AMA Journal of Ethics^®

Peter Ubel's article¹ addresses a quandary experienced by many health care professionals: how to offer quality medical advising without falling back on a paternalistic attitude of commanding patients.

In general, people concentrate their education in a specific area, leaving them with inadequate knowledge in other areas. This is why you go to your lawyer for legal inquiries, your butcher for cooking questions, and your doctor for medical advice. Ubel points out that patients turn to doctors to answer their medical questions in a non-biased and professional manner. In the past, many doctors took a paternalistic approach to advising their patients and influencing medical decisions. That is not accepted as the best model today. Many doctors struggle to find a balance between paternalism and involving their patients in the decision-making process. The modern problem, according to Ubel, is one of accepting responsibility.

Ubel cites several situations in which people are psychologically "more averse to harms of commission than to harms of omission." In the long run, people may regret not having experienced certain things, says Ubel, but they will regret their mistakes of commission more. In his example, Ubel cites the polio vaccine of the 1970s. Some people contracted polio from the vaccine itself. The chance of getting polio from the vaccine, however, was 10-fold less than the chance of contracting it normally. But parents still chose not to vaccinate their children out of a fear of commission; they just didn't want to be responsible for the suffering of their child.

Patients do not want to assume the responsibility for their treatment decisions, but neither do docs. Ubel says that many patients are used to the paternalistic model of the medical profession so they willingly submit to their doctor's decisions. But, Ubel argues, the doctor's role is to advise, not to command. In some cases, just explaining the odds of success and the risks associated with options A and B is enough to help the patient make up his mind. A doctor hears new research findings every day. If the results are strong enough to convince him or her to favor a procedure, says Ubel, they will probably convince the patient, too.

Involving the patient in the decision-making process may also be accomplished by changing the format of the questions. Most patients are not scientists, and therefore need to hear things in their own language. An explanation of various diabetes treatments on the biochemical and statistical level may go completely over the patient's head.

Ubel describes a case where he admitted a patient with emphysema to the hospital for a pulmonary infection. He notes that, if the patient got worse, he would have to be transferred to the ICU and intubated while antibiotics were administered. When asked if he would like to go through with this sort of treatment, the patient asked the doctor for advice. Ubel presented the situation of going on a ventilator to the patient in terms of levels of risk. "Then, rather than ask him what he wanted to do," says Ubel, "I simply asked him what kind of patient he was." The patient said, "I'm the kind of person who's willing to take a chance, even if it's only 1 percent." Ubel replied, "Then I recommend, for now, we keep open the option of ventilation." Ubel concludes, "I don't know who made that decision, but I think it was the right one at the time."

Questions for Discussion

1. If a doctor tries to convince a patient to enter into a particular method of treatment, is that doctor compromising the patient's autonomy?
2. When does a doctor cross the line between advising and deciding for patients?
3. Is it coercion if a physician tries to convince a patient to enter into a particular method of treatment by using argument and data?
4. Is it ethical to make the patient the "active decision maker" by asking if he's a risk-taker rather than asking if he wants the therapy?
5. What justifies a "correct choice"? Is it the unbiased, statistically better one? Is it the one with which the patient has the most security? Is it the one with which the physician feels most comfortable?
6. What should a patient do when his personal values conflict with a paternalistic doctor's decision?
7. Should physicians always recommend the statistically better treatment (Ubel's polio example)?
8. How does Ubel's suggested decision-making process relate to the success of the patient-physician relationship? To the physician's professionalism? To patient responsibility?