Who is the Boss?

The answer to the question "who is the boss?" in the relationship between a physician and the patient was a no-brainer up until 20-40 years ago -- it was the physician. The physician was the party educated in medicine and medical treatment and it was the patient who was the recipient of the results of that education. Nothing more..nothing less. A patient called upon a physician for diagnosis and treatment and it was mainly the physician who made the decisions and then offered them to the patient for final approval. The approval process was not so much based on patient education on the issue but more based on trust. Society looks back on this relationship and now calls it "physician paternalism"-- the physician acting in medical matters as the parent of the patient.


Much has changed in the past few decades. With the development of consumerism and with the associated greater education of the public into matters medical there has been a pressure to deminish the strength of physician paternalism. In addition, there has arisen the discipline of medical bioethics which has come forth with principles of ethical behavior in medicine and particularly stressing one principle -- patient autonomy-- the patient has the right and duty to make their own educated decisions about their own healthcare. Together, consumerism and bioethics have led to a change in the doctor-patient relationship from paternalism to patient autonomy. The question arises as to whether this has been a change to improve medical care in the latter 20th and now 21st century or whether the change is detrimental. Patient autonomy has been associated with guidelines and laws to make the physician responsible for assuring that the patient is as best informed about what decisions are available for the condition and informed about the details of benefit and risk with each of the decisions. The physician may suggest a course but finally it becomes the patient to make an informed decision for the patient's own healthcare for which the physician may follow. Patient autonomy suggests that patients may, through education from sources beyond the physician, request courses which the physician wouldn't offer or might be even against standard medical practice. This patient behavior would either produce an unproductive tension between the parties or if the physician "gave in" might lead to unnecessary expense or unnecessary patient harm.


Before I go any further in this discussion of "who is the boss?", I would ask my blog visitors who are old enough to have experienced medical care during the "paternalistic" era as well as now in the "patient autonomy" period to make a comparison of how one felt about this change. Do you recognize any differences in your relationship to your doctors or in decision-making? In which era did you feel the most comfortable or satisfied? I realize that much has changed also between then and now including different doctors, HMOs, procedures and treatment which might affect your answer but let me know what you think. What relationship between doctor and patient do you think should be the most appropriate for the best in medical care?..Maurice.