The Relationship between Patients and Health Care Providers


      Nature of relationship

      Variability between different professions

      Power differential

      Obligations (usually providers’)

      Rights (usually patients’)

      "Providers" usually = "Physicians"


Emanuel and Emanuel

      Classic paper (though fairly recent)

      Compares/contrasts 4 models with respect to:

   goals of relationship

   physician’s obligations

   role of patient’s values

   conception of patient autonomy


      Note that E&E view the problem that arises in the physician/patient relationship as a conflict between:

  autonomy and health

  patient’s values and physician’s values


Paternalistic Model

      a.k.a. parental/priestly model

      The physician uses his (her?) skill to diagnose patient’s condition and determine appropriate treatment

      Then presents patient with (selected) information to encourage consent

      May simply inform patient of the course to treatment to be taken


      Assumes shared and objective criteria for determining what is best

      Favours health over choice

      Physician is obliged to promote patient’s well being & to seek views of other professionals when necessary

      Autonomy is viewed as patient assent


Informative Model

      Scientific/engineering/consumer model

      Physician provides patient with all relevant information and patient chooses

      physician as "purveyor of technical expertise"

      Obligations of physician: to provide information, maintain professional competence, seek consultation when necessary

      Assumes a clear distinction between facts and values: the physician presents the facts and the patient makes a decision based on these facts plus her values


Interpretive Model

      Physician helps patient to elucidate his/her values and to make a decision based on these values

      Physician provides information and also helps patient to interpret his/her values: presupposes that the patient’s values are not necessarily fixed or known

      The ultimate decision is with the patient, the physician does not impose his/her values (counselor)


      Physician’s obligations include those given in the informative model, but also require her to promote patient’s self understanding

      Autonomy --> self-understanding


Deliberative Model

      Physician helps patient to deliberate and to choose the best (health-related) values

      Interpretive model: patient’s values only. Here the physician’s values are also important

      Persuasion, not coercion: the patient has the final decision

      Physician as teacher/friend

      Autonomy as moral self development relevant to medical care


A fifth model?

      Instrumental model:

      Physician uses patient in order to fulfill her own goals: increased knowledge, social benefit

      Patient’s values are immaterial

      "an aberration" --> rejected!


Applying the 4 models: a case

      43 year-old premenopausal woman

      breast mass found: turns out to be cancerous, no nodal involvement, no metastases

      patient has recently undergone great life changes: divorce, return to work


The 4 models and contemporary debates

             How do the models fit with “real world” issues?

             Contemporary debates:


             Shared decision-making





      All four models have a role for autonomy

      Increased autonomy generally viewed in terms of choice and control

      Adoption of business model (patients as consumers or clients; physicians as providers)


Informed consent

      Paternalistic model: acceptable for physicians to give only the information that would get patients to agree to a course of action (“physician-based” standard of consent)

      More recent views à “patient-oriented” standard of consent

    Physician has obligation to provide all relevant information & patient comes to a decision (informative model)


Shared decision-making (SDM)

      Process of shared decision-making constructed around “mutual participation and consent”

      Two types of account of SDM


SDM 1 (e.g. Eddy)

      “2 experts”

   Physician is “fact expert”

   Patient is “values expert”

      Dialogue about facts and values, but ultimate decision is the patient’s

   Informative model


SDM 2 (e.g. Katz)

      Dialogue between physician and patient leads patient to a better understanding of his/her values and objectives

      Involves reflection and communication by both physician and patient to promote the patient’s self-understanding and self-determination

   Interpretive model


Problems: paternalistic model

      Concept of autonomy in this model does not involve (much) patient choice

      Cannot assume that physicians and patients have similar values

      E&E: this model is acceptable only in emergency situations


Problems: informative model

      Physician’s "care" is limited to technical care: we also want physicians to care in a more human sense, to care about the patient as a person (who suffers)

      Perpetuates current trend towards specialization

      Conception of autonomy is too individualistic


Problems: interpretive model

      Conflict with technical, specialized medicine - Time pressures, patient uncertainty risk slide into paternalism

      Conception of autonomy leaves no room for patient deliberation, self-evaluate or for physician as health advocate

   Self-reflection, but no change or self-development


Problems: deliberative model

      Focus on health-related values, but difficult to balance these with other values (about which physician has no expertise)

      Possibility for too much influence of physician’s own values

      Misconstrues nature of physician-patient relationship: health care, not moral deliberation

      Again, slide into paternalism (possibility of imposing values)


Which model is best?

      The one that can be a paradigm for all physician-patient interactions

      …but still leaves room for exceptions in which other models may be better

      E&E recommend the deliberative model as being best

      descriptively: accurately portrays the relationship

      Prescriptively/normative: best lays out what this relationship should be


Six points in favour of the deliberative model

      Best accounts for our ideal of autonomy

   Autonomy involves second-order desires and values

      Also incorporates our belief that a physician should be caring

      Not a disguised form of paternalism: persuasion rather than coercion

      Patients do find physician values relevant


      A physician should promote health-related values

    E.g. lifestyle counseling, public health, screening

      Contains recommendations for improvement

    in health care

    in physician training

    in relevant social and political factors

    Resource allocation

NOTE: current dominant model is informative model



Storch: Nurses and Clients

      Metaphors used to describe this relationship matter

      "…a figure of speech in which one thing is compared to another thing by being spoken of as if it were the other"

   love is a rose

   time is money (Lakoff and Johnson)


Why do metaphors matter?

      Highlight significant aspects of a relationship and help us to understand it by providing concrete ways of thinking about it

      May also extend our understanding

      Can also limit our understanding (focusing attention on some aspects at the expense of others)


Why do they matter for nurse/client relationships?


      Shape the moral dimensions of the relationship

      Critical reflection is therefore essential


Models and metaphors


      Table 5.1: proposals for metaphors

      Models versus metaphors

   Metaphors and analogies


Historical images

      Importance of war

      Development of profession

      Hierarchy/military model

      Extension to fighting diseases, social ills


Three classes of metaphor

      Limiting metaphors: do a good job of capturing some aspects but not others, so limit our view

      Misguided metaphors

      Helpful metaphors


Limiting metaphors

      Nurse as parent/mother surrogate

      Nurse as friend

      Nurse as servant


      All have both positive and negative implications for understanding the nurse/client relationship


Misguided metaphors


      Nurse as technician/engineer

      Physician extender or surrogate


      Focus attention on wrong aspects of relationship, or get relationship wrong


Helpful metaphors




      Client advocate



     "The metaphors of nurse in a covenental relationship, nurse as healer, and nurse as advocate, approach more closely than the previous metaphors the morally significant aspects of the nurse-client relationship“


   provide insight into nature of relationship



      What are the similarities and differences between E&E’s preferred model of the physician-patient relationship and Storch’s preferred metaphors for the nurse-client relationship?


Another important set of metaphors

      How do we understand the role of the patient?