Medical Paternalism Research Articles

Educating Doctors About Breaking Bad News: An Iranian Perspective

The breaking of bad news is a frequent and well recognized task that is performed by a variety of health professionals including medical doctors. In this article, we explore both how this topic is dealt with in medical education in Iran and also consider how this aspect of the curriculum might be enriched in the future. This article is based on research, which was undertaken using a purposively selected sample of medical course planners in Iran. Semistructured interviews were conducted with each of 10 carefully selected participants. Their interview responses were analyzed in such a way as to provide an in-depth exploration and interpretation of both their perceptions and experiences in relation to this sensitive and highly important topic. Four major themes emerged from the analysis of the interview transcripts: medical paternalism, religion, training issues, and professional barriers. On the basis of this analysis, there appears to be an urgent need for integrating more emphasis on techniques for breaking bad news into the Iranian medical education curriculum. This curriculum could in the future place more emphasis on addressing specific religious issues, which are unique to the local culture. A number of other specific recommendations are formulated and discussed.

Autonomy, Consent, and Medical Paternalism: Legal Issues in Medical Intervention

Patients are increasingly questioning their relationships with their doctors during a time when use of alternative health care approaches is rising, paternalistic models of health care are waning, and police powers related to health care are expanding. Focusing on the topics of mandatory vaccination and forced medical treatment of children with cancer, this paper reviews issues related to autonomy, informed consent, medical paternalism, forced medical treatment, the police powers of the state, and related legal issues. Based upon this review, it becomes clear that the fight over personal autonomy and paternalism in health care is far from over.

Best Practices: A Program to Support Shared Decision Making in an Outpatient Psychiatric Medication Clinic

This column presents preliminary findings of an intervention to support shared decision making in psychopharmacology consultation. The waiting area in an urban psychiatric medication clinic was transformed into a peer-run Decision Support Center featuring a user-friendly, Internet-based software program with which clients could create a one-page computer-generated report for use in the medication consultation. The Decision Support Center was used 662 times by 189 unique users from a young-adult and general adult case management team from October 2006 to September 2007. All clients had severe mental disorders. Only ten clients refused to use the intervention at some point during the pilot study. Focus groups with medical staff (N=4), clients (N=16), case managers (N=14), and peer-specialist staff (N=3) reported that the intervention helped to create efficiencies in the consultation and empower clients to become more involved in treatment-related decision making. A randomized controlled trial is currently in process.

El papel de la epidemiología en la definición de políticas. Hacia la salud pública que se necesita. Informe SESPAS 2008

Epidemiology already plays a substantial role in the definition of public and corporate policies in Spain as well as in other developed countries. The World Health Organization reinforced the position of epidemiology by enshrining the notion of social health determinants and, as a result, the connection between health and social constructs has become more visible. However, the use of epidemiology is usually restricted to the development and evaluation of policies originating in health bureaucracies with health improvement as the only public objective; these are called direct health policies. This view is somewhat reductionistic insofar as health gains and losses occur mainly due to policies outside the health sector. To expand the role of epidemiology as a tool to shape policies, we need a view of exposures and effects beyond healthcare and the biological and behavioral risk factors proposed by medical paternalism. Also required are an attitude that is more participative than prescriptive and the development of more health impact assessments. In addition, the health effects of the decisions taken by politically-empowered institutions should be included in the epidemiologist's tool kit. In other words, a political epidemiology should be constructed. For this endeavor, which may be crucial to attain the public health required, public health practitioners should be more visible and credible, have greater independence from political power, provide information directly to the public and other stake holders (greater transparency), and further develop the professionalization of public health (greater competence) by working increasingly in networks of professionals rather than in bureaucratic pyramids.

Relational autonomy or undue pressure? Family’s role in medical decision‐making

The intertwining ideas of self-determination and well-being have received tremendous support in western bioethics. They have been used to reject medical paternalism and to justify patients' rights to give informed consent (or refusal) and execute advanced directives. It is frequently argued that everyone is thoroughly unique, and as patients are most knowledgeable of and invested in their own interests, they should be the ones to make voluntary decisions regarding their care. Two results of the strong focus on autonomy are the rejection of the image of patients as passive care recipients and the suspicion against paternalistic influence anyone may have on patients' decision-making process. Although the initial focus in western bioethics was on minimizing professional coercion, there has been a steady concern of family's involvement in adult patients' medical decision-making. Many worry that family members may have divergent values and priorities from those of the patients, such that their involvement could counter patients' autonomy. Those who are heavily involved in competent patients' decision-making are often met with suspicion. Patients who defer to their families are sometimes presumed to be acting out of undue pressure. This essay argues for a re-examination of the notions of autonomy and undue pressure in the contexts of patienthood and relational identity. In particular, it examines the characteristics of families and their role in adult patients' decision-making. Building on the feminist conception of the relational self and examining the context of contemporary institutional medicine, this paper argues that family involvement and consideration of family interests can be integral in promoting patients' overall agency. It argues that, in the absence of abuse and neglect, respect for autonomy and agency requires clinicians to abide by patients' expressed wishes.

