Sunday, January 23, 2005

The New Medical Paternalism

The paternalism that was- to varying degrees- part of medical practice has largely been removed by the priority of patient autonomy and the need for informed consent. Medical ethicists seemed to agree that autonomy was important leaving little or no place for paternalism. But the paternalism as we knew it (the physician deciding what was good for the individual patient and not necessarily involving the patient in the decision) is being reborn in a much more dangerous type paternalism.
I referred to this as the "New Paternalism" in a letter to the editor of the JAMA rebutting the position of Dr. David Eddy who advocates a medical practice based on the good of the group and not of the individual patient. (JAMA April 5, 1995, vol 272, no 13 pg.996) .
The abrogation of the individual patients' welfare to the collective good is implicit in the [new] medical professionalism as articulated by the Charter of Medical Professionalism which was published in both the Lancet and The Annals of Internal Medicine. A cogent critique of this "Charter"by Dr. Jerome C. Arnett, Jr. can be found in the Medical Sentinel 2002;7 (2) 56-57. and I will not attempt to improve on his comments. Internists who have read the Annals publication of the Charter should read Arnett's paper to see what their professional organization is advocating.
What I find particularly frightening is the unabashed, explicit suggestions for implementation of this approach in the series of articles by Eddy in reply to which I wrote the 1995 letter.
Eddy (Eddy DM.Rationing resources while improving quality.JAMA 1994;272;817 824) said we must "help patient understand the consequences of a limited resource pool and the need to be fair" and he continued " in most cases the explanation might be "Well, for patients like you the appropriate approach is ...".
Dr. Robert L. Wears in his letter to JAMA said " patients in general (society) must agree to this return to a beneficent paternalism"as at least he seemed to believe that before someone would be sacrificed to the collective good, he should agree to do it. Of course "society" being a figure of speech cannot agree to anything, only individual patients could agree or disagree.
As arguably bad as the old paternalism may have been At least an individual doctor decided what was best for the individual patient.With the new paternalism the medical elite versed in the ways of outcome analysis and cost benefit analysis will decide what is good for all the patients while the individual doctor and the individual patient's assessment and values are no longer relevant let alone determinative.
Similar views to those expressed here were published- in the same general time frame as the letters to JAMA- by Chervenk and McCullough in an article in J.Clin.Ethics 1995;6:320323 titled "The threat of the new managed practice of medicine to patients'autonomy."

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