Four Models of the Physician-Patient Relationship Ezekiel J
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Four Models of the Physician-Patient Relationship Ezekiel J. Emanuel, MD, PhD, Linda L. Emanuel, MD, PhD DURING the last two decades or so, interaction.7 Consequently, they do not neering,10 or consumer model. In this there has been a struggle over the pa- embody minimum ethical or legal stan¬ model, the objective of the physician- tient's role in medical decision making dards, but rather constitute regulative patient interaction is for the physician that is often characterized as a conflict ideals that are "higher than the law" but to provide the patient with all relevant between autonomy and health, between not "above the law."8 information, forthe patient to select the the values of the patient and the values medical interventions he or she wants, THE PATERNALISTIC MODEL of the physician. Seeking to curtail phy- and for the physician to execute the se¬ sician dominance, many have advocated First is the paternalistic model, some¬ lected interventions. To this end, the an ideal ofgreater patient control.1,2Oth- times called the parental9 or priestly10 physician informs the patient of his or ers question this ideal because it fails to model. In this model, the physician-pa¬ her disease state, the nature of possible acknowledge the potentially imbalanced tient interaction ensures that patients diagnostic and therapeutic interven¬ nature 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- this end, physicians use their skills to ventions, and any uncertainties ofknowl¬ tion of technical information.3,4 Still oth- determine the patient's medical condi¬ edge. At the extreme, patients could ers are trying to delineate a more mutual tion and his or her stage in the disease come to know all medical information relationship.5,6 This struggle shapes the process and to identify the medical tests relevant to their disease and available expectations ofphysicians and patients as and treatments most likely to restore interventions and select the interven¬ well as the ethical and legal standards for the patient's health or ameliorate pain. tions that best realize their values. the physician's 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 forces us to ask, What should be the ideal courage the patient to consent to the values. The patient's values are well de¬ physician-patient relationship? 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 physician-patient interaction, emphasiz- thoritatively informs the patient when to provide all the available facts, and ing the different understandings of (1) the intervention will be initiated. the patient's values then determine what the goals of the physician-patient inter¬ The paternalistic model assumes that treatments are to be given. There is no action, (2) the physician's obligations, there are shared objective criteria for role for the physician's values, the phy¬ (3) the role of patient values, and (4) the determining what is best. Hence the sician's understanding of the patient's conception ofpatient autonomy. To elab¬ physician can discern 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 participation. Ultimately, it is assumed informative model, the physician is a of 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 if he ing the patient with the means to ex¬ indicate how these models inform the or she would not agree to them at the ercise control. As technical experts, phy¬ current debate about the ideal physician- time.11 In the tension between the pa¬ sicians have important obligations to pro¬ patient relationship. Finally, we shall tient's autonomy and well-being, be¬ vide truthful information, to maintain evaluate these models and recommend tween choice and health, the paternal¬ competence in their area of expertise, one as the preferred model. istic physician's main emphasis is to¬ and to consult others when their knowl¬ As outlined, the models are Weberian ward the latter. edge or skills are lacking. The concep¬ ideal types. They may not describe any In the paternalistic model, the physi¬ tion ofpatient autonomy is patient con¬ particular physician-patient interactions cian acts as the patient's guardian, artic¬ trol over medical decision making. but highlight, free from complicating de¬ ulating and implementing what is best for tails, different visions of the essential the patient. As such, the physician has ob¬ THE INTERPRETIVE MODEL characteristics 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 when lacking interaction is to elucidate the From the Division of Cancer Epidemiology and patient's Control, Dana-Farber Cancer Institute, Boston, Mass adequate knowledge. The conception of values and what he or she actually wants, (E.J.E.); Program in Ethics and the Professions, patient autonomy is patient assent, either and to help the patient select the avail¬ Kennedy School of Government, Harvard University, at the time or later, to the de¬ able medical interventions that realize Cambridge, Mass (EJE. and L.L.E.); and Division of physician's Medical Ethics, Harvard Medical School, Boston, Mass terminations of what is best. these values. Like the informative phy¬ (L.L.E.). L.L.E. is also a Teaching and Research sician, the interpretive physician pro¬ Scholar of of THE INFORMATIVE MODEL the American College Physicians. vides the patient with information on Reprint requests to Division of Cancer Epidemiology Second is the and Control, Dana-Farber Cancer Institute, 44 Binney informative model, the nature of the condition and the risks St, Boston, MA 02115 (Dr E. J. Emanuel). sometimes called the scientific,9 engi- and benefits of possible interventions. Downloaded From: http://jama.jamanetwork.com/ by a Cleveland Clinic Foundation User on 09/07/2016 Comparing the Four Models Informative Interpretive Deliberative Paternalistic Patient values Defined, fixed, and known to the Inchoate and conflicting, requir¬ Open to development and revi¬ Objective and shared by physi¬ patient ing elucidation sion through moral discussion cian and patient Physician's Providing relevant factual infor¬ Elucidating and interpreting rele¬ Articulating and persuading the Promoting the patient's well- obligation mation and implementing pa¬ vant patient values as well as patient of the most admirable being independent of the pa¬ tient's selected intervention informing the patient and im¬ values as well as informing tient's current preferences plementing the patient's se¬ the patient and implementing lected intervention the patient's selected inter¬ vention Conception of Choice of, and control over, Self-understanding relevant to Moral self-development relevant Assenting to objective values patient's autonomy medical care medical care to medical care Conception of Competent technical expert Counselor or adviser Friend or teacher Guardian physician's role 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 clinical situ¬ model can be endorsed because it alone dating and articulating his or her values ation. To this end, the physician must promotes patient autonomy. Instead the and in determining what medical inter¬ delineate information on the patient's models must be compared and evalu¬ ventions best realize the specified val¬ clinical situation and then help elucidate ated, at least in part, by evaluating the ues, thus helping to interpret the pa¬ the types ofvalues embodied in the avail¬ adequacy of their particular conceptions tient's values for the patient. able options. The physician's objectives of patient autonomy. According to the interpretive model, include suggesting why certain health- The four models are not exhaustive. the patient's values are not necessarily related 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, fifth: the instrumental model. In this are often inchoate, and the patient may the physician and patient engage in de¬ model, the patient's values are irrele¬ only partially understand them; they liberation about what kind of health- vant; the physician aims for some goal 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¬ working with the patient must elucidate discusses only health-related values, that tific knowledge. The Tuskegee syphilis and make coherent these values. To do is, values that affect or are affected by experiment15"17 and the Willowbrook hep¬ this, the physician works with the pa¬ the patient's disease and treatments; he atitis study18·19 are examples of this tient to reconstruct the patient's goals or she recognizes that many elements of model. As the moral condemnation of and aspirations, commitments and char¬ morality are unrelated to the patient's these cases reveals, this model is not an acter.