Case one: Patient interests and medical paternalism.

A 16-year-old Hodgkin lymphoma patient refuses to have his blood specimen drawn, thus canceling his scheduled oncologic treatment. As a 16-year-old, he has no legal standing as an adult. His parents are split over his decision. One supports his right to choose; the other wishes the specimen to be drawn and the chemotherapy reinstated. The physicians at the hospital are seeking legal redress to have the court order the blood specimens to be taken.

The doctor′s dilemma: Truth telling

Byline: G. Swaminath Truth, Whole Truth, And Nothing But That ? Even as we glory in being in the age of right to information, I am occasionally reminded of a story I read during my school days, The doctor's word by Narayan.[sup] [1] It narrates the dilemma of a doctor who diagnoses his friend, who totally trusts him, to be critically ill. doctor realizes that his friend has a good chance of recovery if he does not deteriorate over the night. ethical dilemma relates to whether the doctor should inform the patient of his criticality and lessen hope or deliberately mislead him, and improve chances of survival by instilling hope. patient has expressed his desire to write a will, should his survival be improbable. Thanks to the decision taken by the doctor to deceive, the patient finds hope and survives. doctor fulfils his Hippocratic Oath, reducing patient harm by not revealing upsetting conditions. Trust is belief that someone is honest and will not cause harm, and it is with this conviction that patients confide in doctors and seek advice.[sup] [2] A treatment is more likely to work (placebo effect) if there is faith in the doctor and the prescribed medication, hence is important for the patient's wellbeing. In the long running MORI annual poll,[sup] [3] the British public have voted for doctors as the most trusted professionals, as well as being the most likely to tell the truth. Despite this there is consistent evidence that patients do not always follow doctors' advice, and do not tell doctors when they are not doing so.[sup] [2] This reflects a critical trust where is rarely given unconditionally allowing the lingering of at least faint skepticism. Generally, children are taught to tell the truth absolutely and to avoid lies. Doctors who condemn lying may sometimes misrepresent the patient's condition without actually telling a lie.[sup] [4] They may withhold information about the patient's condition or proposed interventions, or give partial information which is literally true, yet deceptive. This is more common with illness which has stigmatizing diagnosis or poor prognosis. Access to truth is a right (because respect demands it), a utility (to enable making of informed judgments) and a kindness (as lies poison relationships, resulting in withdrawal from constructive liaisons).[sup] [5] Truth could be sabotaged by different ways. For example, while advising a psychotic person about clozapine and its adverse effects, the doctor might take one of these positions with varying forms and degrees of untruthfulness: [sup] [4] *Claim no dangerous side effects (lying). *Emphasize the absence of extrapyramidal symptoms, talk about and suggest blood tests required but not clarify why, use technical jargon, omit important qualifying information, present statistics in a misleading way (deception). *Warn vaguely of agranulocytosis, suggest blood tests claiming it is simple and routine, downgrade probabilities of risk or gravity, not clarify if patient has understood or not (misrepresentation). *Offer no information on side effects till the patient explicitly asks (nondisclosure). withholding the truth by physicians is a form of medical paternalism and is adopted to protect the patient from physical/emotional harm. This paternalism assists generate an optimism which transcends the immediate crisis and promotes decision making. It seems that false optimism about recovery and the absence of side effects (in this case the drug) is the result of an association between doctors' activism and patients' adherence to the recovery plot.[sup] [6] This allows both to not acknowledge explicitly what they should know and can know,[sup] [6] and play out a show orchestrated by the doctor. …

Psychiatric paternalism between Scylla and Charybdis

As much as strong medical paternalism should never be exercised, some weak paternalism towards patients is, on the contrary, part of physicians' and society's moral obligation. So far, this is a widely consented position in medical ethics. What then are the defining and the justifying conditions for legitimate weak paternalism in psychiatry? In this presentation it is argued in favor of three necessary and jointly sufficient conditions for ethically acceptable/obligatory paternalism: (1) the patient must lack specific competency to evaluate his or her treatment options in a sufficiently autonomous way; (2) there must not be evidence that the patient had, in a former healthy state, been opposed to weak paternalism; (3) there must exist treatment options with a truly acceptable cost-benefit balance, that cannot be postponed until regain of competency, without harming the patient. Even if this seems a plausible normative frame, there remain difficulties in detail for both conceptual ethical theory and psychiatric practice. Among them are: assessing patient competency, avoiding undue control in patient preference formation, identifying third parties' interests, and evaluating treatment options. For psychiatry's self-understanding, societal image, and acceptance by patients and their families, it seems important to tackle these issues so as to get a coherent and transparent picture of the justification and limits of psychiatric paternalism.

