Cuatro Modelos de La Relación Médico-Paciente
Cuatro Modelos de La Relación Médico-Paciente
Cuatro Modelos de La Relación Médico-Paciente
Physician-Patient Relationship
Ezekiel J. Emanuel, MD, PhD, Linda L. Emanuel, MD, PhD
DURING the last two decades or so, interaction.7 Consequently, they do not neering,10 or consumer model. In this
there has been a struggle over the pa- embody minimum ethical or legal stan¬ model, the objective of the physician-
tient's role in medical decision making dards, but rather constitute regulative patient interaction is for the physician
that is often characterized as a conflict ideals that are "higher than the law" but to provide the patient with all relevant
between autonomy and health, between not "above the law."8 information, for the patient to select the
the values of the patient and the values medical interventions he or she wants,
of the physician. Seeking to curtail phy- THE PATERNALISTIC MODEL and for the physician to execute the se¬
sician dominance, many have advocated First is the paternalistic model, some¬ lected interventions. To this end, the
an ideal of greater patient control.1,2 Oth- times called the parental9 or priestly10 physician informs the patient of his or
ers question this ideal because it fails to model. In this model, the physician-pa¬ her disease state, the nature of possible
acknowledge the potentially imbalanced tient interaction ensures that patients diagnostic and therapeutic interven¬
nature of this interaction when one party receive the interventions that best pro¬ tions, the nature and probability of risks
is sick and searching for security, and mote their health and well-being. To and benefits associated with the inter¬
when judgments entail the interpreta- this end, physicians use their skills to ventions, and any uncertainties ofknowl¬
tion of technical information.3,4 Still oth- determine the patient's medical condi¬ edge. At the extreme, patients could
ers are trying to delineate a more mutual tion and his or her stage in the disease come to know all medical information
relationship.5,6 This struggle shapes the process and to identify the medical tests relevant to their disease and available
expectations of physicians and patients as and treatments most likely to restore interventions and select the interven¬
well as the ethical and legal standards for the patient's health or ameliorate pain. tions that best realize their values.
the physician's duties, informed consent, Then the physician presents the patient The informative model assumes a
and medical malpractice. This struggle with selected information that will en¬ fairly clear distinction between facts and
forces us to ask, What should be the ideal courage the patient to consent to the values. The patient's values are well de¬
physician-patient relationship? intervention the physician considers fined and known; what the patient lacks
We shall outline four models of the best. At the extreme, the physician au¬ is facts. It is the physician's obligation
physician-patient interaction, emphasiz- thoritatively informs the patient when to provide all the available facts, and
ing the different understandings of (1) the intervention will be initiated. the patient's values then determine what
the goals of the physician-patient inter¬ The paternalistic model assumes that treatments are to be given. There is no
action, (2) the physician's obligations, there are shared objective criteria for role for the physician's values, the phy¬
(3) the role of patient values, and (4) the determining what is best. Hence the sician's understanding of the patient's
conception of patient autonomy. To elab¬ physician can discern what is in the pa¬ values, or his or her judgment of the
orate the abstract description of these tient's best interest with limited patient worth of the patient's values. In the
four models, we shall indicate the types participation. Ultimately, it is assumed informative model, the physician is a
of response the models might suggest in that the patient will be thankful for de¬ purveyor of technical expertise, provid¬
a clinical situation. Third, we shall also cisions made by the physician even if he ing the patient with the means to ex¬
indicate how these models inform the or she would not agree to them at the ercise control. As technical experts, phy¬
current debate about the ideal physician- time.11 In the tension between the pa¬ sicians have important obligations to pro¬
patient relationship. Finally, we shall tient's autonomy and well-being, be¬ vide truthful information, to maintain
evaluate these models and recommend tween choice and health, the paternal¬ competence in their area of expertise,
one as the preferred model. istic physician's main emphasis is to¬ and to consult others when their knowl¬
As outlined, the models are Weberian ward the latter. edge or skills are lacking. The concep¬
ideal types. They may not describe any In the paternalistic model, the physi¬ tion of patient autonomy is patient con¬
particular physician-patient interactions cian acts as the patient's guardian, artic¬ trol over medical decision making.
