Special Communication Four Models of the Physician-Patient Relationship Ezekiel J. Emanuel, MO, PhD, Linda L. Emanuel, MD, PhD DURING the last two decades or so nteraction.Consequently, there has been a struggle over the pa- embody minimum ethical or neerng, or consumer model. In this tients role in medical decision mak model, the objective of the ph that is often characterized as a conflict ideals that are"higherthan patient interaction is for the pbrs cian between autonomy and health, between not "above the law." to provide the patient with all relevant the values of the patient and the values information, for the patient to select the of the physician. Seeking to curtail phy- THE PATERNALISTIC MODEL medical interventions he or she wants and for the phy sician to execute the se. First is the paternalistic model, some- lected interventions. To this end, the ers question this idea because it fails to modeL In this model, the physician-pa- her disease state, the nature of possible mature ofthis interaction when one party receive the interventions that best pro- tions, the nature and probability ofrisks is sick and searching for security, and mote their health and well-being. To and benefits associated with the inter when judgments entail the interpreta is end, physicians use their skills to ventions, and any uncertainties of nowl tion of technical information Still oth- determine the patient' s medical condi- edg ge. At the extreme, patients could relationship. This struggie shapes the process and to identify the medical tests relevant to their disease and available weil as the ethical and legal standards for the patient's health or ameliorate pain. tions that best realize their values the physicians duties, informed consent, Then the physician presents the patient The informative model assumes a and medical malpractice. This struggle with selected information that will en- fairly clear distinction between facts and torces us to ask, What should be the ideal courage the patient to consent to th values. The patient's values are well de- intervention the physician considers fined and known; what the patient lacks We shall outline four models of the best. At the extreme, the physician au- is facts. It is the physician, s obligation hysician-patient interaction, emphasiz- thoritatively informs the patient when to provide all the available facts, and the different understandings of(1) he goais of the physician-patient inter he intervention wiil be initiated the patient' s values then determine what The paternalistic model assumes that treatments are to be given. There is no e physicians obligations, there are shared objective criteria for role for the physician, s values, the phy- 13)the role of patient values, and (4)the determining what is best. Hence the sician,'s understanding of the patie conception of patient autonomy. Toelab- physician can discerm what is in the pa- values, or his or her judgment of the orate the abstract description of these tient s best interest with limited patient worth of the patient's values. In the four models, we shall indicate the types rticipation. Ultimately, it is assumed informative model, the physician is a ot response the models might suggest in that the patient will be thankful for de- purveyor of technical expertise, provid a clinical situation. Third, we shall also cisions made by the physician even ifhe indicate how these models inform the or she would not agree to them at the ercise control. Astechnical experts, phy irent debate about the ideal physician- time. In the tension between the pa cent eehatienshid e anal lrg we shaidtient's au址m,0 truthful information, to maintain Asoutlined, the models are Weberian ward the latter ain emphasis is to- and to consult others when their knowl- istic p lacking. The ideal types. They may not describe any In the paternalistic model, the physi- tion of patient autonomy is patient con- articular physi 'sIctan-patent interaction cian acts as the but highlight free fre ulating and implement ting what is best for tails, different visions of the essential the patient. Assuch, the physician has ob- THE INTERPRETIVE MODEL characteristies of the physician-patient ligations, including that of placing the pa- The third model is the interpretive tient 's interest above his or her own and model. The aim of the physician-patient soliciting the views ofothers whenlacking interaction is to elucidate the patient,'s adequate knowledge. The conce