Parental involvement in treatment decisions regarding their critically ill child: A comparative study of France and Quebec*

To examine whether physicians or parents assume responsibility for treatment decisions for critically ill children and how this relates to subsequent parental experience. A significant controversy has emerged regarding the role of parents, relative to physicians, in relation to treatment decisions for critically ill children. Anglo-American settings have adopted decision-making models where parents are regarded as responsible for such life-support decisions, while in France physicians are commonly considered the decision makers. Grounded theory qualitative methodology. Four pediatric intensive care units (two in France and two in Quebec, Canada). Thirty-one parents of critically ill children; nine physicians and 13 nurses who cared for their children. None. Semistructured interviews were conducted. In France, physicians were predominantly the decision makers for treatment decisions. In Quebec, decisional authority practices were more varied; parents were the most common decision maker, but sometimes it was physicians, while for some decisional responsibility depended on the type of decision to be made. French parents appeared more satisfied with their communication and relationship experiences than Quebec parents. French parents referred primarily to the importance of the quality of communication rather than decisional authority. There was no relationship between parents' actual responsibility for decisions and their subsequent guilt experience. It was remarkable that a certain degree of medical paternalism was unavoidable, regardless of the legal and ethical norms that were in place. This may not necessarily harm parents' moral experiences. Further research is required to examine parental decisional experience in other pediatric settings.

Maximizing the benefits and minimizing the risks associated with prenatal genetic testing

With over 500 prenatal genetic tests currently available, and many more entering the consumer medical market each year, prenatal genetic testing is rapidly becoming routine practice in the medical management of pregnancy. The greatest benefits gained from prenatal genetic testing are the prevention of the birth of a child with a chronic genetic disease and offering prospective parents a degree of liberation from reproductive risk. These benefits are, however, tempered by a series of complex ethical, legal and social risks, which must be identified and managed if the benefits are to be maximized. The aim of this paper is to investigate how a group of experts in human genetics perceive the origin and impact of these risks. Based on a qualitative analysis of semi-structured interviews with experts in the new genetics, seven risks are identified. These include: the risk of state intervention into private lives and the consequent loss in reproductive freedom; the risk of coercive testing emerging from medical paternalism; the risk of ambivalence in knowing whether prenatal testing should be offered for all conditions, or only for severe medical conditions; the risk prenatal testing will amplify existing racial, sexual and disability discrimination; the risk prospective parents will develop inflated expectations of genetic perfectionism; the risk of inequalities in access to genetics counselling and testing services; and the risk of fostering an increase in wrongful birth and wrongful life litigation. The findings of this study have implications for enhancing genetic risk-management policies and for improving the delivery of genetic testing services. They also have implications for advancing our understanding of the relationship between genetic health, genetic risk and society.

