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. At the extreme, the physician disease or treatment and beyond the ideal but an aberration. Thus we have must conceive the patient's life as a nar¬ scope of their professional relationship. not elaborated it herein. rative whole, and from this specify the Further, the physician aims at no more A CLINICAL CASE patient's values and their priority.12·13 than moral persuasion; ultimately, co¬ Then the physician determines which ercion is avoided, 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¬ values. Importantly, the physician does dering of values to be espoused. By en¬ ferences among the models, we will il¬ not dictate to the patient; it is the pa¬ gaging in moral deliberation, the phy¬ 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 ofthe health-related val¬ premenopausal woman who has recently or she is. Neither is the physician judg¬ ues. discovered a breast mass. Surgery re¬ ing the patient's values; he or she helps In the deliberative model, the physi¬ veals a 3.5-cm ductal carcinoma with no the patient to understand and use them cian acts as a teacher or friend,14 en¬ lymph node involvement that is estro¬ in the medical situation. gaging the patient in dialogue on what gen receptor positive. Chest roentgen- In the interpretive model, the physi¬ course of action would be best. Not only ogram, bone scan, and liver function cian is a counselor, analogous to a cab¬ does the physician indicate what the pa¬ tests reveal no evidence of metastatic inet minister's advisory role to a head of tient could do, but, knowing the patient disease. The patient was recently di¬ state, supplying relevant information, and wishing what is best, the physician vorced and has gone back to work as a helping to elucidate values and suggest¬ indicates what the patient should do, legal aide to support herself. What ing what medical interventions realize what decision regarding medical ther¬ should the physician say to this patient? these values. Thus the physician's ob¬ apy would be admirable. The concep¬ In the paternalistic model a physician ligations include those enumerated in tion of patient autonomy is moral self- might say, "There are two alternative the informative model but also require development; the patient is empowered therapies to protect against recurrence engaging the patient in a joint process not simply to follow unexamined pref¬ of cancer in your breast: mastectomy or of understanding. Accordingly, the con¬ erences or examined values, but to con¬ radiation. We now know that the sur¬ ception of patient autonomy is self-un¬ sider, 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 and COMPARING THE FOUR MODELS or her identity. the best cosmetic result, it is to be pre¬ The Table compares the four models ferred. I have asked the radiation ther¬ THE DELIBERATIVE MODEL on essential points. Importantly, all mod¬ apist to come and discuss radiation treat¬ Fourth is the deliberative model. The els have a role for patient autonomy; a ment with you. We also need to protect aim of the physician-patient interaction main factor that differentiates the mod¬ you against the spread of the cancer to is to help the patient determine and els is their particular conceptions of pa- other parts of your body. Even though

Downloaded From: http://jama.jamanetwork.com/ by a Cleveland Clinic Foundation User on 09/07/2016 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¬ studies in terms of survival are THE CURRENT DEBATE AND THE involving chemotherapy suggest motherapy FOUR MODELS improvements in survival without re¬ smaller and more controversial. Given currence of breast cancer. Indeed, the the 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 with your type months of chemotherapy for a question¬ some have called it, "patient sover¬ ofbreast cancer. Chemotherapy has side able benefit. Do I understand you? We eignty,"20 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." gin by outlining the same factual infor¬ embodied in the adoption of business In the informative model a physician mation, engage in a conversation to elu¬ terms for medicine, as when physicians 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. It offers maximal sur¬ be found in the propagation of patient local control, the options are mastec¬ vival with minimal risk, disfigurement, rights statements,21 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 radiation. From many studies we know chemotherapy is different, fraught with human experimentation. For instance, that mastectomy and lumpectomy with conflicting data. Balancing all the op¬ the opening sentences of one law state: radiation result in identical overall sur¬ tions, I think the best one for you is to "The Rights of the Terminally 111 Act vival, about 80% 10-year survival. enter a trial that is investigating the authorizes an adult person to