Paternalistic Defined, fixed, and known to the Inchoate and confiding requir Open to development and rey ctive and shared by phy through moral discussIon an and paton Physician's uPdating and interpretor p an nts current profesor emending che patients se- Setundarstanding relevant to Moral sell-deveiopment televant Assenting to objective values Competent tochnical expert Counselor or adviser Guardian Beyond this, however, the interpretive choose the best health-related values tient autonomy. Therefore, no single physician assists the patient in eluci. that can be realized in the elinical situ. model can be endorsed because it alor ating and articulating his or her values ation. To this end, the physician must tes patient autonomy. Instead the and in determining what medical inter- delineate information on the patient's is must be compared and evalu ventions best realize the specified val- clinical situation and then help elucidate at least in part, by evaluating the ues, thus helping to interpret the types of values embodiedin the avail- adequacy of theirparticular conceptions tients values for the patient. ble options. The physician s objectives of patient autonomy. interpretive me inelude suggesting why certain health- The four models are not exhaustive. lated values are more worthy and at a minimum there might be added a fixed and known to the patient. They should be aspired to. At the extreme, fith: the instrmental model. In this only partially understand them; they liberation about what kind of health- vant; the physician aims for some go may conflict when applied to specific related values the patient could and ul- independent of the patient, such as the situations. Consequently, the physician timately should pursue. The physician good of society or furtherance of scien- and make coherent these values. To do is, values that affect or are affected by experiment and the willowbrook hep- this, the physician works with the pa- the patient's disease and treatments; he atitis study. s are examples of this andaspirations, commitments and char- morality are unrelated to the patients these cases reveals, this model is not an 1 acter. At the extreme, the physician disease or treatment and be t an aberration. Thus we have must conceive the patient's life as a na scope of their professional relationship. not elaborated it herein rative whole, and from this specify the Further, the physician aims at no more patient's values and their priority. 1 3 than moral persuasion; ultimately, co- A CLINICAL CASE ided, and the patient must To make tangible these abstract de- tests and treatments best realize these define his or her life and select the or- scriptions and to crystallize essential dif- atient: it is the pa- gaging in moral deliberation, the ph lustrate the responses they suggest in a tient who ultimately decides which val-- sician and patient judge: the worthiness. clinical situation, that of a 43-year-old ues and course of action best fit who he and importance of the health-related val- premenopausal woman who hasrecently r she is Neither is the physician jud discovered a breast mass. Surgery re- ing the patient' s values; he or she helps In the deliberative model, the physi- veais a3 5-cm ductal carcinoma with no i in the medical situation. gaging the patient in dialogue on what gen receptor positive. Chest roentgen gram, bone scan, and liver function cian is a counselor, analogous to a cab. does the physician indicate what the pa eveal no evidence of metastatic inet ministers advisory role to a head of tient could do, but, knowing the patient disease. The patient was recently state, supplying relevant information, and wishing what is best, the physician vorced and has gone back to work as a ing what medical interventions realize what decision regarding medical ther- should the physician say to this patient? the informative model but also require. development; the patieny is moral seif. might say, There are two aitemabire o these values. Thus the physician' s ob. apy would be admirable. The concep engaging the patient in a joint process not simply to follow unexamined pref- of cancer in your breast:mastectomy or ception of patient autonomy is sell-un- s ences or examined values, but to con- radiation. We now know that the sur er, through dialogue, alternative vival with lumpectomy combined with derstanding the patient comes to know health-related values, their worthiness, radiation therapy is equal to that with more clearly who he or she is and how and their implications for treatment mastectomy. Because lumpectomy and the various medical options bear on his radiation offers the best survival an
the chance of recurrence is low, you are Conversely, chemotherapy would pro- or a cardiologist discussing cholesterol- young, and we should not leave any ther- long the duration of therapy by many reducing interventions apeutic possibilities untried. Recent months. Further the benefits of che- THE CURRENT DEBATE AND THE studies involving chemotherapy suggest motherapy in terms of survival are improvements in survival without re- smaller and more controversial Given FOUR MODELS currence of breast cancer. Indeed, ti he recent changes in your life, you have In recent decades there has been a National Cancer Institute recommends too many new preoccupations to undergo call for greater patient autonomy or, as chemotherapy for women withyourtype months of chemotherapy for a question- some have called it, "patient sover ofbreast cancer Chemotherapy hasside able benefit. Do I understand you? We eignty, 2 conceived as patient choice effects. Nevertheless, a few months of can talk again in a few days. and control over medical decisions. This hardship now are worth the potential The deliberative physician might be- shift toward the informative model is added years of life without cancer. might say, With node-negative breast