Four Models of the Physician-Patient Relationship

Introduction

The relationship between physicians and patients has evolved, marked by a struggle between patient autonomy and physician authority.
This struggle influences expectations, ethical standards, informed consent, and legal duties.
The central question is: What should the ideal physician-patient relationship be?
Four models of physician-patient interaction are outlined, focusing on:
- Goals of the interaction.
- Physician's obligations.
- Role of patient values.
- Conception of patient autonomy.
These models serve as ideals, not minimum ethical or legal standards.

The Paternalistic Model

Also known as the parental or priestly model.
Goal: To ensure patients receive interventions that best promote their health and well-being.
Physician's Role: Determines the patient's condition, identifies the best treatments, and presents selected information to encourage consent.
Core Assumption: Shared objective criteria exist for determining what is best, allowing the physician to discern the patient's best interest with limited patient participation.
Emphasis: Prioritizes patient well-being over autonomy.
Physician acts as a guardian, placing the patient's interests first.
Conception of Patient Autonomy: Patient assent to the physician's determinations of what is best.

The Informative Model

Also called the scientific, engineering, or consumer model.
Goal: To provide the patient with all relevant information, enabling them to select the interventions they want, which the physician then executes.
Physician's Role: Informs the patient of their disease state, possible interventions, risks, benefits, and uncertainties.
Core Assumption: Clear distinction between facts and values; patient's values are well-defined, but they lack facts.
Physician's Obligation: Provide all available facts without imposing their own values.
Physician as a technical expert providing the means for the patient to exercise control.
Conception of Patient Autonomy: Patient control over medical decision-making.

The Interpretive Model

Goal: To elucidate the patient's values and help them select interventions that align with those values.
Physician's Role: Provides information and assists the patient in understanding and articulating their values.
Core Assumption: Patient's values may be inchoate and conflicting, requiring clarification.
Physician helps reconstruct the patient's goals, aspirations, commitments, and character to specify their values.
The patient ultimately decides which values and actions fit them best.
Physician refrains from judging the patient's values, instead helping them understand and use them.
Physician as a counselor, supplying information and helping to elucidate values.
Conception of Patient Autonomy: Self-understanding; the patient gains clarity about who they are and how medical options relate to their identity.

The Deliberative Model

Goal: To help the patient determine and choose the best health-related values that can be realized in the clinical situation.
Physician's Role: Delineates information on the patient's clinical situation and helps elucidate the values embodied in available options.
The physician suggests why certain health-related values are more worthy and should be pursued, aiming for moral persuasion without coercion.
Core Assumption: Engaging in moral deliberation helps the patient and physician judge the worthiness and importance of health-related values.
Physician acts as a teacher or friend, engaging the patient in dialogue about the best course of action, indicating what the patient should do.
Conception of Patient Autonomy: Moral self-development; the patient considers alternative health-related values and their implications for treatment.

Comparing the Four Models

All models incorporate patient autonomy, but they differ in their conception of it.

Table x. Comparing the Four Models

	Paternalistic	Informative	Interpretive	Deliberative
Patient Values	Objective and shared by physician and patient	Defined, fixed, and known to the patient	Inchoate and conflicting, requiring elucidation	Open to development and revision through moral discussion
Physician's Role	Guardian	Competent technical expert	Counselor or advisor	Friend or teacher
Physician's Obligation	Promoting the patient's well-being	Providing factual information and implementing	Elucidating and interpreting patient values and implementing patient's intervention	Articulating and persuading the patient of the most admirable values implementing patient's intervention
Patient Autonomy	Assenting to objective values	Choice of, and control over, medical care	Self-understanding relevant to medical care	Moral self-development

An Aberrant Model

Instrumental model: The physician aims for a goal independent of the patient's values, such as the good of society or the furtherance of scientific knowledge. (e.g., Tuskegee syphilis experiment and the Willowbrook hepatitis study).
Considered an aberration.

