Paternalism Revisited – Science-Based Medicine
Download Citation on ResearchGate | Doctor-patient Relationship: From Medical Paternalism to Enhanced Autonomy | For centuries, physicians have been. One argument is that weak paternalism allows the physician to stay completely hands-off. If the patient is in a. Singapore Med J. Mar;43(3) Doctor-patient relationship: from medical paternalism to enhanced autonomy. Chin JJ(1). Author information.
Is it justified to override the DNR order if you think the patient will recover and thank you? Is there really any such thing as fair informed consent?
The way the doctor presents the options can influence perceptions. He may be frightened of chemotherapy because a family member went through an unusually bad experience. He may reject intubation because of false beliefs. A surgeon may not be entirely objective when recommending surgery over medical treatment.
Doctor-patient Relationship: From Medical Paternalism to Enhanced Autonomy
What if the patient refuses life-saving treatment? First, do no harm, I had been taught, but what about the harm a patient can inflict upon himself?
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- Doctor-patient Relationship: From Medical Paternalism to Enhanced Autonomy
- Paternalism Revisited
A model might be willing to accept a greater risk of death to avoid a scar. We have to respect differences of judgment and patient autonomy, but do we go too far? Informed consent was intended to protect patients, but in practice it is often used to protect doctors from hard decisions or to abdicate responsibility.
A signed consent form provides some protection from malpractice suits. If the outcome is poor, doctors can blame the patient for a poor decision. Maybe a little judicious beneficent paternalism is not such a bad thing after all. This meant that the individual history of the patient didn't matter in providing care, so the patient him or herself was irrelevant in the medical encounter. Thus it was deemed necessary that physicians make decisions for patients.
This view of paternalism was only encouraged by the rise of hospitals in the later 18th century. Because patients in hospitals were often sick and disabled, the view of them as passive recipients of medical care only became more prevalent. The movement away from paternalism can be traced back to the relationship between early psychologists and their patients. In particular, Josef Breuer and Sigmund Freud urged that importance be placed on communication with and understanding of the patient.
This sharply contrasted the view of patients as passive, and placed them at the center of the medical encounter.
These practices also treated patients as unique, instead of simply being a collection of symptoms to be fixed by a paternalistic doctor. InSzasz and Hollender  introduced three models of paternalism to the medical community, thereby legitimizing the view that doctors did not necessarily have to dominate patients. The models are as follows: Activity—passivity refers to the traditional version of paternalism, in which the doctor treats the patient as one who cannot or should not make decisions.
This relationship is similar to that of a parent and child.
Treatment is performed "irrespective of the patient's contribution and regardless of outcome. Guidance—co-operation is a relationship used in more long-term situations.
The doctor provides instructions to the patient, to which the patient is expected to comply.
Doctor-patient relationship: from medical paternalism to enhanced autonomy.
The name comes from the expectation that the physician will guide the patient, who will co-operate, but who retains their individuality. Mutual participation involves the physician making it clear that he or she is not infallible and does not always know what is best.
This model is more of a partnership, in which the doctor helps the patient to help him or herself. This model is often employed in cases of chronic disease or pain, in which the patient can have a higher degree of freedom and be more independent of the doctor. The fundamental difference lies in the patient's capacity to make well-informed decisions for themselves. As such, even if the doctor disagrees with the patient's desire, he or she will not intervene as long as the patient is of sound mind.
Strong or extended paternalism involves a doctor superseding a patient's requests in cases where the doctor has determined a better course of action, even when the patient's requests are made voluntarily.