cidate the patient's values, but continue, are described as health care providers cancer there are two issues before you: "It seems clear that you should undergo and patients as consumers. It can also local control and systemic control. For radiation therapy. Itoffers maximalsur- be found in the propagation of patient nd the local control, the options are mastec. vival with minimal risk, disfigurement, rights statements, in the promotion of tomy or lumpectomy with or without and disruption of your life. The issue of living will laws, and in rules regarding omy without radiation results potential benefit of chemotherapy for decisions regard: ei or a? radiation. From many studies we know chemotherapy is different, fraught with human expec ntence For instance, that mastectomy radiation result in identical overall sur- tions, I think the best one for you is to The Rights of the Terminally Ill Act stive vival, about 80% 10-year survival. enter a trial that is investigating the authorizes an ad ng administration of ded a n this in a 30% to 40% chance of tumor recur- women with node-negative breast can- life-sustaining treatment irrele. rence in the breast. The second issue cer. First, it ensures that you receive merely provides one way by which a relates to systemic control. We know excellent medical care. At this point, we terminally-ill patient's desires regard that chemotherapy prolongs survivalfor do not know which therapy maximizes the use of life-sustaining procedures premenopausal women who have axil- survival. In a clinical study the schedule can be legally implemented"(emphasis and decisIor philis ok hep- role for women, with node-negative is specified by leading breast eancer ex- require or encourage patients to discuss udies suggest that chemotherapy is of ceive care that is the best available any- physicians before signing such docu no beneft in terms of improving overall where. a second reason to participat ents. Similarly, decisions in"right-to- all studies suggests that there is a sur- contribute something to women with medical decisions. As one court puts, vival benefit. Several years ago, the NCI breast cancer in the future who will face The right to refuse medical treatment is ba- hemotherapy can have a positive ther- sands of women have participated in quires no one 's approval. .(TJhe control apeutic impact. Finally, let me inform studies that inform our current treat- will il- you that there are clinical trials, for ment practices. without those women, inforn est in a benefits of chemotherapy for patients we would probably still be giving you noal and philosophi ecently enroll you in a study if you want. I will mastectomies. By enrolling in a trial you Probably the most forceful endorse. with no be happy to give you any estro mation you feel you need of one generation receive the highest ment of the informative model as the ideal The interpretive physician might out- standard of care available but also en- inheres in informed consent standards. e much of the same information as the hance the care of women in future gen- Prior to the 1970s, the standard for in- ntly di sion to elucidate the mething about whichinterventions are based. "a Since 1972 and the Canter wishes, and conclude, "It sounds to me better. I must tell you that I am not bury case, however, the emphasis ha as if you have conflicting wishes. Un. involved in the study; if you elect to been on a"patient-oriented"standard of derstandably, you seem uncertain how enroll in this trial, you will initially see informed consent in which the physi to balance the demands required for re- another breast cancer expert to plan has a"duty"to provide appropriate med iving additional treatment, rejuvenat- your therapy. I have sought to explain ical factstoempower the patient touse his ng your personal affairs, and maintain- ourcurrent knowledge and offermy rec- or hervalues todetermine whatinterven- omy or me try to express a perspective that fits possible decision your position. Fighting your cancer is Lacking the normal interchange with the informed exercise of a choice, and that my and althy self-image and quality time out. contrived, even caricatures. Neverthe [e]t is the prerog ival and side the hospital. This view seems com- less, they highlight the essence of each attendant on options available and the 0
SHARED DECISION MAKIN are inherently limited because of un- ates and accentuates the trend toward ventive Despite its dominance, many have conscious influences, Katz views dia- specialization and impersonalization fervent: found the informative model "arid. o logue as a mechanism for greater self- within the medical profession The Presidents Commission and others understanding Most importantly, the health-r contend that the ideal relationship does objectives. According to Katz, this view model s conception of patient autonomy not vest moral authority and medical places a duty on physicians and patients seems philosophically untenable. Thein- terol lew dietary patient but must be a process of shared patients can gain a greater self- decision making constructed around understanding and self-determination. but this is inaccurate. People