The Relationship between Patients and Health Care Providers

Issues

• 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:

• Autonomy

• Shared decision-making

• Eddy

• Katz

Autonomy

• 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

• Covenant

• Healer

• 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?

– Patient

– Client

– Consumer