My recent brush with the “healthcare choice” concept, as well as a podcast interview I listened to with Dr. Paul Offit on Point of Inquiry put me in mind of an interesting and challenging puzzle in the philosophy of medical practice; the question of the tension between the role of health care providers as experts and the autonomy of patients of veterinary clients. I subsequently ran across an articulate and cogent discussion of this problem from the Annals of Internal Medicine, Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice, which I highly recommend to anyone interested in understanding the complexities of the relationship between healthcare providers and patients.
Briefly, human medicine has traditionally followed the paternalistic model, in which the doctor is viewed as an expert with knowledge and skills the patient does not have. The doctor is expected to determine what is best for the patient and make the treatment decisions, which the patient is expected to accept. The disadvantages of this approach are obvious. As the authors of the article from the Annals put it, “it can be difficult to determine what a patient’s best interests are; inappropriate biases caused by sex, race and socioeconomic status can affect decision making; and patients can be deprived of the opportunity to make decisions that reflect the reality of their conditions.” The paternalistic model ultimate fails to give appropriate respect to the rights of patients to control their bodies and lives.
Many decisions made in the context of health care are not truly medical decisions so much as decisions about values. Quality of life, physical and emotional suffering, tolerance for risk, and many other factors affect the appropriateness of a given treatment plan that are subjective and truly accessible only to the patient. It is widely understood now that the paternalistic model is not ideal, and for at least 30 years most physicians have been trained in a more patient-centered model in which patient autonomy is properly valued.
What is less well-recognized, however, is that there are strengths and benefits associated with the paternalistic mindset. The reality is that despite the easy availability of large quantities of raw information, a deep and accurate understanding of medicine and the basic scientific principles underlying it is not readily available without the years of study and training health care providers undergo. The Internet has convinced us that we can quickly be experts in any area regardless of our personal abilities, skills, and experiences, but this is an illusion. Knowledge without understanding is dangerous because it leads us to confidently make poor decisions. The reality is that in the complex world of modern medicine even professional physicians can easily be overwhelmed by the required and ever-growing knowledge they need to make sound decisions, and lay people will only do poorer in judging the potential risks and benefits of particular interventions, no matter how much time they spend Googling the issue.
The alternative patient-centered or independent choice model of medicine has the obvious strength of giving proper respect to the autonomy of the patient and their feelings and values. However, in its extreme form it explicitly prohibits the doctor from offering recommendations or counsel, and limits the role of the provider to a neutral recitation of the statistical and technical features of various options among which the patient must choose entirely independently. This abdicates any responsibility for the welfare of the patient so long as autonomy is preserved.
There are some differences between human and veterinary medicine in how this tension between reliance on doctor expertise and authority and the autonomy of veterinary clients plays out. The paternalistic model was never fully realized in veterinary medicine due, in part, to the role of the animal patient in the lives of the clients. Traditionally dominated by agricultural applications, veterinary medical decision-making was long constrained by the need to focus on the utilitarian or economic value of the patient. Even non-agricultural animals were often viewed in a more utilitarian way than is now the rule, and the dominant model of companion animal medicine was not unlike that of auto mechanics. People would bring their dysfunctional pets to be repaired or, if this was not possible or the economic cost was too high, to be destroyed.
The profession has changed greatly, and now companion animal medicine is far larger a domain than agricultural practice, at least in terms of the number of veterinarians if not the total economic value of the industry. The prevailing model is much closer to that of pediatric human medicine than auto repair. Pets are commonly seen as individual family members, and the focus is on their health and well-being rather than their utility in most cases. Of course, economic limitations are still far more stringent than in human medicine, and the resources available are less, but very similar principles apply. The decisions made affect the patient directly, but the patient cannot themselves make decisions or even express their wishes. The interests of clients and patients sometimes conflict, and the veterinarian must attempt to serve both while maintaining acceptable professional and ethical standards and an economically viable practice.
The issues discussed in the Annals paper often arise in companion animal medicine. Many decisions, especially involving quality and end of life as well as economics, are value decisions rather than medical decisions, and so the autonomy and independence of the client must be respected. However, the doctor does have knowledge and understanding not available to most clients, and so ought to be able to offer guidance as well as factual information to assist in decision-making. What is more, the veterinarian has a duty to the patient, and protecting the patient’s interests sometimes requires working against the desires of the client.