are often therapy "mutual participation and respect. "20, Katz' insight is also available on uncertain about what they actually want. changes The President's Commission argues that grounds other than Freudian psycho- Further, unlike animals, people have their h∈ the physicians role is"to help the pa- logic eory and is consistent with the what philosophers call "second order de- tient understand the medical situation interpretive model res, that is, the capacity to reflect on their wishes and to revise their own and available courses of action, and the OBJECTIONS TO THE atient conveys his or her concerns and PATERNAUSTIc MODEL wishes, m0 Brock and Wartman2stress this fact-value"division of labor"--hav It is widely recognized that the pater- having"second order desires"and be- ing the physician provide information nalistic model is justified during emer- ing able to change our preferences and not mac pa while the makes value deci. gencies when the time taken to obtain in- modify our identity. Self-reflection and ng"shared decision formed consent might irreversibly harm the capacity to change what we want on an al making as umstances, however, it is no longer ten- liberation in which we assess the value make able to assume that the physician and pa- of what we want. And this is a process cians bring their medical training, knowl. tient espouse similar values and views of that occurs with other people who know siCi &se, and exv the diaailable treatment even physicians rarely advocate the pa- we ought to be that we can assent to. 1 to the diagnosis and manage- ternalistic model as an ideal for routine Even though changes in health or im- OBJEC DELIBE dition. Patients bril lementation of alternative interven ons can have profound effects on what The ft values, through which risks and benefits of OBJECTIONS TO THE we desire and how we realize our de- libera ous treatment options ean be evaluated. INFORMATIVE MODEL nent for a particular patient requires the seriptively and prescriptively inaccu- physician-patienoie in the informative ion. The infor- t ms to have no mative models possess Similarly, in discussing ideal place for essential qualities of the ideal atible n ot a ority of decision making, Eddy> argues for physician-patient relationship. The in- that incorporate fact-value division of labor betwe plural physician and patient as the tient in the sense of competently imple- OBJECTONSTOTHE mouse It is important to separate the decision pro- menting the patient s selected interven- INTERPRETIVE MODEL The first step tions. However, the informative physi- The interpretive model rectifies this of whicl w IThe second step is a understanding what the patient values have second-order desires and dynamic f personal values or or should value and how his or her ill- value structures and placing the eluci- ness impinges on these values. Patients dation of values in the context of the liberat ytic but personal and subjective.. [I]t. seem to expect their physician to have. patient's medical condition at the center t, tI caring approach; they deem a techni- of th ally proficient but detached physician Nevertheless, there are objections t Ithe physician not in the picture. What as deficient, and properly condemned. the interpretive model matters is what Mrs. Smith thinks Further, the informative physician is Technical specialization militates This view of shared decision making proscribed from giving a recommenda- against physicians cultivating the skills seems to vest the medical decision- tion for fear of imposing his or her will necessary to the interpretive model n the l aking authority with the patient while on the patient and thereby competing With limited interpretive talents and relegating physicians to technicians for the decision-making control that has limited time, physicians may unwittingly SiCL "transmitting medieal information and been given to the patient. Yet, if one their own values under the guis using their technieal skills as the patient of the essential qualities of the ideal phy-. of articulating the patient's values. And directs.Thus, while the advocates of sician is the ability to assimilate medical patients, overwhelmed by their medieal "shared decision making may aspire to- facts, prior experience of similar situa- condition and uncertain of their own ward a mutual dialogue between physi- tions, and intimate knowledge of the views, may too easily accept this impo- cian and patient, the substantive viewin atient's view into a recommendation sition. Such eircumstances may push the forming their ideal reembodies the infor- designed for the patients specific med- interpretive model toward the pater- patients mative model under a different lab ical and personal condition, 34.2 then the nalistic model in actual practice Other commentators have informative physician cannot be ideal Further, autonomy viewed as self-un- 1 lated more mutual models of Second, in the informative model the derstanding excludes evaluative judg ledical ment of the patient's values or attempts nent among these efforts is Katz" The cialist who provides detailed factual infor- to persuade the patient to adopt other Thire Silent World of the Doctor and Patient. mation and competently implements the values. This constrains the guidance and berati
