Paternalism in Medicine

We all learn about the different styles of relationships that people have. As a physician, the doctor-patient relationship greatly impacts the approach to education, motivation, and negotiation of treatment plans. Emanuel and Emanuel described the following four models of the physician-patient relationship:
 * Paternalistic - The physician is parental, recommending what he/she feels is best for the patient. The patient chooses whether or not to follow the recommendations.
 * Informative - This is a "consumer" model of care. The physician provides information about all available treatment choices in as accurate and as unbiased a manner as possible. The patient chooses from the available options.
 * Interpretive - In this model, the patient is not expected to simply choose among available options because he/she lacks medical training. Instead, the physician tries to understand or interpret the patient’s general values and preferences. The physician then recommends the treatment option which is most consistent with the patient’s values.
 * Deliberative - In this model, part of the physician’s role is to promote health by influencing the patient’s health-related choices, using noncoercive approaches to motivate the patient.

Introduction and Question
In Miguel's case, do you think that the doctor was being too paternalistic by telling the mother that her child had a bad case of empacho, rather than telling her that the child did not have empacho but rather a different disease that required a different treatment?

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Discussion
The Hippocratic oath that all medical students take upon graduation is based on the principle of beneficence: “for the benefit of the sick according to (the physician’s) ability and judgment.” However, this principle of beneficence has led to medical paternalism. Many times, paternalism focuses on the patient’s actual care and outcomes rather than the patient’s needs and rights. It goes up against the principle of patient autonomy. In Western medicine, paternalism has a large influence on the way that physicians interact with patients. Miguel’s mother has a right to know what her son’s diagnosis is in order to guide the family unit towards proper treatment in the best interest of the child. The doctor in this case does not need to be overbearing and “force” a dx on a family, but needs to be able to incorporate the “correct” dx into an acceptable treatment plan that satisfies both parties. Western medicine stems from the 17th century Cartesian model of thought and often thinks itself “better” than older schools such as Eastern philosophies. One of my favorite quotes from studying this topic in past years is from a study by Sullivan, Menapace and White (2001), in which it was written, “I’m not the God of this patient, just a technician with an education”.

Medicine is an art, and each of us will approach problems differently. (Although humorous, I am sure that most doctors would disagree with being called a "technician with an education.") I would guess that, in the case of Miguel, most of us would have made a better effort to establish rapport with the mother than the doctor did in the first video. I also think that probably most of us would have made an effort to explain Miguel's illness in a way that the mother could understand without resorting to calling it a "bad case of empacho," as the doctor did in the second video. Our non-verbal communication, directed toward the patient (not the translator,) can help the patient understand that we care about them (or their family member.) If they feel that we care, then they are more likely to believe what we say and comply with our treatment recommendations.

For advice on how to deal with difficult cases, where there is a collision between the Western medical culture and the patient and family's culture, see the link to the discussion of Fadiman's book. The questions start off with, "What do you call your illness? What name does it have?"

Recommended Resources
In regards to exploring a patient's cultural understanding of an illness, Anne Fadiman's book refers to eight questions that can be helpful: http://erc.msh.org/aapi/tt11.html

The Autonomous Patient: Ending Paternalism in Medicine; The Resourceful Patient: http://www.bmj.com/cgi/content/full/326/7402/1338-a

Links to Cases
Back to Miguel or Case studies.