes torn about whether to endure the risks of reinduction chemotherapy
in order to live to see her first grandchild or whether to refuse therapy, resigning
herself to not seeing her grandchild. In such cases, the physician may justifiably
adopt the interpretive approach. In other circumstances, where there is only
a one- time physician-patient interaction without an ongoing relationship in
which the patient's values can be elucidated and compared with ideals, such
as in a walk-in center, the informative model may be justified.
Descriptively and prescriptively, we claim that the ideal physician-patient
relationship is the deliberative model. We will adduce six points to justify
this claim. First, the deliberative model more nearly embodies our ideal of
autonomy. It is an oversimplification and distortion of the Western tradition
to view respecting autonomy as simply permitting a person to select, unrestricted
by coercion, ignorance, physical interference, and the like, his or her preferred
course of action from a comprehensive list of available options.14,15 Freedom
and control over medical decisions alone do not constitute patient autonomy.
Autonomy requires that individuals critically assess their own values and preferences;
determine whether they are desirable; affirm, upon reflection, these values
as ones that should justify their actions; and then be free to initiate action
to realize the values. The process of deliberation integral to the deliberative
model is essential for realizing patient autonomy understood in this way.
Second, our society's image of an ideal physician is not limited to one who
knows and communicates to the patient relevant factual information and competently
implements medical interventions. The ideal physician-often embodied in literature,
art, and popular culture-is a caring physician who integrates the information
and relevant values to make a recommendation and, through discussion, attempts
to persuade the patient to accept this recommendation as the intervention that
best promotes his or her overall well-being. Thus, we expect the best physicians
to engage their patients in evaluative discussions of health issues and related
values. The physician's discussion does not invoke values that are unrelated
or tangentially related to the patient's illness and potential therapies. Importantly,
these efforts are not restricted to situations in which patients might make
"irrational and harmful" choices'9 but extend to all health care decisions.
Third, the deliberative model is not a disguised form of paternalism. Previously
there may have been category mistakes in which instances of the deliberative
model have been erroneously identified as physician paternalism. And no doubt,
in practice, the deliberative physician may occasionally lapse into paternalism.
However, like the ideal teacher, the deliberative physician attempts to persuade
the patient of the worthiness of certain values, not to impose those values
paternalistically; the physician's aim is not to subject the patient to his
or her will, but to persuade the patient of a course of action as desirable.
In the Laws, Plato37 characterizes this fundamental distinction between persuasion
and imposition for medical practice that distinguishes the deliberative from
the paternalistic model:
A physician to slaves never gives his patient any account of his illness
... the physician offers some orders gleaned from experience with an air of
infallible knowledge, in the brusque fashion of a dictator... The free physician,
who usually cares for free men, treats their diseases first by thoroughly discussing
with the patient and his friends his ailment. This way he learns something from
the sufferer and simultaneously instructs him. Then the physician does not give
his medications until he has persuaded the patient; the physician aims at complete
restoration of health by persuading the patient to comply with his therapy.
Fourth, physician values are relevant to patients and do inform their choice
of a physician. When a pregnant woman chooses an obstetrician who does not routinely
perform a battery of prenatal tests or, alternatively, one who strongly favors
them; when a patient seeks an aggressive cardiologist who favors procedural
interventions or one who concentrates therapy on dietary changes, stress reduction,
and life-style modifications, they are, consciously or not, selecting a physician
based on the values that guide his or her medical decisions. And, when disagreements
between physicians and patients arise, there are discussions over which values
are more important and should be realized in medical care. Occasionally, when
such disagreements undermine the physician-patient relationship and a caring
attitude, a patient's care is transferred to another physician. Indeed, in the
informative model the grounds for transferring care to a new physician is either
the physician's ignorance or incompetence. But patients seem to switch physicians
because they do not "like" a particular physician or that physician's attitude
or approach.
Fifth, we seem to believe that physicians should not only help fit therapies
to the patients' elucidated values, but should also promote health-related values.
As noted, we expect physicians to promote certain values, such as "safer sex"
for patients with HIV or abstaining from or limiting alcohol use. Similarly,
patients are willing to adjust their values and actions to be more compatible
with health-promoting values.38 This is in the nature of seeking a caring medical
recommendation.
Finally, it may well be that many physicians currently lack the training and
capacity to articulate the values underlying their recommendations and persuade
patients that these values are worthy. But, in part, this deficiency is a consequence
of the tendencies toward specialization and the avoidance of discussions of
values by physicians that are perpetuated and justified by the dominant informative
model. Therefore,4 the deliberative model seems most appropriate, then we need
to implement changes in medical care and education to encourage a more caring
approach. We must stress understanding rather than mere provisions of factual
information in keeping with the legal standards of informed consent and medical
malpractice; we must educate physicians not just to spend more time in physician-patient
communication but to elucidate and articulate the values underlying their medical
care decisions, including routine ones; we must shift the publicly assumed conception
of patient autonomy that shapes both the physician's and the patient's expectations
from patient control to moral development. Most important, we must recognize
that developing a deliberative physician- patient relationship requires a considerable
amount of time. We must develop a health care financing system that property
reimburses-rather than penalizes -physicians for taking the time to discuss
values with their patients.
CONCLUSION
Over the last few decades, the discourse regarding the physician-patient relationship
has focused on two extremes: autonomy and paternalism. Many have attacked physicians
as paternalistic, urging the empowerment of patients to control their own care.
This view, the informative model, has become dominant in bioethics and legal
standards. This model embodies a defective conception of patient autonomy, and
it reduces the physician's role to that of a technologist. The essence of doctoring
is a fabric of knowledge' understanding, teaching, and action, in which the
caring physician integrates the patient's medical condition and health-related
values, makes a recommendation on the appropriate course of action, and tries
to persuade the patient of the worthiness of this approach and the values it
realizes. The physician with a caring attitude is the ideal embodied in the
deliberative model, the ideal that should inform laws and policies that regulate
the physician-patient interaction.
Finally, it may be worth noting that the four models outlined herein are not
limited to the medical realm; they may inform the public conception of other
professional interactions as well. We suggest that the ideal relationships between
lawyer and client,14 religious mentor and laity, and educator and student are
well described by the deliberative model, at least in some of their essential
aspects.
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From JAMA, 267:2221-2226-1992