Patient Doctors

In an essay in this issue of the Report, Eric Cassell—an internist, Hastings fellow, and recipient two years ago of a lifetime achievement award from the American Society for Bioethics and the Humanities—celebrates and laments what bioethics has achieved. He celebrates the field's discovery that patients are people. He laments that the field has not gone very far beyond this discovery. He believes bioethics has only a thin account of personhood, one that does not make sense either of the physician-patient relationship or of health care decisions. The problem is with autonomy: patients need autonomy, but some of the usual ways of thinking about autonomy do a disservice to patients because they make patients out to be completely self-determining—processing input from doctors and making completely independent decisions about their health care. These accounts also offer physicians no help in understanding their role.

In the lead article in this issue—and in an earlier article on which this article builds—Rebecca Kukla, a philosopher, digs into portions of Cassell's agenda. Kukla's target is "a relational understanding of autonomous inquiry." The earlier article (published in March-April 2005) argued that depending on physicians' expertise—even refusing to question some of the medical suggestions physicians make—is a perfectly appropriate part of what it means to be a self-determining patient. The present article, however, reintroduces patient independence, although in a way consistent with the earlier paper: Kukla argues that autonomy has to be understood in terms of "everyday practices of inquiry"—finding information, assessing it, making predictions and guesses, deciding whose expertise to rely on and when to rely on it, and so on. In the Internet Age, and given the crescendo of medical research, a motivated patient may put her hands on considerably more medical information about a given condition than her physician has time to do. Yet because patients are usually not trained in sorting through medical information, they must rely on physicians to help them assess it. In fact, they must rely on physicians not only to think about the scientific accuracy of their information, but also to think about how it will affect their values and preferences. Technical expertise does not reside solely with physicians; moral expertise does not reside solely with patients.

If this picture is accurate, Kukla argues, then the clinical encounter should be considerably different from one standard picture, in which the patient comes into the clinic with information only about herself and the physician wields the medical knowledge. The patient waits for the physician's medical analysis, and then the physician waits for the patient to make a choice that squares with her values. The relationship should be more collaborative on both technical and moral issues.

Kukla also offers some suggestions for how clinicians can achieve that goal. Not surprisingly, there is no magic formula; is there ever any one key to a human relationship? But as revealed in the "Another Voice" commentary by Anna Reisman, another internist, taking a deep breath when a patient pulls out a magazine clipping is a useful start.