but highlight, free from complicating de¬ ulating and implementing what is best for
tails, different visions of the essential the patient. As such, the physician has ob¬ THE INTERPRETIVE MODEL
characteristics of the physician-patient ligations, including that of placing the pa¬ The third model is the interpretive
tient's interest above his or her own and model. The aim of the physician-patient
From the Division of Cancer Epidemiology and
soliciting the views of others when lacking interaction is to elucidate the patient's
Control, Dana-Farber Cancer Institute, Boston, Mass adequate knowledge. The conception of values and what he or she actually wants,
(E.J.E.); Program in Ethics and the Professions, patient autonomy is patient assent, either and to help the patient select the avail¬
Kennedy School of Government, Harvard University, at the time or later, to the physician's de¬ able medical interventions that realize
Cambridge, Mass (EJE. and L.L.E.); and Division of
Medical Ethics, Harvard Medical School, Boston, Mass
terminations of what is best. these values. Like the informative phy¬
(L.L.E.). L.L.E. is also a Teaching and Research
Scholar of the American College of Physicians. THE INFORMATIVE MODEL sician, the interpretive physician pro¬
vides the patient with information on
Reprint requests to Division of Cancer Epidemiology Second is the informative model,
and Control, Dana-Farber Cancer Institute, 44 Binney the nature of the condition and the risks
St, Boston, MA 02115 (Dr E. J. Emanuel). sometimes called the scientific,9 engi- and benefits of possible interventions.
Beyond this, however, the interpretive choose the best health-related values tient autonomy. Therefore, no single
physician assists the patient in eluci¬ that can be realized in the clinical situ¬ model can be endorsed because it alone
dating and articulating his or her values ation. To this end, the physician must promotes patient autonomy. Instead the
and in determining what medical inter¬ delineate information on the patient's models must be compared and evalu¬
ventions best realize the specified val¬ clinical situation and then help elucidate ated, at least in part, by evaluating the
ues, thus helping to interpret the pa¬ the types of values embodied in the avail¬ adequacy of their particular conceptions
tient's values for the patient. able options. The physician's objectives of patient autonomy.
According to the interpretive model, include suggesting why certain health- The four models are not exhaustive.
the patient's values are not necessarily related values are more worthy and At a minimum there might be added a
fixed and known to the patient. They should be aspired to. At the extreme, fifth: the instrumental model. In this
are often inchoate, and the patient may the physician and patient engage in de¬ model, the patient's values are irrele¬
only partially understand them; they liberation about what kind of health- vant; the physician aims for some goal
may conflict when applied to specific related values the patient could and ul¬ independent of the patient, such as the
situations. Consequently, the physician timately should pursue. The physician good of society or furtherance of scien¬
working with the patient must elucidate discusses only health-related values, that tific knowledge. The Tuskegee syphilis
and make coherent these values. To do is, values that affect or are affected by experiment15"17 and the Willowbrook hep¬
this, the physician works with the pa¬ the patient's disease and treatments; he atitis study18·19 are examples of this
tient to reconstruct the patient's goals or she recognizes that many elements of model. As the moral condemnation of
and aspirations, commitments and char¬ morality are unrelated to the patient's these cases reveals, this model is not an
acter. At the extreme, the physician disease or treatment and beyond the ideal but an aberration. Thus we have
must conceive the patient's life as a nar¬ scope of their professional relationship. not elaborated it herein.
