Art by Craig Klugman, Ph.D. from his essay Rise of Neopaternalism on Bioethics.net
In prior blogs in this series, we introduced the concept of person-centered care as a human right, defined it, and reviewed the evidence suggesting person-centered care improves multiple important health outcomes. In reviewing this literature, there are very few arguments against person or patient-centered care. In fact, most of the critiques are actually about improving and refining person-centeredness rather than abandoning it. (1) So, why is it that for decades, person-centered care has remained an exciting aspiration rather than a reality? (2)
To make the shift towards person-centered care, we must first acknowledge that there are strong cultural and economic forces that support our current non-person-centered approach; there are people who, consciously or not, prefer non-person-care and benefit from it. If our healthcare system was simply driven by the best evidence, person-centered care would have happened some time ago. What we need now is not more research, but cultural and political changes. Or, in the words of the rap group Public Enemy, “We’ve got to fight the powers that be.”
The most immediate barrier to person-centered care is the culture of medical paternalism, a culture in which doctors are assumed to know what is best for their patients and supported in making decisions for them. Outside of cults and dictatorships, the main place we see this drastic imbalance of power and presumed competence is the parent-child relationship; therefore, the term paternalism is highly appropriate. Paternalism is deeply ingrained in the culture of medicine with roots going back at least to Hippocrates who advised physicians to “conceal most things from the patient.” (3) The benefits of paternalism to doctors and other healthcare providers include a sense of control, power, and respect, often compared to a god-like status. Even for doctors who are consciously aware that paternalism does not fit their values, it takes a very conscious effort to develop new habits and skills in working with patients, and many are not aware of some of the subtle ways that paternalism may still show up in their practice (e.g. dismissing certain types of questions or requests). (4)
A less direct consequence of medical paternalism is that by sacrificing the sacredness and centrality of the patient’s voice in healthcare decisions, doctors have opened the door for other players in the healthcare system (e.g. insurance companies, hospital administrators) to also make decisions for the patient (and sometimes the doctor), a situation termed neopaternalism. When we don’t put patients first, other, often financially-driven considerations, can take priority. (5) While this is seen to some degree in socialized medicine, it is much more rampant in the US market-driven medical system where special interests push to cut costs and increase efficiency (the “McDonaldization” of medicine)(6) while simultaneously working to boost utilization of high-cost medications and procedures. (7)
A final barrier to truly person-centered care is a tendency for healthcare professionals to treat patients as people in proportion to various metrics of worth, including similarity to the healthcare professional and social status. (1) This tendency may in part underlie disparities in care-based on race and class, (8) improvements in outcomes for individuals seeing a provider of their same gender or race,(9) and overtreatment and testing (often with deleterious consequences) for patients deemed to be VIPs (very important people).(10)
These considerations are not unidirectional, meaning that healthcare providers and administrators may also be the victims of non-person-centered care, particularly when they are treated as a role rather than a person. Medical paternalism is perpetuated when doctors are treated like gods (or robots, or agents of pharmaceutical companies) rather than people, a situation that also harms doctor-patient relationships and can lead to feelings of helplessness on the part of doctors.11 Similarly, part of the gender and race concordance effect may be an increased willingness for patients to trust and listen to their doctor. In my own work advocating for person-centered care, I’ve found that hospital administrators often care deeply about patients and welcome the opportunity to support person-centered projects. Getting to this point, however, required me to drop my assumptions that they only cared about the bottom line and creating presentations that incorporated both business and human elements.
This takes us to my belief that making the shift to person-centered care is possible. However, it will require us to do more than acquire research evidence; we need to change the culture of medicine. Healthcare providers will need training to develop skills in person-centered care, and awareness to break habits of paternalism.(12,13) Hospitals and clinics will need to reconsider structures and policies–ideally involving persons living with serious illness in redesign and ongoing management–to put patients first in reality rather than just in motto. Politicians must work to put patients (e.g. everyone with a body) above special interest groups representing various stakeholders in the healthcare industry.(5) Last, and perhaps most importantly, we must all enter our healthcare encounters as full people, demanding respect for ourselves and loved ones, and allowing for the possibility that healthcare workers would also benefit from the freedom and compassion inherent in being a person rather than a role.
References:
1. Hansson SO, Froding B. Ethical conflicts in patient-centered care. Clinical Ethics. 2020.
2. Bezold C. The future of patient-centered care: scenarios, visions, and audacious goals. J Altern Complement Med. 2005;11 Suppl 1:S77-84.
3. Taylor K. Paternalism, participation and partnership – the evolution of patient centeredness in the consultation. Patient Educ Couns. 2009;74(2):150-155.
4. Moore L, Britten N, Lydahl D, Naldemirci O, Elam M, Wolf A. Barriers and facilitators to the implementation of person-centred care in different healthcare contexts. Scand J Caring Sci. 2017;31(4):662-673.
5. Slavitt A. The triple aim must overcome the triple threat. JAMA FOrum Archive. 2018.
6. Dorsey ER, Ritzer G. The McDonaldization of Medicine. JAMA Neurol. 2016;73(1):15-16.
7. Rosenthal E. An American Sickness. New York, NY: Penguin Press; 2017.
8. Kawachi I, Daniels N, Robinson DE. Health disparities by race and class: why both matter. Health Aff (Millwood). 2005;24(2):343-352.
9. Greenwood BN, Carnahan S, Huang L. Patient-physician gender concordance and increased mortality among female heart attack patients. Proc Natl Acad Sci U S A. 2018;115(34):8569-8574.
10. Gershengoren L. Our Duty to the “VIP Patient”. J Grad Med Educ. 2016;8(5):784.
11. Greenall P. The barriers to patient-driven treatment in mental health: why patients may choose to follow their own path. Int J Health Care Qual Assur Inc Leadersh Health Serv. 2006;19(1):xi-xxv.
12. Hawkes N. Seeing things from the patients’ view: what will it take? BMJ. 2015;350:g7757.
13. Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125(9):763-769.
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