Empowering Patients is Good Medical Care

Walter and Ross rightfully argue that healthcare providers need to employ a less authoritarian, more empowering approach if they want to support patients’ behavioral changes. They show how motivational interviewing (MI), informed by self-determination theory, engages patients and thus may inspire enduring changes. They ground these interventions in an important, new model of relational autonomy, emphasizing the patient’s self-respect and self-cohesion as well as self-determination, and they show how patient–provider interactions influence these three aspects of autonomy. It may be surprising then, that in the first part of this essay, I argue that it is problematic for them to ground their empowerment model in the ethical obligation to respect patient autonomy. In the second part of this essay, I offer an alternative justification for their important practical recommendations, arguing that the obligation to empower patients derives not from the patient’s autonomy rights, but from the provider’s foundational responsibility to promote the patient’s health and well-being.

It may seem fitting to locate an obligation to promote autonomy under the existing autonomy rights that patients have but an argument is needed. My best attempt at reconstructing the author’s argument is as follows. First, children and adolescents develop their capacity for autonomy socially. Second, social contexts influence the degree to which adults can articulate and act on their values (which I call exercising their autonomy). Third, caregivers thus influence whether or not patients develop their capacities for autonomy. Fourth, if caregivers are to respect patients in virtue of their capacities for autonomy, they ought to promote those capacities.

The first two claims are empirical, and the evidence supports them. The third claim is problematic. The concept of ‘capacities’ rather than ‘capacity’ needs to be unpacked. Although I endorse the authors’ view of full autonomy as including self-cohesion and self-respect as well as self-determination, their use of the term ‘capacities’ is confusing for another reason. Walter and Ross seem to use the plural term to reject the existing distinction between having a threshold capacity and then exercising it or not. That is, they seem to view the very capacity for self-determination as itself fluid and dependent on social contexts.

However, it is a mistake to speak of caregivers influencing the adult patient’s development of capacities for autonomy. Although it is true that illness makes people vulnerable, dependent, and subject to their doctors’ influence, a sick adult does not usually rely on her healthcare providers to develop her capacity for autonomy. There is no logical reason to describe an inability to do something as a lack of capacity. When a patient is silenced or even unable to think in the presence of an oppressive doctor, we have no reason to say she lacks the capacity to speak.

Most important, the field of bioethics has sought to delineate a clear threshold for decision-making capacity (which is a truncated version of the capacity for autonomy) precisely to protect the rights of adult patients to make decisions that doctors do not agree with. Patients are not obligated to exercise their capacity for autonomy by deliberating and acting from their considered values. This means that patients have the right to make their decisions however they want to, including by flipping a coin, even though caregivers might rightfully attempt to dissuade them from doing so.

When a patient fails to meet the threshold conditions for decision-making capacity (in relation to a specific decision), doctors are obligated to help restore it. This may mean overriding the patient’s immediate expressions and choices. Doctors should not do this when patients do have decision-making capacity but are not exercising it. Yet by blurring the distinction between the capacity for autonomy and exercising autonomy, this might seem permissible. An ironic result of trying to expand the scope of the very strong (and limited) obligation to respect autonomy to include an obligation to scaffold autonomy is that it may promote paternalism.

Consider how public health interventions aimed at empowering people often involve soft...