Ezekiel J. Emanuel, MD, PhD, Linda L. Emanuel, MD, PhD
DURING the last two decades or so, there has been a struggle over the patient's rolein medical decision making that is often characterized as a conflict between autonomy and health, between the values of the patient and the values of the physician. Seeking to curtail physiciandominance, many have advocated an ideal of greater patient control.1,2 Others question this ideal because it fails to acknowledge the potentially imbalanced nature of this interaction when one party issick and searching for security, and when judgments entail the interpretation of technical information.3,4 Still others are trying to delineate a more mutual relationship.5,6 This struggle shapes theexpectations of physicians and patients as well as the ethical and legal standards for the physician's duties, informed consent, and medical malpractice. This struggle forces us to ask, What should bethe ideal
interaction.7 Consequently, they do not embody minimum ethical or legal stan¬ dards, but rather constitute regulative ideals that are "higher than the law" but not "above the law."8
THEPATERNALISTIC MODEL First is the paternalistic model, some¬ times called the parental9 or priestly10 model. In this model, the physician-pa¬ tient interaction ensures that patients receive theinterventions that best pro¬ mote their health and well-being. To this end, physicians use their skills to determine the patient's medical condi¬ tion and his or her stage in the disease process and toidentify the medical tests and treatments most likely to restore the patient's health or ameliorate pain. Then the physician presents the patient with selected information that will en¬ courage thepatient to consent to the intervention the physician considers
We shall outline four models of the
physician-patient interaction, emphasizing the different...