yentive medicine and risk-reduction in health care, not to engage in determine whether they are desirabl terventions, physicians often attempt deliberation or to revise their affirm, upon reflection these values as persuade patients to adopt particular m Finally, like the interpretive ones that should justify their actions; health-related values. Physicians fire- model, the deliberative model may eas- and then be free to initiate action to quently urge patients with high choleg- ily metamorphose into unintended pa- realize the values. The process of de- erol levels who smoke to change their termalism, the very practice that gen- bration integral to the deliberative dietary habits, quit smoking, and begi rated the public debate over the model is essential for realizing patient exercise programs before initiatingdrug proper physician-patient interaction Second, our society simage of an ideal therapy. The justification given forthese THE PREFERRED MODEL AND THe physican is not limited to one who knows changes is that patients should value their health more than they do. Simi- PRACTICAL IMPLICATIONS larly, physicians are encouraged to per- Clearly, under different clinical cir- vant factual information and compe a 1 rus(HIvh-infected patients who might propriate. Indeed, at different times all tions. The ideal physician-often em oe engaging in unsafe sexual practices four models may justifiably guide phy- bodied in lterature, art, and popular eithertoabstainor, realistically, to adopt sicians and patients. Nevertheless, it is culture-is a caring physician who in "safer sex"practices. Such appeals are important to specify one model as the tegrates the information and relevant :n, not made to promote the HIV-infected shared, paradigmatic reference: exce values to make a recommendation and patient's own health, but are grounded tions to use other models would not be hrough discussion on an appeal for the patient to assume automaticaily condemned, but wouidre- suade the patient to accept this recom- responsibility for the good of other. quire justification based on the circum- mendation as the intervention that best Consequently, by excluding evaluative stances of a particular situation. Thus, promotes his or her overall well-being judgments, the interpretive model it is widely agreed that in an emergency Thus, we expect the best physicians to seems to characterize inaccurately ideal. where delays in treatment to obtain in- engage their patients in evaluative dis- physician-patient interactions. formed consent might irreversibly harm cussions ofheaith issues and related val- the patient, the paternalistic model cor- ues. The physician's discussion does not OBJECTIONS TO THE rectly guides physician-patient interac- invoke values that are unrelated ortan DELIBERATTVE MODEL The fundamental objections to the de- clear but conflicting values, the interpre- and potential therapies. Importantly, 1 lberative model focus on whether it is tive model is probabiy justified. For in- these efforts are not restricted to situ- roper for physicians to judge patients' stance, a 65-year old woman who has ations in which patients might make"ir related values. First, physicians do not Early decided against reinduction che- tend to all health eare decision at ex- alues and promote particular health- been treated for acute leukemamay have rational and harmful"choices-bt possess privileged knowledge of the pri- motherapy if she relapses. Several Third, the deliberative model is not a orsv othealth-related vaiues relative to nths before the anticipated birth ofher disguised form of paternalism. Previ nther values. Indeed, since ours is a Erst grandchild, the patientrelapses. The ously there may have been category mis iuralistic society in which people es- patient becomes torn about whether to takes in which instances of the deliber- pouse incommensurable values, it is endure the risks of reinduction chemo- ative model have been erroneously iden likely that a physician, s values an therapy in order to live to see her first led as physician paternalism, And no of which values are higher will grandchild or whether to refuse therapy ubt, in practice, the deliberative phy with those of other physicians an ning herseif to not seeing sician may occasionally lapse into pa of his or her patients child. In such cases, the physician may termalism. However, like the ide Second, the nature of the moral de- justifiably adopt the interpretive ap- teacher, the deliberative physician at- liberation between physician and pa-.. proach. In other circumsta where mpts topermuade the patient ofthe tient, the physicians recommended in- there is only a one-time physician-patient thiness of certain vaiues, not to impos terventions, and the actual treatments interaction without an ongoing relation. those values paternalistically; the rticularphysiciantreatingthe patient. elucidated and compared with ideals, his or herwill, but to persuade the patient rovided to patients shouid not depend tive model may be justified the informa- Laws, Plato