Patient Autonomy and the Twenty-First Century Physician

In this issue of the Report, Daniel Groll suggests new ways to understand old tensions between autonomy and paternalism. He categorizes disagreements between doctors and patients in four ways. Some are about the ends or goals of medical treatment. For these, he claims, patient choices are based upon patient values, and physicians should neither challenge nor assess them. More common are disagreements about the appropriate means to achieve an agreed-upon goal. These subdivide into two distinct categories—those in which the relative efficacy of possible means is “medically assessable” and those in which it is not. When disagreements are medically assessable, Groll argues, doctors can legitimately challenge patient choices because their training makes them experts regarding which treatments are most likely to achieve certain ends. Thus, doctors can—and should—help patients understand whether surgery or physical therapy is more likely to relieve back pain. So far, this is relatively uncontroversial.

The controversy emerges with those disagreements about means that are, as Groll puts it, nonmedically assessable. Consider a patient with strep throat who wants to get better but believes God will cure him. We know the relative efficacy of antibiotics. But empirically assessing whether God will bring about his cure is impossible. Thus, the relative efficacy of antibiotics compared to faith is not medically accessible.

Nevertheless, Groll defends a legitimate role for physicians in such nonmedically assessable means-end disagreements. The role he defines, however, is uniquely twenty-first century; he advocates neither the unbridled paternalism of traditional medical ethics nor the rigid, simplistic deference to patient autonomy of the late twentieth century. He acknowledges that medical expertise is not relevant in these cases but argues that the doctor’s role should not be limited to that of technical expert. She can also offer advice as a sensible person who wants to help the patient reach the best possible decision. Medical providers should “hold firm (but not hubristically or dogmatically so) to their conceptions of their patients’ good, while recognizing that in many cases their confidence in what is best is not rooted in their medical expertise.”

Groll’s taxonomy highlights two aspects of the physician’s role—one as a technical expert, the other as a knowledgeable and caring person. In that latter role, physicians can offer nonmedical recommendations without violating patient autonomy. This simple concept sometimes gets lost in spirited defenses of autonomy that view doctors as inordinately powerful and patients as inordinately susceptible to authority.

Groll’s provocative arguments suggest that doctors can function as moral agents rather than as comprehensive interactive databases of objective information. From this perspective, his arguments do not go far enough. If doctors can step outside of the role of legitimate medical authority to weigh in on disagreements about nonmedically assessable means, why could they not legitimately participate in discussions about ends? Why should “the constraints demanded by the need to respect patients’ autonomy” forbid physicians playing any role in such disagreements?

This gets to the fundamental question of what it means to truly respect a competent patient’s autonomy. Does it mean that physicians should not inquire about, critically discuss, or even challenge their patients’ choices of ends? Or does it only mean that clinicians should ultimately accede to patients’ choices? These are two very different roles.

In allowing physicians to challenge patients on nonmedically assessable means, Groll offers the caveat that the clinician must carefully delineate “between her roles as someone who has a tremendous amount of medical knowledge and someone who is specially tasked to look out for the patient’s well-being.” With such a caveat, clinicians could also engage patients in discussions about the goals of therapy.

But can physicians step between roles in this way, and will patients understand if they try? The real question this challenging paper raises is whether the physician-patient relationship has changed. In the past, concerns about patients’ lack of medical knowledge and psychological vulnerability grounded ethical limitations on what doctors could do. But today’s patients may be different. Often, they are not acutely ill. They have access to more medical...