control Lumpectomy without radiation results potential benefit of chemotherapy for decisions regarding administration of in a 30% to 40% chance of tumor recur¬ women with node-negative breast can¬ life-sustaining treatment. . . . The Act 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 survival for do not know which therapy maximizes ing the use of life-sustaining procedures premenopausal women who have axil¬ survival. In a clinical study the schedule can be legally implemented" (emphasis lary nodes involved with tumor. The of follow-up visits, tests, and decisions added).22 Indeed, living will laws do not role for women with node-negative is specified by leading breast cancer ex¬ require or encourage patients to discuss breast cancer is less clear. Individual perts to ensure that all the women re¬ the issue of terminating care with their studies suggest that chemotherapy is of ceive care that is the best available any¬ physicians before signing such docu¬ no benefit in terms of improving overall where. A second reason to participate ments. Similarly, decisions in "right-to- survival, but a comprehensive review of in a trial is altruistic; it allows you to die" cases emphasize patient control over all studies suggests that there is a sur¬ contribute something to women with medical decisions. As one court put it23: vival benefit. Several the NCI breast cancer in the future who will face years ago, The right to refuse medical treatment is ba¬ that for women like difficult choices. Over thou¬ suggested yourself, decades, sic and fundamental. ... Its exercise re¬ a ther¬ sands of women have in chemotherapy can have positive participated quires no one's approval. . . . [T]he control¬ apeutic impact. Finally, let me inform studies that inform our current treat¬ ling decision belongs to a competent you that there are clinical trials, for ment practices. Without those women, informed patient. ... It is not a medical which you are eligible, to evaluate the and the knowledge they made possible, decision for her physicians to make. It is benefits of for we would still be a moral and philosophical decision .that,. . be¬ chemotherapy patients probably giving you is with breast cancer. I can and all other women with breast cancer ing a competent adult, [the patient's] node-negative alone, (emphasis added) enroll you in a study if you want. I will mastectomies. By enrolling in a trial you endorse¬ be happy to give you any further infor¬ participate in a tradition in which women Probably the most forceful mation you feel you need." of one generation receive the highest ment ofthe informative model as the ideal inheres informed standards. The interpretive physician might out¬ standard of care available but also en¬ in consent standard line much of the same information as the hance the care of women in future gen¬ Prior to the 1970s, the for in¬ informative physician, then engage in erations because medicine has learned formed consent was "physician discussion to elucidate the patient's something about which interventions are based."2426 Since 1972 and the Canter¬ wishes, and conclude, "It sounds to me better. I must tell yoti that I am not bury case, however, the emphasis has been on a standard of as if you have conflicting wishes. Un¬ involved in the study; if you elect to "patient-oriented" informed in which the derstandably, you seem uncertain how enroll in this trial, you will initially see consent physician to balance the demands required for re¬ another breast cancer expert to plan has a "duty" to provide appropriate med¬ ical facts the use his ceiving additional treatment, rejuvenat¬ your therapy. I have sought to explain to empower patient to or her values determine what interven¬ your personal affairs, and maintain¬ our current knowledge and offer my rec¬ to ing should ing your psychological equilibrium. Let ommendation so you can make the best tions be implemented.25-27 me try to express a perspective that fits possible decision." True consent to what happens to one's self is your position. Fighting your cancer is Lacking the normal interchange with the informed exercise of a choice, and that important, but it must leave you with a patients, these statements may seem entails an opportunity to evaluate knowl- healthy self-image and quality time out¬ contrived, even caricatures. Neverthe¬ edgeably the options available and the risks . . . the side the hospital. This view seems com¬ less, they highlight the essence of each attendant upon each. [I]t is prerog¬ with radiation ther¬ model and suggest how the ative of the patient, not the physician, to de¬ patible undergoing objectives terminefor the direction in which his but not A and of each inform a himself apy chemotherapy. lumpec¬ assumptions phy¬ interests seem to lie. To enable the patient to with radiation maximizes sician's to his or her tomy your approach patients. chart his course understandably, some fa¬ chance of surviving while preserving Similar statements can be imagined for miliarity with the therapeutic alternatives your breast. Radiotherapy fights your other clinical situations such as an ob¬ and their hazards becomes essential.27 (em¬ breast cancer without disfigurement. stetrician discussing prenatal testing phasis added)

