Error in Breast Cancer Detection Rate
Authors: Paul Mathew, David Einstein, Keren Ladin
Journal: JAMA Oncology (2016)

In Reply We described healthy paternalism as a model of guided decision making in which information and counsel is provided to patients and families in a truthful and compassionate framework by a medical team with the requisite expertise and insight.This model seeks to remedy the deliberate withholding of prognostic information and recommendations by physicians when discussing cardiopulmonary resuscitation in advanced refractory cancer at the end of life, in deference to a surprisingly common and flawed notion of patient autonomy, 1 the adverse consequences of which are yet to be fully understood.The seeds of this phenomenon in US medicine emerged from a necessary backlash against a form of paternalism that subjugated the patient's voice, values, and preferences to those of the physician.Now, in response to a swing too far toward a flawed notion of autonomy, we proposed this model in which the voice of the clinical expert is not subjugated, but is rather fully required-without constraint on the patient's voice, values, and preferences among the legitimate choices.We specifically endorse the SPIKES model 2 as a compassionate and practical strategy toward exploring patients' understanding of their illness and discerning goals, values, and preferences while offering empathy, information, and necessary guidance toward end-of-life decision making.Marron and Truog assert that healthy paternalism is incompatible with shared decision making and reject "decisions that are based on the physician's view of what is best for the patient," but they simultaneously argue that physicians have an obligation to provide recommendations and guide patients.By constraining healthy paternalism to the negative meaning of paternalism-restricting autonomy to a point where the decision is no longer the patient's-Marron and Truog obscure the ethical imperative that requires medical professionals to act in the best interest of their patients, in this case obligating them to provide an evidence-based recommendation tailored to the patient.Our approach draws on an extensive theoretical and empirical literature of soft, libertarian paternalism, 3 which demonstrates the legitimacy of limiting choices while concurrently respecting individual freedoms.By requiring the voice of the clinical expert, we also create space for discernment.The physician may recommend cardiopulmonary support to a patient with treatment-responsive disease but recommend against such support in a treatmentrefractory situation.It is ethically imperative in both circumstances for the physician to guide the patient toward beneficial, nonfutile care, and in neither case does healthy paternalism require the patient to accept the physician's guidance.In our study, physician dissatisfaction with the outcomes of end-of-life discussions was common. 1 We believe that the root of this dissatisfaction may be the habitual withholding of what doctors believe to be the truth and consequences.The United States has the highest rates of intensive care unit admissions and among the highest costs in the last 6 months of life 4 and current end-of-life discussion practices may well be one contributor.In this regard, the answer to the rhetorical question posed by Marron and Truog is that healthy paternalism is indeed healthy for patients, their families, the medical care team, and society.