Letter

Back to table of contents Previous article Next article LetterFull AccessLetterPatricia E. Deegan Ph.D.Robert E. Drake M.D., Ph.D.Patricia E. Deegan Ph.D.Search for more papers by this authorRobert E. Drake M.D., Ph.D.Search for more papers by this authorPublished Online:1 Jan 2007https://doi.org/10.1176/ps.2007.58.1.140AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail In Reply: In response to the thoughtful letters about our Open Forum—the two above and the letter in the December issue from Peyser and Shadoan ( 1 )—we would like to offer this vignette and commentary. In a psychiatric medication clinic located in an urban center in the Midwest, a young woman arrived for her appointment accompanied by her case manager. She was a longtime client of the center and had a diagnosis of a substance use disorder and schizophrenia. Her presentation on this day was disorganized, distressed, and psychotic. At the clinic, she was greeted by a peer specialist, offered food and beverage, and encouraged to use assistive technology to organize the information she wanted to share with her doctor. The young woman sat at a kiosk, put on headphones and, when prompted, entered her responses via a touch screen. The software organized the story that she wanted to tell her doctor, at a time when she could not organize this story herself. When finished, she pressed a print icon, walked to the printer and picked up her one-page report.The report generated by the software program summarized how this client felt she was doing, how she had been using medications, and what her goals for meeting with her doctor were. It also identified her decisional uncertainty about using medications. She brought the report into her appointment. According to the young woman and her doctor, assistive technology enabled her to effectively communicate her concerns and to participate in shared decision making. The technology described in the vignette is part of a decision support center in a psychiatric medication clinic. It represents the types of innovations in decision support that are the future of medicine in the 21st century. As the vignette illustrates, when we move beyond medical paternalism and the related notions of compliance and coercion, innovative strategies to collaboratively engage even the most challenging clients in shared decision making often emerge. Sweeping assumptions that large groups of people require benevolent paternalism and are not fit for shared decision making are empirically unsubstantiated ( 2 ). Most people, including those with a diagnosis of schizophrenia, want some level of involvement in medical decision making ( 3 ). Reliance on unilateral decision making and involuntary interventions can lead to unnecessary curtailment of fundamental civil liberties and little clinical or psychosocial improvement ( 4 ). The 2006 follow-up to the Institute of Medicine's Quality Chasm report concluded that the principles of person-centered care can be applied to those with substance use and mental disorders. Shared decision making is a key to realizing the report's recommendation and "ensuring that patient values guide all clinical decisions" ( 5 ). Shared decision making may not be possible in situations of temporary decisional incapacity. In such situations the use of medical guardianships, advanced crisis planning, and psychiatric advance directives may help clinicians remain faithful to clients' values and preferences. However, this does not mean that shared decision making is a privilege for those with milder mental disorders. Shared decision making is an ethical imperative and is a fundamental tenet of evidence-based medicine. People with psychiatric disabilities want to be involved in treatment decisions. Rather than excluding large groups of people on the basis of clinical or cultural characteristics, we seek ways to create assistive technologies and supports so that all people with psychiatric disabilities can participate in shared decision making.

Shared Decision Making and Medication Management in the Recovery Process

Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence. The authors argue that compliance is an inadequate construct because it fails to capture the dynamic complexity of autonomous clients who must navigate decisional conflicts in learning to manage disorders over the course of years or decades. Compliance is rooted in medical paternalism and is at odds with principles of person-centered care and evidence-based medicine. Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts. It requires a partnership between two experts: the client and the practitioner. Shared decision making provides a model for them to assess a treatment's advantages and disadvantages within the context of recovering a life after a diagnosis of a major mental disorder.

Shared Decision Making and Medication Management in the Recovery Process

Mental health professionals commonly conceptualize medication management for people with severe mental illness in terms of strategies to increase compliance or adherence. The authors argue that compliance is an inadequate construct because it fails to capture the dynamic complexity of autonomous clients who must navigate decisional conflicts in learning to manage disorders over the course of years or decades. Compliance is rooted in medical paternalism and is at odds with principles of person-centered care and evidence-based medicine. Using medication is an active process that involves complex decision making and a chance to work through decisional conflicts. It requires a partnership between two experts: the client and the practitioner. Shared decision making provides a model for them to assess a treatment's advantages and disadvantages within the context of recovering a life after a diagnosis of a major mental disorder.

Patient autonomy and the ethics of responsibility

The principle of patient autonomy dominates the contemporary debate over medical ethics. In this examination of the doctor-patient relationship, physician and philosopher Alfred Tauber argues that the idea of patient autonomy -- which was inspired by other rights-based movements of the 1960s -- was an extrapolation from political and social philosophy that fails to ground medicine's moral philosophy. He proposes instead a reconfiguration of personal autonomy and a renewed commitment to an ethics of care. In this formulation, physician beneficence and responsibility become powerful means for supporting the autonomy and dignity of patients. Beneficence, Tauber argues, should not be confused with the medical paternalism that fueled the patient rights movement. Rather, beneficence and responsibility are moral principles that not only are compatible with patient autonomy but strengthen it. Coordinating the rights of patients with the responsibilities of their caregivers will result in a more humane and robust medicine.Tauber examines the historical and philosophical competition between facts (scientific objectivity) and values (patient care) in medicine. He analyzes the shifting conceptions of personhood underlying the doctor-patient relationship, offers a topology of autonomy, from Locke and Kant to Hume and Mill, and explores both philosophical and practical strategies for reconfiguring trust and autonomy. Framing the practicalities of the clinical encounter with moral reflections, Tauber calls for an ethical medicine in which facts and values are integrated and humane values are deliberately included in the program of care.