Downloaded From: http://jama.jamanetwork.com/ by a Cleveland Clinic Foundation User on 09/07/2016 SHARED DECISION MAKING are inherently limited because of un¬ ates and accentuates the trend toward conscious Katz views dia¬ and Despite its dominance, many have influences, specialization impersonalization found the informative model "arid."20 logue as a mechanism for greater self- within the medical profession. The President's Commission and others understanding of one's values and Most importantly, the informative of contend that the ideal relationship does objectives. According to Katz, this view model's conception patient autonomy a and seems untenable. The in¬ not vest moral authority and medical places duty on physicians patients philosophically to reflect and communicate so that formative model that decision-making power exclusively in the presupposes per¬ can a self- sons known and fixed patient but must be a process of shared patients gain greater possess values, decision making constructed around understanding and self-determination. but this is inaccurate. People are often "mutual participation and respect."20·28 Katz' insight is also available on uncertain about what they actually want. The President's Commission that grounds other than Freudian psycho¬ Further, unlike animals, people have argues and is consistent with the what call "second order de¬ the physician's role is "to help the pa¬ logical theory philosophers tient understand the medical situation interpretive model.13 sires,"3335 that is, the capacity to reflect on their wishes and to revise their own and available courses of and the action, OBJECTIONS TO THE desires and In free¬ his or her concerns and preferences. fact, patient conveys PATERNALISTIC MODEL inhere in wishes."20 Brock and Wartman29 stress dom of the will and autonomy and this fact-value "division of labor"—hav¬ It is widely recognized that the pater¬ having "second order desires" be¬ ing the physician provide information nalistic model is justified during emer¬ ing able to change our preferences and while the patient makes value deci¬ gencies when the time taken to obtain in¬ modify our identity. Self-reflection and sions—by describing "shared decision formed consent might irreversibly harm the capacity to change what we want the such limited cir¬ often a of moral de¬ making" as a collaborative process patient.1·2·20 Beyond require "process" cumstances, however, it is no longer ten¬ liberation in which we assess the value in both which physicians and patients make able to assume that the physician and pa¬ of what we want. And this is a process active and essential contributions. Physi¬ tient similar values and views of that occurs with other who know medical knowl¬ espouse people cians bring their training, what constitutes a benefit. us well and can articulate a vision of who and an under¬ Consequently, edge, expertise—including even advocate we to be that we can assent to.13 standing of the available treatment physicians rarely the pa¬ ought ternalistic model as an ideal for routine Even in health or im¬ alternatives—to the diagnosis and manage¬ though changes ment of patients' condition. Patients bring physician-patient interactions.32 plementation of alternative interven¬ of their own aims and tions can have profound effects on what knowledge subjective TO THE values, through which risks and benefits of OBJECTIONS we desire and how we realize our de¬ INFORMATIVE MODEL various treatment options can be evaluated. sires, self-reflection and deliberation play With this approach, selecting the best treat¬ The informative model seems both de¬ no essential role in the informative ment for a particular patient requires the scriptively and prescriptively inaccu¬ physician-patient interaction. The infor¬ contribution of both parties. rate. First, this model seems to have no mative model's conception ofautonomy is Similarly, in discussing ideal medical place for essential qualities of the ideal incompatible with a vision of autonomy decision making, Eddy30 argues for this physician-patient relationship. The in¬ that incorporates second-order desires. fact-value division of labor between the formative cares for the pa¬ physician OBJECTIONS TO THE physician and patient as the ideal: tient in the sense of competently imple¬ the selected interven¬ INTERPRETIVE MODEL to the decision menting patient's It is important separate pro¬ tions. However, the informative physi¬ The interpretive model rectifies this cess into these two steps. . . . The first