For quite a long time doctors have the freedom to interfere and dominate the patient’s desires with the sole objective of avoiding harm to the patient . The emphasis in today’s medical practice is individual independence and control and medical paternalism no longer enjoys the indubitable acceptance by the society as the dominant approach to decision making in medicine. But neither is a decision-making approach that is based on absolute patient autonomy a satisfactory one. A more ethical and tested approach is to facilitate a patient’s autonomy by advocating a medical beneficence that includes patients’ ideas and perspectives .
This can be accomplished via a model for shared decision making recognizing the fact that the final decision lies ultimately with the patients and that it is only through the doctor’s beneficence that the patient can be empowered to make meaningful and sensible decision that work best for them. For such a model to be efficacious, the return of trust to the doctor patient relationship and patient doctor communication are both important. Introduction The benefit of the patient has been a major preoccupation of the medical profession for a long time.
The Hippocratic oat stipulated that the physicians will do their best not to injure the patient and also to restore the patient to their healthy state. Generations of physicians have sworn to this oat. The perspective of the patients about physician is that of guidance with professional skills, knowledge and training to benefit the patient including making unilateral decision about what constitute benefit to the patient. The situation is therefore comparable to that of a caring father and a child and hence the use of the term paternalism. Medical beneficence stood for a long time as the operation mode for doctor patient relationship.
Such relationship work well as it represents the essential role of medicine in the society. Since the beginning of few centuries ago, there has been a shift to the individual away from political and religious authorities. Similar changes are experienced in medicine as orchestrated by difference in the tone of the ethical codes of America medical association (AMA) in the last two centuries. Considering the article II of the 1847AMA ethical code entitled “Obligations of the Patients to their Physicians”, Section 6 stated that “The obedience of a patient to the prescriptions of his physician should be prompt and implicit.
He should never permit his own crude opinions as to their fitness, to influence his attention to them. A failure in one particular may render an otherwise judicious treatment dangerous, and even fatal. ”On the contrary AMA’s opinion in 1990 on “Fundamental Elements of the Patient-Physician Relationship” now states a completely different position:“The patient has the right to make decisions regarding the health care that is recommended by his or her physician. Accordingly, patients may accept or refuse any recommended medical treatment.
” in today’s practice, the principle of autonomy of the patient and self determination has emerged as the dominant ethos In health care, threatening in many instances to totally eclipse the principle of medical beneficence. The simple pendulum has taken such a drastic tilt that, with the exception perhaps of soft feeble paternalism with respect to non-autonomous patients, paternalism is almost always seen in negative light, regardless of its intention and outcome. But medicine is, after all, a human activity aimed at healing and restoration of health.
The question now is that can medicine therefore continue to serve the patient if cleansed totally of a paternal motivation? In an essay written by Tan , validity of medical paternalism was rejected and he debated violently on its deconstruction. By giving a passionate support for a patient autonomy against “excessive expression of beneficience”, many of Tan’s views are nonetheless less than persuasive as it can be invalidated. For instance he gave a real life example of a physician who was said to be unwell singularly on the ground of noncompliance.
This is a rare scenario . Also it is hasty to have declared such patient as incompetent and hence the disqualification from making decisions as there was no legal process which include any preexisting psychopathology and a complete assessment of the cognitive functions which are mandatory to determine the incompetence or otherwise of a patient. Another example would be Tan’s accusation that the move by Singapore’s Health Ministry to regulate the practice of the traditional Chinese Medicine (TCM) was a “laughable” one .
He seems to have omitted the fact that irrespective of the review methodology used, any system of medicine that is seeking acceptance and official acknowledgment in society should be able to make provision for appropriate level of assurance to the public in terms of how safe its practices are and also the minimal standards of its practitioners. Such thoughts are not what Tan describes as“Western medical criteria”, but are instead very basic representative standards demanded by regulatory leaderships to ensure public safety.
The choice of Society over which system of medicine it adopts as its mainstream, be it allo- or homeopathic (complementary disease treatment system), empirical or experimental, is hardly a result of paternalism in Western medicine. But Tan however is right in suggesting that there is a need for the ‘western-trained’ doctor to utilise an open mind to alternative schools of medicine. This can only extend as far as a sincere admission of ignorance and a commitment to critically examine any available evidence.
Modesty cannot and should not equate unfounded ratification of and recommendation of therapies for which a doctor is void of understanding or conviction. For that group who vehemently oppose beneficence as the reason and justification to overrule patients’ choices, a model advocating supremacy of individual freedom and autonomy is advocated. In this approach, which some people call the informative model. Physician’s role is relegated to that of a technician who provides patient with information and leaves the patient to decide. The model is assumptuous. It assumes the physician role in patient doctor encounter to be passive.
