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