step cian lacks a that that is a question of facts. The anchor is empiri¬ caringapproach requires deficiency by recognizing persons what the values have second-order desires and cal evidence. . [T]he second step is a understanding patient dynamic question not of facts. . but ofpersonal values or or should value and how his or her ill¬ value structures and placing the eluci¬ preferences. The thought process is not an¬ ness impinges on these values. Patients dation of values in the context of the alytic but personal and subjective. . . [I]t seem to expect their physician to have patient's medical condition at the center is the patient's preferences that should. de¬ a caring approach; they deem a techni¬ of the physician-patient interaction. . . . I termine the decision. Ideally, you and cally proficient but detached physician Nevertheless, there are objections to are not in the What [the physicians] picture. as and condemned. the model. matters what Mrs. Smith thinks. deficient, properly interpretive is 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. making 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 "transmitting medical information and been given to the patient.25 Yet, if one impose their own values under the guise using their technical skills as the patient ofthe essential qualities ofthe ideal phy¬ of articulating the patient's values. And directs."20 Thus, while the advocates of sician is the ability to assimilate medical patients, overwhelmed by their medical "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 view in¬ patient's view into a recommendation sition. Such circumstances may push the forming their ideal reembodies the infor¬ designed for the patient's specific med¬ interpretive model toward the pater¬ mative model under a different label. ical and personal condition,35·25 then the nalistic model in actual practice. Other commentators have articu¬ informative physician cannot be ideal. Further, autonomy viewed as self-un¬ lated more mutual models of the phy¬ Second, in the informative model the derstanding excludes evaluative judg¬ sician-patient interaction.5·6·25 Promi¬ ideal physician is a highly trained subspe- ment of the patient's values or attempts nent among these efforts is Katz'31 The cialist who provides detailed factualinfor¬ to persuade the patient to adopt other Silent World ofthe Doctor and Patient. mation and competently implements the values. This constrains the guidance and Relying on a Freudian view in which patient's preferred medical intervention. recommendations the physician can of¬ self-knowledge and self-determination Hence, the informative model perpetu- fer. Yet in practice, especially in pre-

Downloaded From: http://jama.jamanetwork.com/ by a Cleveland Clinic Foundation User on 09/07/2016 ventive medicine and risk-reduction in¬ receive health care, not to engage in determine whether they are desirable; terventions, physicians often attempt moral deliberation or to revise their affirm, upon reflection, these values as to persuade patients to adopt particular values. Finally, like the interpretive ones that should justify their actions; health-related values. Physicians fre¬ model, the deliberative model may eas¬ and then be free to initiate action to quently urge patients with high choles¬ ily metamorphose into unintended pa¬ realize the values. The process of de¬ terol levels who smoke to change their ternalism, the very practice that gen¬ liberation integral to the deliberative dietary habits, quit smoking, and begin erated the public debate over the model is essential for realizing patient exercise programs before initiating drug proper physician-patient interaction. autonomy understood in this way. therapy. The justification given for these Second, our society's image ofan ideal is that should value THE PREFERRED MODEL AND THE is not limited to one who knows changes patients PRACTICAL IMPLICATIONS physician their health more than they do. Simi¬ and communicates to the patient rele¬ larly, physicians are encouraged to per¬ Clearly, under different clinical cir¬ vant factual information and compe¬ suade their human immunodeficiency vi¬ cumstances different models may be ap¬ tently implements medical interven¬ rus (HlV)-infected patients who might propriate. Indeed, at different times all tions. The ideal physician—often em¬ be engaging in unsafe sexual practices four models may justifiably guide phy¬ bodied in literature, art, and popular either to abstain or, 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 not made to promote the HIV-infected shared, paradigmatic reference; excep¬ values to make a recommendation and, patient's own health, but are grounded tions to use other models would not be through discussion, attempts to per¬ on an appeal for the patient to assume automatically condemned, but would re¬ suade the patient to accept this recom¬ responsibility for the good of others. 