rative whole, and from this specify the Further, the physician aims at no more
patient's values and their priority.12·13 than moral persuasion; ultimately, co¬ A CLINICAL CASE
Then the physician determines which ercion is avoided, and the patient must To make tangible these abstract de¬
tests and treatments best realize these define his or her life and select the or¬ scriptions and to crystallize essential dif¬
values. Importantly, the physician does dering of values to be espoused. By en¬ ferences among the models, we will il¬
not dictate to the patient; it is the pa¬ gaging in moral deliberation, the phy¬ lustrate the responses they suggest in a
tient who ultimately decides which val¬ sician and patient judge the worthiness clinical situation, that of a 43-year-old
ues and course of action best fit who he and importance of the health-related val¬ premenopausal woman who has recently
or she is. Neither is the physician judg¬ ues. discovered a breast mass. Surgery re¬
ing the patient's values; he or she helps In the deliberative model, the physi¬ veals a 3.5-cm ductal carcinoma with no
the patient to understand and use them cian acts as a teacher or friend,14 en¬ lymph node involvement that is estro¬
in the medical situation. gaging the patient in dialogue on what gen receptor positive. Chest roentgen-
In the interpretive model, the physi¬ course of action would be best. Not only ogram, bone scan, and liver function
cian is a counselor, analogous to a cab¬ does the physician indicate what the pa¬ tests reveal no evidence of metastatic
inet minister's advisory role to a head of tient could do, but, knowing the patient disease. The patient was recently di¬
state, supplying relevant information, and wishing what is best, the physician vorced and has gone back to work as a
helping to elucidate values and suggest¬ indicates what the patient should do, legal aide to support herself. What
ing what medical interventions realize what decision regarding medical ther¬ should the physician say to this patient?
these values. Thus the physician's ob¬ apy would be admirable. The concep¬ In the paternalistic model a physician
ligations include those enumerated in tion of patient autonomy is moral self- might say, "There are two alternative
the informative model but also require development; the patient is empowered therapies to protect against recurrence
engaging the patient in a joint process not simply to follow unexamined pref¬ of cancer in your breast: mastectomy or
of understanding. Accordingly, the con¬ erences or examined values, but to con¬ radiation. We now know that the sur¬
ception of patient autonomy is self-un¬ sider, through dialogue, alternative vival with lumpectomy combined with
derstanding; the patient comes to know health-related values, their worthiness, radiation therapy is equal to that with
more clearly who he or she is and how and their implications for treatment. mastectomy. Because lumpectomy and
the various medical options bear on his radiation offers the best survival and
or her identity. COMPARING THE FOUR MODELS the best cosmetic result, it is to be pre¬
The Table compares the four models ferred. I have asked the radiation ther¬
THE DELIBERATIVE MODEL on essential points. Importantly, all mod¬ apist to come and discuss radiation treat¬
Fourth is the deliberative model. The els have a role for patient autonomy; a ment with you. We also need to protect
aim of the physician-patient interaction main factor that differentiates the mod¬ you against the spread of the cancer to
is to help the patient determine and els is their particular conceptions of pa- other parts of your body. Even though
rence in the breast. The second issue cer. First, it ensures that you receive merely provides one way by which a
relates to systemic control. We know excellent medical care. At this point, we terminally-ill patient's desires regard¬
that chemotherapy prolongs survival for do not know which therapy maximizes ing the use of life-sustaining procedures
premenopausal women who have axil¬ survival. In a clinical study the schedule can be legally implemented" (emphasis
lary nodes involved with tumor. The of follow-up visits, tests, and decisions added).22 Indeed, living will laws do not
role for women with node-negative is specified by leading breast cancer ex¬ require or encourage patients to discuss
breast cancer is less clear. Individual perts to ensure that all the women re¬ the issue of terminating care with their
studies suggest that chemotherapy is of ceive care that is the best available any¬ physicians before signing such docu¬
no benefit in terms of improving overall where. A second reason to participate ments. Similarly, decisions in "right-to-
survival, but a comprehensive review of in a trial is altruistic; it allows you to die" cases emphasize patient control over
all studies suggests that there is a sur¬ contribute something to women with medical decisions. As one court put it23:
vival benefit. Several years ago, the NCI breast cancer in the future who will face The right to refuse medical treatment is ba¬
suggested that for women like yourself, difficult choices. Over decades, thou¬ sic and fundamental. Its exercise re¬
...
chemotherapy can have a positive ther¬ sands of women have participated in quires no one's approval. [T]he control¬
. . .
apeutic impact. Finally, let me inform studies that inform our current treat¬ ling decision belongs to a competent
you that there are clinical trials, for ment practices. Without those women, informed patient. ... It is not a medical
which you are eligible, to evaluate the and the knowledge they made possible, decision for her physicians to make. It is
benefits of chemotherapy for patients we would probably still be giving you a moral and philosophical decision that, be¬ . . .
