Anna Mead-Robson: In defence of paternalism

anna1I recently had the good fortune to attend “Medicine Unboxed,” a two day series of talks and events exploring the links between art and medicine. This year as an audience we were asked to consider the proposal: “Patient choice will be the death knell of the NHS.” What followed was a debate covering a range of issues: from whether true patient choice is possible in the current economic climate, to the role of paternalism in the consultation room.

Perhaps understandably, the event organisers welcomed views from “both doctors and non-doctors.” I have a confession to make. I am both a doctor and a non-doctor. Indeed, I personally find the distinction ridiculous; we will all succumb to the status of non-doctor at some stage in our lives, be it after an unexpected skiing accident or when we are living out our final days in an EMI (elderly mentally infirm) nursing home.

When I went to medical school in 2005, it was hammered into me that informed patient choice is a key component of most clinical decisions. The concept of paternalism was always frowned upon. Doctors of a bygone era got it wrong in their paternalistic approach. We, the enlightened doctors of the 21st Century, listened to our patients, and informed and empowered them to make their own decisions.

To this day the doctor side of me, to some extent, fears taking a paternalistic approach. I fear getting it wrong. I fear going against the grain of medical and political opinion. I am never sure how to respond when asked the dreaded question, “But what would you do doctor?”

But the non-doctor side of me, at times, craves paternalism.

Earlier this year I found myself the victim of a cruel, albeit brief, depressive episode. At no stage did I lose capacity, but despite understanding, retaining, weighing up, and communicating my decisions, this was a grossly “slowed,” confusing, and painful process. During moments of slowness I longed for decisions to be made for me. Indeed, the moment my psychiatrist announced I would be re-starting a medication I loathed and resisted, I breathed a sigh of relief. I cannot be the only person to have felt this.

As a non-doctor, I visit other doctors because I want their expert opinion. I want to know their experiences of prescribing a particular treatment and what they would do in my shoes. If it was simply a matter of learning the pros and cons of a treatment, I would pay a trip to Dr Google for advice.

Of course shared decision making is important, as has been argued by Layla McCay in a previous blog. In most circumstances, I would actively encourage involving patients in decisions about their care. But I would argue that by continuing to champion patient choice at the expense of “old fashioned” paternalism we risk depriving some patients of the advice and relief they are seeking.

Anna Mead-Robson is a CT2 psychiatry trainee and former BMJ Clegg scholar.

Competing interests: None declared.

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  • Oliver Boney

    As an anaesthetist, I
    also grapple with the notions of ‘informed patient choice’. Every patient ought
    to have a say on what we’re planning to do to them in the operating theatre,
    with a clear understanding of the intended benefits and the possible risks,
    right? Trouble is, we often don’t know the risks – nor can we predict the
    benefits: we are still a long way from being able to offer patients
    personalised risk scores, because our risk prediction tools just aren’t that
    robust. Quantifying the pros and cons of any healthcare decision is fraught
    with difficulty, and the idea that doctors have all the information at their
    fingertips to empower patients to make an informed choice is a fallacy. By all
    means let’s promote patient choice, but let’s not leave them
    to shoulder the burden of making life-changing decisions without our support.

  • arnold_armadillo

    Anna finishes by writing: “But I would argue that by continuing to champion patient choice at the expense of “old fashioned” paternalism we risk depriving some patients of the advice and relief they are seeking.”

    It is more important than that. By insisting that every patient be directly involved in any decision, we are denying our professional responsibility. As trained professionals, we need to be able to recognise which patients want involvement, and which do not. We need to recognise when all choices need explaining and when they do not. If we simply assume that every patient wants all information, or complete involvement, then we risk harming patients who do not want that information or involvement; and we risk harming them just as much as those patients who do want the information from whom we withhold it.

    Too many developments in medicine seem to be steadily removing the professional part of being a doctor. There are ways of getting doctors down from pedestals without losing professionalism: it’s a matter of babies and bath water.

    Neville W Goodman
    Retired Anaesthetist