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 ofhealth issues and related val¬ the the paternalistic model cor¬ ues. The physician's discussion does not OBJECTIONS THE patient, TO rectly guides physician-patient interac¬ invoke values that are unrelated or tan- DELIBERATIVE MODEL tions. Conversely, for patients who have gentially related to the patient's illness The fundamental objections to the de¬ clear but conflicting values, the interpre¬ and potential therapies. Importantly, liberative model focus on whether it is tive model is probably justified. For in¬ these efforts are not restricted to situ¬ proper for physicians to judge patients' stance, a 65-year-old woman who has ations in which patients might make "ir¬ values and promote particular health- been treated for acute leukemia may have rational and harmful" choices29 but ex¬ related values. First, physicians do not clearly decided against reinduction che¬ tend to all health care decisions. possess privileged knowledge of the pri¬ motherapy if she relapses. Several Third, the deliberative model is not a ority of health-related values relative to months before the anticipated birth ofher disguised form of paternalism. Previ¬ other values. Indeed, since ours is a first grandchild, the patient relapses. The ously there may have been category mis¬ pluralistic 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 and view therapy in order to live to see her first tified as physician paternalism. And no of which values are higher will conflict grandchild or whether to refuse therapy, doubt, in practice, the deliberative phy¬ with those of other physicians and those resigning herselfto not seeing her grand¬ sician may occasionally lapse into pa¬ of his or her patients. child. In such cases, the physician may ternalism. However, like the ideal 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 circumstances, where tempts topersuade the patient ofthe wor¬ tient, the physician's recommended in¬ there is only a one-time physician-patient thiness of certain values, not to impose terventions, and the actual treatments interaction without an ongoing relation¬ those values paternalistically; the physi¬ used will depend on the values of the ship in which the patient's values can be cian's aim is not to subject the patient to particular physician treating the patient. elucidated and compared with ideals, his or her will, but to persuade the patient However, recommendations and care such as in a walk-in center, the informa¬ of a course of action as desirable. In the provided to patients should not depend tive model may be justified. Laws, Plato37 characterizes this funda¬ on the physician's judgment of the wor¬ Descriptively and prescriptively, we mental distinction between persuasion thiness of the patient's values or on the claim that the ideal physician-patient and imposition for medical practice that physician's particular values. As one relationship is the deliberative model. distinguishes the deliberative from the bioethicist put it36: We will adduce six points to justify this paternalistic model: claim. the deliberative model more The hand is broken; the physician can repair First, A physician to slaves never gives his patient embodies our ideal of autonomy. the hand; therefore the physician must re¬ nearly any account of his illness . . . the physician It is an and distortion pair the hand—as well as possible—without oversimplification offers some orders gleaned from experience regard to personal values that might lead the ofthe Western tradition to view respect¬ with an air of infallible knowledge, in the physician to think ill of the patient or of the ing autonomy as simply permitting a brusque fashion of a dictator. The free

. . . patient's values. . . . [A]t the level of clinical person to select, unrestricted by coer¬ physician, who usually cares for free men, practice, medicine should be value-free in cion, ignorance, physical interference, treats their diseases first by thoroughly dis¬ sense his friends the that the personal values of the and the like, his or her course cussing with the patient and his not preferred This physician should distort the making of of action from a list of ailment. way he learns something from medical decisions. comprehensive the sufferer and instructs him. available Freedom and con¬ simultaneously options.34·35 Then the physician does not give his medica¬ de¬ trol over medical decisions alone do Third, it may be argued that the not tions until he has persuaded the patient; the liberative model misconstrues the pur¬ constitute patient autonomy. Autonomy physician aims at complete restoration of pose of the physician-patient interac¬ requires that individuals critically as¬ health by persuading the patient to comply tion. Patients see their physicians to sess their own values and preferences; with his therapy.

