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 role in 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 is sick 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 be the 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 the interventions 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 to identifythe 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 the patient to consent to the intervention the physician considers
We shall outline four models of the
physician-patient interaction, emphasizing the different understandingsof (1) the goals of the physician-patient inter¬ action, (2) the physician's obligations, (3) the role of patient values, and (4) the conception of patient autonomy. To elab¬ orate the abstract description of these four models, we shall indicate the types of response the models might suggest in a clinical situation. Third, we shall also
indicate how these models inform the current debate aboutthe ideal physicianpatient relationship. Finally, we shall evaluate these models and recommend one as the preferred model. As outlined, the models are Weberian ideal types. They may not describe any particular physician-patient interactions but highlight, free from complicating de¬ tails, different visions of the essential characteristics of the physician-patient
From the Division of CancerEpidemiology and Control, Dana-Farber Cancer Institute, Boston, Mass (E.J.E.); Program in Ethics and the Professions, Kennedy School of Government, Harvard University,
Mass (EJE. and L.L.E.); and Division of Medical Ethics, Harvard Medical School, Boston, Mass (L.L.E.). L.L.E. is also a Teaching and Research Scholar of the American College of Physicians. Reprint requests to Division of CancerEpidemiology and Control, Dana-Farber Cancer Institute, 44 Binney St, Boston, MA 02115 (Dr E. J. Emanuel).
best. At the extreme, the physician au¬ thoritatively informs the patient when the intervention will be initiated. The paternalistic model assumes that there are shared objective criteria for determining what is best. Hence the physician can discern what is in the pa¬ tient's bestinterest with limited patient participation. Ultimately, it is assumed that the patient will be thankful for de¬ cisions made by the physician even if he or she would not agree to them at the time.11 In the tension between the pa¬ tient's autonomy and well-being, be¬ tween choice and health, the paternal¬ istic physician's main emphasis is to¬ ward the latter. In the paternalistic model, the...