Should women be able to choose caesarean section

Caesarean section is one of the commonest operations performed in the UK. The rise in incidence has been partly due to increased importance being placed on the patient's right to choose. This paper, written from a female medical student's viewpoint, looks at whether caesareans should be performed solely because of patient request. The risks and benefits of caesarean sections are reviewed and the balance between patient autonomy and medical paternalism is evaluated. It is argued that the risks of performing a possibly needless operation are important and should not be dismissed, and the conclusion is that caesarean section should be performed only when medically indicated. The majority of young doctors now entering obstetrics in the UK are female, but this does not necessarily mean that there will be a shift in favour of women's rights. South African Journal of Obstetrics and Gynaecology Vol. 12(2) 2006: 84-87

Are Human Rights Important In Bioethics?

Are Human Rights Important In Bioethics?

The Clinical Duty of Care: Is it enough that the doctor did what all or many of the other doctors do?

Who decides what is required in order to fulfil the duty of care, the doctors or the judges? This paper examines what the judges have been saying of late and gives an analysis of recent judgements. It also looks at the extent to which judges are challenging the medical experts. The trend away from medical paternalism to patient autonomy is discussed in the light of continuing uncertainty of the law and medical practice.

The burden of paediatric intensive care: a South American perspective

Paediatric intensive care is a relatively new medical specialty that has shown a marked growing up around the world over the last three decades. The limits and the development of this new specialty are not uniform from country to country. Original articles relating to paediatric intensive care and some South American data bases of health care were evaluated and relevant results were selected. Using these data, we describe the main characteristics of paediatric intensive care in South America and discuss some associated factors (e.g. economic aspects, health systems, ethical aspects) that could interfere with the quality and extent of care. A strong relationship between the financial stability of each region and the complexity and quality of paediatric intensive care was seen. A better coverage and more sophisticated paediatric intensive care units (PICUs) are concentrated in the more developed countries (Brazil, Chile and Argentina). Compared to the northern hemisphere, children admitted to the South American PICUs have higher mortality and higher rates of intervention (mechanical ventilation and indwelling catheters). Medical paternalism has a strong influence in the decision-making process offered to terminally ill patients. This phenomenon increases the length of stay, reduces the number of available beds and increases costs. In conclusion, during the last 20 years PICUs have developed and increased their coverage in South America. However, the most sophisticated and well equipped PICUs are preferentially located in the more developed areas whereas those areas with higher infant mortality rates have few PICU beds. Improvements in the economical stability, regional health organisation as well as the rationale for PICU localisation are some of the important goals to be reached in the near future.

The expert patient: Valid recognition or false hope?

The United Kingdom Department of Health initiative on "The Expert Patient" (2001) reflects recent trends in political philosophy, ethics and health services research. The overall objective of the initiative is to encourage patients, particularly those suffering from chronic conditions to become more actively involved in decisions concerning their treatment. In doing so there would be (perhaps) an expectation of better patient compliance and (arguably) a resultant improvement in quality of life. Despite these anticipated beneficial influences on health outcomes, there may be a danger that such initiatives are being carried along by the general swell of enthusiasm for recognising and facilitating the claims of disadvantaged or discriminated against groups. What more attractive than that patients should be "liberated" from what might be seen as the oppression of medical paternalism? To a great extent the potential for success of the Expert Patient venture turns on:(a) whether and to what extent a patient can be considered truly to be an expert and (b) full acceptance by the medical and heath care professions of allowing patients a more equitable and positive role. Whilst clearly the patient is an expert in the hermeneutic sense - it is they and they alone who experience their illness - there is nevertheless a risk of confusing experience with expertise. Experience limited to an individual does not of itself give rise to the generalisations that underlie reliable clinical treatment. Neither do the vast majority of patients possess the physiological and pharmacological knowledge to fully appreciate the biological nature of their illness nor the basis, risks or limitations of therapeutic measures. Might the notion of "The Expert Patient" as informed co-decision maker become a well-meaning but rather vacuous aspiration similar to that of informed consent? Even worse, could patient "empowerment" have a deleterious effect? The paper reviews some of the major issues and concludes that the expert patient initiative could have benefits for both patients and health professionals if operated on the basis of concordance: an informed collaborative alliance that optimises the potential benefits of medical care.

Information et consentement

Providing information for patients is a pre-requisite to obtain appropriate patient's consent for a research project or for health care. After having been fully informed, the patient can decide whether or not to participate in the suggested procedure. In a dentistry private practice context or for aesthetic surgery, the treatment contract reflects the specificity inherent in the fee-for-service system. Recognizing the place of the patient's consent is recognizing the right of patients to autonomy. Consent is a counter-weight to that medical paternalism which has long shackled patients in the inferior position of dominated/dominator relationships; it marks the end of medical imperialism. The consent, as based on the patient's autonomy, creates a new equilibrium in medical team/patient relationships. Law n o 2002-303 of March 4, 2002, which deals with patients' rights and the quality of the health system, is a crucial text in terms of patient/care provider relationship.