Downloaded From: http://jama.jamanetwork.com/ by a Cleveland Clinic Foundation User on 09/07/2016 Fourth, physician values are relevant shapes both the physician's and the pa¬ 713-715. to and do inform their choice of tient's from control 6. Szasz TS, Hollender MH. The basic models of patients expectations patient the doctor-patient relationship. Arch Intern Med. a physician. When a pregnant woman to moral development. Most important, 1956;97:585-592. chooses an obstetrician who does not we must recognize that developing a de¬ 7. Weber M; Parsons T, ed. The Theory of Social routinely perform a battery of prenatal liberative physician-patient relationship and Economic Organization. New York, NY: The Free 1947. tests one who a considerable amount of time. Press; or, alternatively, requires 8. Ballantine HT. Annual discourse\p=m-\thecrisis in when a We a health care strongly favors them; patient must develop financing ethics, anno domini 1979. N Engl J Med. 1979;301: seeks an aggressive cardiologist who system that properly reimburses— 634-638. favors procedural interventions or one rather than penalizes—physicians for 9. Burke G. Ethics and medical decision-making. Prim Care. who concentrates on the time to discuss values with 1980;7:615-624. therapy dietary taking 10. Veatch RM. Models for ethical medicine in a stress and their changes, reduction, life-style patients. revolutionary age. Hastings Cent Rep. 1975;2:3-5. or 11. Stone AA. Mental Health and Law: A in modifications, they are, consciously CONCLUSION System not, selecting a physician based on the Transition. New York, NY:JasonAronsonInc; 1976. 12. A. Virtue. South Ind: values that his or her medical de¬ Over the last few the dis¬ Maclntyre After Bend, guide decades, University of Notre Dame Press; 1981. cisions. And, when disagreements be¬ course regarding the physician-patient 13. Sandel MJ. Liberalism and the Limits of Jus- tween physicians and patients arise, relationship has focused on two ex¬ tice. New York, NY: Cambridge University Press; there are discussions over which values tremes: autonomy and paternalism. 1982. 14. Fried C. The as friend: the moral foun- are more and should be real¬ have attacked as lawyer important Many physicians pa¬ dations of the lawyer client relationship. Yale Law ized in medical care. Occasionally, when ternalistic, urging the empowerment of J. 1976;85:1060-1089. such disagreements undermine the patients to control their own care. This 15. Jones JH. Bad Blood. New York, NY: Free physician-patient relationship and a view, the informative model, has be¬ Press; 1981. 16. Final the a care is trans¬ come dominant in bioethics and Report of Tuskegee Syphilis Study caring attitude, patient's legal Ad Hoc Advisory Panel. Washington, DC: Public ferred to another physician. Indeed, in standards. This model embodies a de¬ Health Service; 1973. the informative model the grounds for fective conception of patient autonomy, 17. Brandt AM. Racism and research: the case of transferring care to a new physician is and it reduces the physician's role to the Tuskegee Syphilis Study. Hastings Cent Rep. either the or in¬ that of a The essence of 1978;8:21-29. physician's ignorance technologist. 18. Krugman S, GilesJP. Viral hepatitis: new light But seem is a fabric of un¬ competence. patients to doctoring knowledge, on an old disease. JAMA. 1970;212:1019-1029. switch physicians because they do not derstanding, teaching, and action, in 19. Ingelfinger FJ. Ethics of experiments on chil- "like" a physician or that which the caring physician integrates dren. N Engl J Med. 1973;288:791-792. particular for attitude or the medical condition and 20. President's Commission the Study of Ethical physician's approach. patient's Problems in Medicine and Biomedical and Behavioral Fifth, we seem to believe that physi¬ health-related values, makes a recom¬ Research. Making Health Care Decisions. Washing- cians should not only help fit therapies mendation on the appropriate course of ton, DC: US Government Printing Office; 1982. to the patients' elucidated values, but action, and tries to persuade the patient 21. Statement on a Patient's Bill of Rights. Chi- should also health-related val¬ of the worthiness of this and cago, Ill: American Hospital Association; Novem- promote approach ber 17, 1972. ues. As noted, we expect physicians to the values it realizes. The physician with 22. Uniform Rights of the Terminally Ill Act. In: promote certain values, such as "safer a caring attitude is the ideal embodied Handbook of Living Will Laws. New York, NY: sex" for patients with HIV or abstain¬ in the deliberative model, the ideal that Society for the Right to Die; 1987:135-147. 