It is sadly simplistic view of the profession’s essential roles, duties and responsibilities (Adelaja, 2003) Admittedly although sadly, some doctors are found guilty of promoting this impression and therefore neglecting the essential humanistic aspect of the practice. Furthermore, physicians who are dreadful of the consequences of not respecting and recognizing the autonomy of the patient have been known to adopt such a model. This can eventually lead to a total neglect and dereliction of their professional responsibilities, with a possible danger of administering therapies that are not medically indicated or relevant.
By trying to honor autonomy and freedom, physicians merely offer possible options with no professional contribution in addition, and so this informative model is unlikely to serve patient’s interest. In this kind of system, even non-coercive trial to discuss with patients the advantages and disadvantages of their decisions can be considered a total violation of their rights or freedom when in fact, such efforts sincerely reflect appropriate care and emotional concern for the patient’s well-being.
“This model of clinical encounter is therefore unsatisfactory as it can lead to a form of moral and professional neglect by the physician” (Pellegrino, 1976,pg37). Another thing is that the model assumes all competent individual being capable of management of their daily affairs and events based on their beliefs and experiences which also include decision making capacity about their health. Tan in 1978 cited that illness does not have effect on the cognition and the emotion and that patient can therefore make decision about the treatment they receive.
We now know that sickness does not affect or lower the rights and morals of a patient(olumuyiwa,2003). However the ability to make informed decision is affected by the biopsychosocial effect of the illness(Engel,1989). To confirm a person as incompetent there must be demonstrable psychopathology and mental incapacity. Steven wears noted in his works about informed choice in health care that if only for freedom and control ,without thinking well on their own choice, it will be hazardous for patients to exercise autonomy rights and therefore overrule the choice of the doctor.
Freedom without moral responsibility is counterproductive to the goals and objectives of medicine. A better service could be rendered to patients by minimizing paternalism without so much compromise on the freedom of the patient. Tim further acknowledged though famishly the model to deconstruct or critically analyze paternalism when he said that the exercise of autonomy “may fulfill patient’s expressed desire but not necessarily transform into serving the patient best ,if at all” .
In lim’s own view, hard paternalism is not prevalent in the medical practice of today and that most people are the so-called “grey cases” (dismal). He used the word “ guided paternalism” as a model to better serve the patient and the aim is to facilitate and enhance the autonomy of the patient. The approach recognizes patients as having the final say in decision making as they are responsible for whatever outcome of their decision . It however emphasizes the duties of the patient and the professionalism of the medical team.
The model is a deliberative one and sees the physician as the tutor who clarifies patient’s values and help in the processing of possible intervention. A model like this that takes professional guidance into consideration is relevant for the computer age that we live where patients are equipped with medical information gotten from the internet even though the information is raw and invalidated. The model is consistent with what Thomasma and Pellegrino put forward as “true benefit”.
It holds that the doctor’s assistance in patient’s decision making should cut across enhancing the patient’s capacity with respect to the reasoning ability of the patient. There is therefore congruence between autonomy and baneficience. In this deliberative otherwise known as the shared model, there is a need for mutual trust between doctor and the patient Hard or absolute paternalism is no longer popular because of the waning public trust and regard for medicine. The pluralistic society also sees paternalism as unethical and diabolic.
The shared model of patient doctor relationship also has a lot of advantages and the patients and doctors should therefore first be educated on the enormity of the problem. Doctor- patient relationship should be a form of partnership. Under the shared model, Patients need to be enlightened on the importance of a good doctor patient relationship. Time and finance has been a major drawback to shared decision making in health care system. Such problems need to be solved .
The communication gap between patients and doctors should be bridged to allow for patient participation in decision making pertaining their health. Patient should learn to be responsible for their healthcare and they should comply with treatment and should not withhold their trust even in the presence of obvious medical uncertainty. “There is no real need to make an absolute distinction between Paternalism and autonomy and to prefer one over the other” (Davehere, 2000). The drive behind paternalism is beneficence, seeking for the good of the patient.
Autonomy on the other hand is based on the fact that patient are responsible for whatever decision they make and should face the consequence. The best approach therefore is the one that mingles Autonomy with beneficence. By sharing the process of decision making, the precision and wealth of patient’s choice can be facilitated by doctor’s advice. The doctor is not patient’s messiah . Similarly; he is not just a mere technician with education. The doctor is indeed the friend of the patient. The doctor cares for the patient as they voyage towards comfort, cure, deliverance and relief.
References Code of Ethics. American Medical Association, 1847. Devettere RJ. Practical decision making in health care ethics: Cases and concepts. 2nd Edition. Washington DC: Georgetown University Press, 2000 Lim SL. Medical paternalism serves the patient best. S Med J 2002; 43(3):143-7 Olamuyiwa, O (2001, pg278). Introduction to Psychiatry, Oxford University Press. Pellegrino ED, Thomasma DC. The virtues in medical practice. New York: Oxford University Press, 1993 Tan NHSS. Deconstructing paternalism – what serves the patient best? S Med J 2002; 43(3):148-51