Clinical Case Examples

A 43-year-old pre-menopausal woman diagnosed with a 3.5 cm ductal carcinoma.
Each model suggests a different approach to advising the patient.

Paternalistic Model Response

Mastectomy or radiation. Lumpectomy and radiation offers the best survival and the best cosmetic result, it is to be preferred. Chemotherapy has side effects. Nevertheless , a few months of hardship now are worth the potential added years of life without cancer.

Informative Model Response

Mastectomy and lumpectomy with radiation result in identical overall survival. Chemotherapy prolongs survival for premenopausal women who have axillary nodes involved with tumor.

Interpretive Model Response

Fighting your cancer is important, but it must leave you with a healthy self-image and quality time outside the hospital. undergoing radiation therapy but not chemotherapy. A lumpectomy with radiation maximizes your chance of surviving while preserving your breast. Radiotherapy fights your breast cancer without disfigurement. Conversely, chemotherapy would prolong the duration of therapy by many months.

Deliberative Model Response

undergo radiation therapy. The best one for you is to enter a trial that is investigating the potential benefit of chemotherapy for women with node-negative breast cancer.

The Current Debate

A push for greater patient autonomy, framed as patient choice and control.
Reflected in the adoption of business terms in medicine (patients as consumers).
Evident in patient rights statements, living will laws, and human experimentation rules.
Informed consent standards moving toward a patient-oriented approach.

Shared Decision Making

An ideal relationship involves shared decision-making built around mutual participation and respect.
Division of labor: physicians provide information, and patients make value decisions.
This view vests medical decision-making authority with the patient, casting physicians as technicians.

Objections to the Paternalistic Model

Acceptable in emergencies but not as a routine model.
Assumption of shared values is no longer tenable.

Objections to the Informative Model

Lacks essential qualities of a caring physician-patient relationship.
Physician is proscribed from giving a recommendation.
Perpetuates and accentuates specialization and impersonalization within the medical profession.
Presupposes that persons possess known and fixed values, but this is inaccurate.

Objections to the Interpretive Model

Technical specialization militates against physicians cultivating the skills necessary to the interpretive model.
May push the interpretive model towards the paternalistic model in actual practice.
Excludes evaluative judgment of the patient's values.

Objection to the Deliberative Model

Focus on whether it is proper for physicians to judge patients' values and promote particular health-related values.
Physicians do not possess privileged knowledge of the priority of health-related values.
Patients see their physicians to receive health care, not to engage in moral deliberation or to revise their values.
The deliberative model may easily metamorphose into unintended paternalism, the very practice that generated the public debate over the proper physician-patient interaction.

The Preferred Model

Under different clinical circumstances different models may be appropriate.
The deliberative model more nearly embodies our ideal of autonomy.
The process of deliberation integral to the deliberative model is essential for realizing patient autonomy understood in this way.
Our society's image of an ideal physician is not limited to one who knows and communicates to the patient relevant factual information and competently implements medical interventions.
The deliberative model is not a disguised form of paternalism.
Physician values are relevant to patients and do inform their choice of a physician.
Physicians should also promote health-related values.
We must educate physicians not just to spend more time in physician-patient communication but to elucidate and articulate the values underlying their medical care decisions.
We must shift the publicly assumed conception of patient autonomy that shapes both the physician's and the patient's expectations from patient control to moral development.
Most important, we must recognize that developing a deliberative physician-patient relationship requires a considerable amount of time.

Conclusion

The discourse regarding the physician-patient relationship has focused on two extremes: autonomy and paternalism.
The essence of doctoring is a fabric of knowledge, understanding, teaching, and action, in which the caring physician integrates the patient's medical condition and health-related values, makes a recommendation on the appropriate course of action, and tries to persuade the patient of the worthiness of this approach and the values it realizes.
The physician with a caring attitude is the ideal embodied in the deliberative model, the ideal that should inform laws and policies that regulate the physician-patient interaction.
The ideal relationships between lawyer and client, religious mentor and laity, and educator and student are well described by the deliberative model.