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It is no secret that all is not well -- and hasn't been for some time now -- in the realm of doctor-patient relations. Patients should have trust in the expertise of their physicians, and yet, study after study indicates the erosion of such trust. At the same time, the pressures of the modern clinical setting encourage a growing distance between doctors and their patients. In Patient Autonomy and the Ethics of Responsibility, Alfred Tauber provides an engagingly written diagnosis of the situation, and offers some necessarily rough suggestions towards a cure for the disease.
We cannot do adequate justice here to the depth and extent of Tauber's explanation of how medicine came to be in the state that it is in. However, he points his finger at four broad trends that have encouraged a growing mistrust between patients and their doctors. First -- and this is not an uncommon view -- there is the economics of modern health care provision, which reduces health care to the status of a commodity. Such an institutional setting places the interests of patients and their health care providers at odds: where patients desire care and cure, and desire that their care be administered in a humane way, providers work under imperatives of efficiency and cost-effectiveness. Patients are all too aware that their interests are in tension with those of the institutions taking "care" of them, and this leads to the erosion of trust.
Second, the twentieth century trend towards positivism and scientific reductionism has had the effect of reducing patients to their diseases in the eyes of scientific physicians; medicine is viewed as the manipulation of causes and effects to reach a desired goal (patient health), while ignoring the fact that the patient herself may have divergent goals and needs. Cold scientism replaces the traditionally personal and collaborative nature of the patient-physician relationship.
Third, Tauber blames the rise of "defensive medicine" resulting from the proliferation of malpractice claims. Here it is hard to tell which comes first, the chicken or the egg: was the growth of malpractice litigation the result of growing mistrust of doctors, or did high-profile cases of medical abuse result in growing distrust, and consequently litigation? In any case, scientific reductionism encouraged doctors to work single-mindedly on the cure of patients, while subordinating the needs and desires of the patients themselves. Abuses often are the result of doctors who cavalierly disregard their patients qua human beings in their quest for cures, or else of doctors who simply do not listen to their patients. As an illustration, Tauber cites studies showing that a mere sixteen to twenty-two seconds elapse from between when a patient first begins to explain her primary concern to when her doctor interrupts her. In any event, Tauber urges doctors to recognize that medicine is an inherently value-laden practice, and that aspirations for a dispassionate and objective medical science are misguided. Doctors must listen to their patients, and the values and personal needs of those patients must be made to count in medicine.
At the same time, doctors must avoid the natural response to this, which hitherto has been a stress on autonomy and on rituals of "informed consent". A misplaced reliance on poorly-defined notions of autonomy is the fourth root of the loss of trust that Tauber identifies. He spends a good portion of his book outlining the historical development of ideas of autonomy and the role they have come to play in medical ethics. For our purposes, we can note two of the difficulties Tauber sees in current practices of autonomy. First, sick patients are too often not in a position to exercise their supposed autonomy and would actually be better off deferring to the expertise of a physician; it is simply too much to expect a weakened and vulnerable patient to take on the kind of responsibility for health that a robust autonomy would demand. Second, it is often too much to expect patients -- and not only weak and vulnerable ones -- to gain a deep enough knowledge of diagnoses, prognoses, and available treatment options. Thus, the ritual of "informed consent" begins to look a little hollow, and even worse, it may even look from the patient's viewpoint as if the physician is simply attempting to avoid responsibility and litigation, thereby contributing to the erosion of trust in the doctor-patient relationship.
So much for Tauber's diagnosis of the problem. What does he offer by way of solution? Speaking broadly, he has two strategies, both of which clearly place the onus on medical practitioners. The main one involves changes in the medical education physicians receive. This would involve four improvements (p. 217 ff.): (i) "a radical assertion of medical ethics as foundational to medical education", (ii) inculcating an appreciation of how value is necessarily embedded in medical practice, (iii) "a thorough grounding in the ethics of humane care", involving the cultivation of empathy, as well as rewarding good clinical practice among students, and (iv) "selecting medical students with a broadened vision of medicine", including admissions policies that emphasize character in addition to simple academic aptitude.
The second strategy, besides educational reform, involves adding what he calls an "ethical workup" to the standard patient medical chart. Such a workup would include personal, social, and ethical issues that have a bearing on the effective care of individual patients, and that take account of patients' personal histories and health care goals.
Tauber's book is largely addressed to practicing clinicians and to the educators of such clinicians. It does not touch on pressing issues of medical research and technology, nor is it concerned with concrete issues like, say, the allocation of scarce health care resources -- topics which are the usual bread and butter of bioethicists. The book is simply concerned with rebuilding trust in the personal relationship between a doctor and her patient. Although the book could be improved by including some more concrete examples and case studies, it is written in a clear and lively style by a man of obviously humane outlook and is well worth reading, particularly by those who may be tired of typically "principlist" approaches to medical ethics, especially ones that privilege notions of patient autonomy.
© 2007 James Pratt
James Pratt is currently completing his PhD in philosophy at York University in Toronto, Canada. His main area of research is in moral psychology.
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