23. Bouvia V 225 Cal 297 from or alcohol use. Simi¬ should inform laws and that Superior Court, Rptr ing limiting policies reg¬ (1986). are their ulate the interaction. larly, patients willing to adjust physician-patient 24. Natanson V Kline, 350 P2d 1093 (Kan 1960). values and actions to be more compati¬ Finally, it may be worth noting that the 25. Appelbaum PS, Lidz CW, Meisel A. Informed ble with health-promoting values.38 four models outlined herein are not lim¬ Consent: Legal Theory and Clinical Practice. New NY: Oxford Press 3. This is in the nature of a ited to the medical in¬ York, University Inc; 1987:chap seeking caring realm; they may 26. Faden RR, Beauchamp TL. A History and medical recommendation. form the public conception of other pro¬ Theory of Informed Consent. New York, NY: Ox- Finally, it may well be that many phy¬ fessional interactions as well. We suggest ford University Press Inc; 1986. sicians currently lack the training and ca¬ that the ideal relationships between law¬ 27. Canterbury V Spence, 464 F2d 772 (DC Cir 1972). to articulate the values and mentor and la¬ 28. Brock D. The ideal of shared decision-making pacity underlying yer client,14 religious between physicians and patients. Kennedy Insti- their recommendations and persuade pa¬ ity, and educator and student are well de¬ tute J Ethics. 1991;1:28-47. tients that these values are worthy. But, scribed by the deliberative model, at least 29. Brock DW, Wartman SA. When competent in part, this deficiency is a consequence of in some of their essential aspects. patients make irrational choices. N Engl J Med. the tendencies toward and 1990;322:1595-1599. specialization We would like to thank Robert Mayer, MD, 30. Eddy DM. Anatomy of a decision. JAMA. the avoidance of discussions of values by Craig Henderson, MD, Lynn Peterson, MD, and 1990;263:441-443. physicians that are perpetuated and jus¬ John Stoeckle, MD, as well as Dennis Thompson, 31. Katz J. The Silent World of Doctor and Pa- tified by the dominant informative model. PhD, Arthur Applbaum, PhD, and Dan Brock, tient. New York, NY: Free Press; 1984. if the deliberative model PhD, for their critical reviews of the manuscript. 32. Tannock IF, Boyer M. When is a cancer treat- Therefore, We would also like to thank the "ethics and the pro¬ ment worthwhile? N Engl J Med. 1990;322:989-990. seems then we need most appropriate, to fessions" seminar participants, especially Robert 33. Frankfurt H. Freedom of the will and the con- implement changes in medical care and Rosen, JD, Francis Kamm, PhD, David Wilkins, JD, cept of a person. J Philosophy. 1971;68:5-20. education to encourage a more caring ap¬ and Oliver Avens, who enlightened us in discussions. 34. Taylor C. Human Agency and Language. New We must stress York, NY: Cambridge University Press; 1985:15-44. proach. understanding 35. Dworkin G. The and Practice Au- References Theory of rather than mere provisions offactual in¬ tonomy. New York, NY: Cambridge University formation in keeping with the legal stan¬ 1. Veatch RM. A Theory of Medical Ethics. New Press; 1988:chap 1. dards of informed consent and medical York, NY: Basic Books Inc Publishers; 1981. 36. Gorovitz S. Doctors' Dilemmas: Moral Con- Macklin R. Mortal Choices. New NY: and Medical Care. we must educate 2. York, flict New York, NY: Oxford malpractice; physicians Pantheon Books Inc; 1987. University Press Inc; 1982:chap 6. not just to spend more time in physician- 3. Ingelfinger FJ. Arrogance. N Engl J Med. 37. Plato; Hamilton E, Cairns H, eds; Emanuel patient communication but to elucidate 1980;304:1507. EJ, trans. Plato: The Collected Dialogues. Prince- and articulate the values underlying their 4. Marzuk PM. The right kind of paternalism. ton, NJ: Princeton University Press; 1961:720 c-e. N J Med. 38. Walsh DC, et al. medical care decisions, including routine Engl 1985;313:1474-1476. Hingson RW, Merrigan DM, 5. Siegler M. The progression of medicine: from The impact of a physician's warning on recovery we shift the assumed ones; must publicly physician paternalism to patient autonomy to bu- after alcoholism treatment. JAMA. 1992;267:663- conception of patient autonomy that reaucratic parsimony. Arch Intern Med. 1985;145: 667.

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