Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice

Patients faced with serious medical decisions are subject to being over- or under-influenced by physicians. Imagine a patient who is admitted to an intensive care unit with a chronic, progressive illness and has a small but real chance of leaving the hospital alive if he submits to invasive treatment. The patient feels that he has suffered enough, and he requests supportive care only. By the luck of the draw, he has been assigned one of three hypothetical physicians. Dr. Able minimizes the patient's request for supportive care, heavily emphasizes the patient's small chance of recovery and her own strong belief that the patient should not give up, and convinces the patient to continue receiving aggressive therapy. Dr. Baker makes sure that the patient understands his options and the statistics associated with them and then accedes to the patient's request for supportive care without sharing his own opinion, which is that the patient is making a serious mistake. Dr. Charlie enters into an extended dialogue with the patient, explores various alternatives, and recommends that the patient try aggressive therapy. When the patient continues to request a palliative approach, Dr. Charlie struggles openly with the patient about her concern that he is making this transition prematurely. Through conversation, Dr. Charlie learns the rationale behind the patient's decision and assures herself that the patient is well informed. She then initiates a palliative care plan. Data from SUPPORT (Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment [1]) suggest that the dominant mode of decision making in acute care hospitals may still be the paternalism evidenced by Dr. Able. However, recognition of the value of patient autonomy has gained strength in the United States, and a new generation of physicians has been trained in a patient-centered approach [2]. Some patient-centered physicians have gone beyond encouraging patients to participate in medical decisions, forcing them to make decisions almost independently. Dr. Baker allowed the patient in the above scenario to take full control of a critical decision, but he avoided the intense interaction that would have resulted if he had shared his own reservations. He tried to respect his patient's autonomy, but he did so at the cost of withholding his recommendations. On the other hand, Dr. Charlie allowed her patient to have a central role in the final decision but only after fully exploring the implications of that decision and sharing her belief that palliative care was not the patient's best choice. Such intense interactions between patient and physician may allow patients to exercise autonomy more powerfully by making choices that fully integrate the physician's experience with their own. The Shift from Paternalism to Autonomy Twenty-five years ago, most major medical decisions were left exclusively in the hands of physicians. They were usually made with beneficent intent but without open discussion, much less the full participation of the patient [3-6]. This paternalistic approach had some benefits. Physicians struggled to make the best possible decisions on behalf of patients, and they spared patients and their families from agonizing about interventions that had little chance of working. Practitioners also had much more control over the way that medical technology, with its increasing potential to help as well as to harm, was used. In retrospect, physicians now see obvious problems with excessive paternalism: It can be difficult to determine what a patient's best interests are [7]; inappropriate biases caused by sex, race, and socioeconomic status can affect decision making [8, 9]; and patients can be deprived of the opportunity to make decisions that reflect the reality of their conditions. However, some of the truly beneficent potential of medical paternalism has been lost. In the United States in the late 20th century, the pendulum has swung away from paternalism and toward patient autonomy [10, 11]. Too often, autonomous patients and families are asked to make critical medical decisions on the basis of neutrally presented statistics, as free as possible from the contaminating influences of physicians. The causes of this trend are multifactorial. The consumer movement has taught patients to be more assertive, to question physicians' recommendations, and to demand interventions that might otherwise be withheld [12, 13]. Many physicians feel that giving patients the full range of choices and withholding their own recommendations are safeguards against lawsuits [14, 15]. The probabilistic nature of medical decision making in real life is in unnerving contrast to the grand successes and simplistic solutions suggested in the mass media [16, 17]. The information explosion within the field of medicine has left physicians and their patients uncertain about whether the limitations they encounter are inherent in medicine or are a reflection of deficits in the physician's expertise [18, 19]. Furthermore, when a bad outcome results from a good clinical decision, the chagrin that a physician feels is more emotionally painfuland the risk for being sued is higherif that decision was recommended to the patient [16, 20]. Many physicians have come to believe that the safest course is to withhold their recommendations and give patients the choice of any treatment they might want. We intend to show that physicians fail to use their power appropriately when they withhold their guidance. This failure reflects a misunderstanding about the moral requirements of respecting patient autonomy. We compare an independent choice model of medical decision making with an enhanced autonomy approach Table 1 and suggest ways to achieve a more effective, respectful balance between physician recommendations and patient choice. Table 1. Characteristics of Two Medical Decision Making Models Independent Choice According to the independent choice model, the physician's primary role in medical decision making is to inform patients about their options and the odds of success. Patients should be free to make choices unencumbered by the contaminating influence of the physician's experience or other social forces [19]. The independent choice model is literally patient-centered and requires that physicians withhold their recommendations because they might bias the patient [21]. The physician should objectively answer questions but should avoid influencing the patient to take one path or another, even if the physician has strong opinions or if the patient asks for advice. After the patient makes the decision, the physician's duty is to implement the medical aspects of that decision. As evidence of the force and pervasiveness of the independent choice model, debates rage about whether patients have the right to choose futile treatment [22, 23] and continue it indefinitely [24]. A generation of physicians has now been trained under the independent choice model, and this has created new problems as serious as those posed by medical paternalism. The physician as a person, with values and experience, has become an impediment to rather than a resource for decision making. More objective treatment algorithms could better be presented by using interactive computer systems. Physicians may gradually regress from refusing to express their recommendations to not valuing them or to not even formulating them. Too often, the intense exchanges on medical rounds about what should be done have been replaced by a bland recitation of statistics. The primary intellectual exercise is to cover all of the possibilities, the odds associated with them, and their implications for treatment. The central clinical tasks are to inform patients about their medical options and then to carry out patients' decisions. Patients in this situation often navigate treacherous medical terrain without adequate medical guidance. Enhanced Autonomy The independent choice model reflects a limited conceptualization of autonomy [25-27]. Under this model, it is thought that an independent choice is best made with no external influence, even when one's competence to make the choice is limited. However, autonomous medical choices are usually enhanced rather than undermined by the input and support of a well-informed physician. Only after a dialogue in which physician and patient aim to influence each other might the patient fully appreciate the medical possibilities [28-31]. Consider, by analogy, the decision to select medicine as a career. Few potential physicians made this decision by wandering alone in the desert to avoid being influenced by the biases of others. Most engaged both peers and senior mentors in extended conversations, confident that they could correct for any biases. The absence of valuable advice that would result if they did not engage experienced persons outweighed the danger that the final choice would be made as a result of inappropriate influence. It is patronizing to imagine that our patients cannot make decisions in a similar manner, especially when many are desperately asking for guidance. Enhancing patient autonomy requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient's values and their own, and then offer recommendations that consider both sets of values and experiences. This model is relationship-centered (both patient and physician, and sometimes family members and others, are included in the decision making process) rather than exclusively patient-centered [32]. It denies neither the potential imbalance of power in the relationship nor the fact that some patients might be inappropriately manipulated or coerced by an overzealous physician. It assumes that an open dialogue, in which the physician frankly admits his or her biases, is ultimately a better protector of the patient's right to autonomous choice than artific