with node-negative breast cancer. I can and all other women with breast cancer ing a competent adult, is [the patient's]
alone, (emphasis added)
enroll you in a study if you want. I will mastectomies. By enrolling in a trial you
be happy to give you any further infor¬ participate in a tradition in which women Probably the most forceful endorse¬
mation you feel you need." of one generation receive the highest ment ofthe informative model as the ideal
The interpretive physician might out¬ standard of care available but also en¬ inheres in informed consent standards.
line much of the same information as the hance the care of women in future gen¬ Prior to the 1970s, the standard for in¬
informative physician, then engage in erations because medicine has learned formed consent was "physician
discussion to elucidate the patient's something about which interventions are based."2426 Since 1972 and the Canter¬
wishes, and conclude, "It sounds to me better. I must tell yoti that I am not bury case, however, the emphasis has
as if you have conflicting wishes. Un¬ involved in the study; if you elect to been on a "patient-oriented" standard of
derstandably, you seem uncertain how enroll in this trial, you will initially see informed consent in which the physician
to balance the demands required for re¬ another breast cancer expert to plan has a "duty" to provide appropriate med¬
ceiving additional treatment, rejuvenat¬ your therapy. I have sought to explain ical facts to empower the patient to use his
or her values to determine what interven¬
ing your personal affairs, and maintain¬ our current knowledge and offer my rec¬
tions should be implemented.25-27
ing your psychological equilibrium. Let ommendation so you can make the best
me try to express a perspective that fits possible decision." True consent to what happens to one's self is
your position. Fighting your cancer is Lacking the normal interchange with the informed exercise of a choice, and that
important, but it must leave you with a patients, these statements may seem entails an opportunity to evaluate knowl-
healthy self-image and quality time out¬ contrived, even caricatures. Neverthe¬ edgeably the options available and the risks
side the hospital. This view seems com¬ less, they highlight the essence of each attendant upon each. . .[I]t is the prerog¬
.
model and suggest how the objectives ative of the patient, not the physician, to de¬
patible with undergoing radiation ther¬ termine for himself the direction in which his
apy but not chemotherapy. A lumpec¬ and assumptions of each inform a phy¬
interests seem to lie. To enable the patient to
tomy with radiation maximizes your sician's approach to his or her patients. chart his course understandably, some fa¬
chance of surviving while preserving Similar statements can be imagined for miliarity with the therapeutic alternatives
your breast. Radiotherapy fights your other clinical situations such as an ob¬ and their hazards becomes essential.27 (em¬
breast cancer without disfigurement. stetrician discussing prenatal testing phasis added)
is a question of facts. The anchor is empiri¬ cian lacks a caringapproach that requires
cal evidence. . [T]he second step is a understanding what the patient values have second-order desires and dynamic
question not of facts but of personal values or
. . or should value and how his or her ill¬ value structures and placing the eluci¬
preferences. The thought process is not an¬ ness impinges on these values. Patients dation of values in the context of the
alytic but personal and subjective. [I]t . .
seem to expect their physician to have patient's medical condition at the center
is the patient's preferences that should de¬ .
pair the hand—as well as possible—without It is an oversimplification and distortion offers some orders gleaned from experience
regard to personal values that might lead the of the Western tradition to view respect¬ with an air of infallible knowledge, in the
physician to think ill of the patient or of the ing autonomy as simply permitting a brusque fashion of a dictator. The free
patient's values. . .
[A]t the level of clinical
.
person to select, unrestricted by coer¬ physician, who usually cares for free men,
. . .
practice, medicine should be value-free in cion, ignorance, physical interference, treats their diseases first by thoroughly dis¬
the sense that the personal values of the and the like, his or her preferred course cussing with the patient and his friends his
physician should not distort the making of of action from a comprehensive list of ailment. This way he learns something from
medical decisions. available options.34·35 Freedom and con¬ the sufferer and simultaneously instructs him.
Then the physician does not give his medica¬
Third, it may be argued that the de¬ trol over medical decisions alone do not tions until he has persuaded the patient; the
liberative model misconstrues the pur¬ constitute patient autonomy. Autonomy physician aims at complete restoration of
pose of the physician-patient interac¬ requires that individuals critically as¬ health by persuading the patient to comply
tion. Patients see their physicians to sess their own values and preferences; with his therapy.