characterizes this funda- on the physician's judgment of the wor. Descriptively and prescriptively, we mental distinction between persuasion i thiness of the patient' s vaiues or on the claim that the ideal physician-patient and imposition or medical practice that bioethicist put it We will adduce six points to justify this paternalistic model d: therefore the physician must re- nearly embodies our ideal of autonomy. any account of his illne ng autonomy shion of a dictator [Alt the level of clinical person to select. nrestricted by coer. physician, who usually cares for free men, practice. medicine should be value-free in cion, ignorance, phy ieal interference, treats their diseases rst by thoroughly dis- the sense that the personal values of the and the like, his or her preferred course cussing with the patient and his friends his
Fourth, physician values are re vant shapes both the physician's and the pa- 713-715 to patients and do inform their choice of tient's expectations from patient control 6. Sasz Ts Hollender MH. The basie modelk of physician. When a pregnant woman to moral development. Most important, 1956:35:585-59 ent relationship. dh Intera f strongly favors them; when a patient We must develop a health care fnancir essive cardiologist who system that properly reimburses hics. anno domini 1979. N Engl edural interventions or one rather than penalizes-physicians for 9. Burke GEthies and who concentrates therapy on dietary taking the time to discuss values with in ny care. 1980. :613-24ediczl decisione-makingk. dhanges, stress reduction, and life-st modifications, they are consciously or olutionary age. Hastings on the CONCLUSION values that guide his or her medical de- Over the last few decades. the dis- New York. NY: Jason Aronson incI9'i csions. And, when disagreements be- course regarding the physician-patient tween physicians and patients arise, relationship has focused on two ex there are discussions over which values emes: autonomy and paternalism. ce. New York. NY: Cambridge Univeraity Pre re more important and should be real- Many have attacked physicians as pa- 14. Fried C. The Lawyer as friend: the moral to such disagreements undermine the patients to control their own care. This 15. Jones JH. Bad Blood. New York NT:Free caringattitude, a patient's care is trans. come dominant in bioethies and legal 16, Fimat Report of the Tuskegee Syphilis Stud erred to another physician. Indeed, in standards. This model embodies a de- Health erncerygranel. Washington. DC: Publie ctive conception of patient autonomy, 1. Brandt AM. Racism and research: the case of transferring care to a new physician is and it reduces the physician, s role to gee Syphilis Study, Hastings CeNt Re cther the physician's ignorance or in- that of a technologist. The essence of 1978: 8-21-29 Krugman S. Giles JP. Vi physician' s attitude or approve the patient's medical condition and ommission for the Studv of Ethical ifth, we seem to believe that physi- health-related values, makes a recom should also promote health-related val- of the worthiness of .suade the patient 21. Stalement on a Patient' s Ril of Right. Chi ing from or limiting alcohol use. Simi- should informlaws and policies thatreg- 23. Boneia e Superior Coe: 1987: 133-144. sex"for patients with HIV or abstain- in the deliberative model, the ideal that larly, patients are willing to adjust their ulate the physician-patient interact ralues and actions to be more compati- Finally, it may be worthnotingthatth We with health-promoting values. four models outlined herein are not fe 25. Appel baum Ps Lidz Cw. Meisel A Informe This is in the nature of seeking a caring medical recommendation Finally, it may well be that many ph scans currently lack the training and ca- that the ideal relationships between law. 27. Canterbury e Spence.464 F24 T2(DC Cir19r9\ tients that these values are worthy. But, scribed by thedeliberativemodel, at least fute ja ibysirians and patients. Re medy luati. their recommendations and persuade pa... ity, and educator and student are well de- ence of in some of their essential aspects. ck Dw, Warman SA. When comp t4 pecialization and we wau比X22d1a A. Anatomy of a decision. JAMA. uated and jus- John Steckle. MD. as well as be tified by the dominant informative mode hD, Arthur Applbaum. PhD, and Dan 31. Hatz J. The Stent World of Doctor and Pa- herefore if the deliberative model PhD. f seems most a ke to thank the "ethics and the pr ment changes in medical care and Rosen.JD, Francis Kamm Ph1:员证强cam poach. We must stress understanding rather than mere provisions of factual in-References rkn G. The thversity Press: 1985:154 formation in keeping with the legal stan- RM A Theory of Medieal Ethics. New dards of informed consent and medical inc Publishers: 1981 malpractice; we must educate physicians Mortal Choices. New York. NY:i ork NY: oxford pot just to spend more time in physician- 3. Ingelfinger FI. Arrogance. x Eng! , Med articulate the values underlying their 4. Marzuk PM. The rigbt kind of paternalist re decisions, including routine Engd.ed 1985: 313: 14:4-1 cnes: we must shift the publicly assur Siegler M.The he impact of a physician