Until quite recently, the ethical principle of benificence (or paternalism, as it is also known) was the standard. This meant that the doctor was understood to be a professional with a deep understanding of a complex body of knowledge whose duty was to make complex decisions for patients with the best interests of the patient in mind. Please note that the "decider" is the doctor and that the doctor also determined what was in the patient's interests.
This article by James Hamblin in The Atlantic is an interview with Barron Lerner, whose father was an infectious disease specialist in the 1950's. The interview is in the setting of a book written by him on the evolution of medical ethics from the reflections of he and his father, both of whom are doctors.
A part of the civil rights and free speech movements was the development of ethical autonomy, in which the doctor and the patient are understood to be shared decision-makers. The physician is there to provide expert knowledge and experience, and to provide and describe a full range of options to allow the patient to be as fully informed as possible and to be able to decide for him/herself what is the best course of action.
Hamblin's article nicely addresses the intersection of autonomy with real concerns like time and differences of goals or opinions. I'm sure every doctor has had cases where they have felt that the patient was making a truly bad decision, and I'm equally sure every patient has had visits or encounters where they've simply wished the doctor would just get to the point and tell them what needed to be done. And time certainly is a factor. Fully investigating the medical concerns at hand, performing a physical examination (yes, a good directed physical examination is still valuable and helpful in arriving at a diagnosis, but it does take time) and then fully describing the range of diagnostic and treatment options, their upside and downside risks and fully answering all questions and concerns is pretty near impossible to do in fifteen minutes in all but the most straightforward problems or concerns. This is of course coupled with patient focus-grouping which reveals the importance of completeness and length of time with the doctor. And also promptness. Doh! Hello, quality-control triangle!
This article by Brandon Cohen in Medscape talks about the elephant in the exam room. Can ethical autonomy go to the extreme of consumerism? Is medicine another service in which customer satisfaction trumps the actual quality of the service? Are HealthGrades reviews of doctors just like Yelp reviews of restaurants (read closely how many negative restaurant reviews relate to dissatisfaction with wait service and not so much the actual quality of the food which is what restaurants provide)? Which is more important: that patients get the best care and have the best health, or that they are personally satisfied? When are these goals mutually exclusive and when are they not?
If it sounds like I have more questions on this than answers, that's because it's true. I do know that it's not unusual for Canadians to come to the U.S. for knee replacement because it takes longer in Canada to get MRI's or surgery for chronic conditions. I also know that Canadians live longer than Americans, and can get timely tests and treatment for serious problems. I know that most patients complain about TV ads for medicines, but I also know that the ads still run because they work. I know that a bad rating of a hospital may mean the hospital is really bad, but it also may mean they treat a lot of complicated patients with rare conditions that no one else can treat.
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