How, then, do we negotiate the complexities of the veterinarian-patient-client relationship in a way that safeguards the interests of the patient, respects the values and autonomy of the client, makes optimal use of the expertise of the veterinarian, and is economically tenable for all parties? I cannot claim to have a comprehensive answer, but as always I have a few thoughts.
To begin with, veterinarians should be trained to explicitly acknowledge the questions and issues involved. Very little time in vet school is spent discussing these concerns or how they might be addressed, and most veterinarians end up stumbling into an approach that seems to work for them with little or no guidance. As a consequence, practice styles range from those veterinarians who only discuss options they wish the client to pursue and who freely tell clients what they ought and ought not to do, to veterinarians who try to practice a strictly “independent choice” model and never make an explicit recommendation or voice any personal opinions in the consultation room. As is so often the case, the best solution seems to be between the extremes, and it is likely to be an ever-evolving, self-aware process rather than a rigidly fixed formula or algorithm.
The Annals paper discusses at length what the authors call the “enhanced autonomy” approach. Essentially, this involves trying to integrate the factual details of the medical situation with the values, feelings, and interests of the doctor and the patient through open and careful communication. While the patient must ultimately make the final decision about their own care, the doctor is not obligated to ignore the medical facts as they understand them, nor their own judgment. The authors describe the advantages of their model in this way:
“The independent choice model reflects a limited conceptualization of autonomy. Under this model, it is thought that an independent choice is best made with no external influence, even when one’s competence to make the choice is limited. However, autonomous medical choices are usually enhanced rather than undermined by the input and support of a well-informed physician. Only after a dialogue in which physician and patient aim to influence each other might the patient fully appreciate the medical possibilities…Enhancing patient autonomy requires that the physician engage in open dialogue, inform patients about therapeutic possibilities and their odds for success, explore both the patient’s values and their own, and then offer recommendations that consider both sets of values and experiences. This model is “relationship-centered”….rather than exclusively patient-centered. It denies neither the potential imbalance of power in the relationship nor the fact that some patients might be inappropriately manipulated or coerced by an overzealous physician. It assumes that an open dialogue, in which the physician frankly admits his or her biases, is ultimately a better protector of the patient’s right to autonomous choice than artificial neutrality would be. Because the biases of a physician will probably subtly infiltrate the conversation even if he or she tries hard to remain neutral, it may be better to explicitly label these values than to leave them outside of the conscious control of either participant.”
Such a model is well-suited to companion animal medicine as well. It requires first and foremost open acknowledgement of the roles both client and veterinarian play in making decisions for the patient. The veterinarian has knowledge and competence the client does not. They are able to appreciate the complexities of the medical situation, and they have the emotional objectivity to view potential outcomes realistically. The veterinarian also has a responsibility to advocate for the interests of the patient and to adhere to their own ethical and professional standards. Finally, the veterinarian has a fiduciary responsibility to the client.
The client has the ultimate responsibility for caring for their pet in a way consistent with their own values and resources. They understand the pet and their interests in a direct and personal way not available to the veterinarian. Therefore, the client must be the ultimate decision-maker regarding their pet’s care. However, part of their responsibility to the pet is to be aware of and attempt to compensate for the interference of their own interests with those of the pet. And as part of the duty to give the best care possible, the client should understand and acknowledge the need for the guidance the veterinarian can offer out of their deeper understanding of the medical questions at issue.
Interestingly, this model for the veterinary-client-patient relationship shares some features with the principles of evidence-based veterinary medicine. One widely used definition of EBVM, which I have cited before, is “the integration of the best research evidence available with clinical expertise as well as the unique needs or wishes of each client in clinical practice.” Balancing the best available information, which of course is primarily the province of the veterinarian, with the needs and wishes of the client requires both the client and the veterinarian to accept the limitations of their own knowledge. The client should defer in matters of medical fact to the veterinarian, who is in a better position to understand the medical issues in a deep and meaningful way. The veterinarian, in turn, should acknowledge the limitations of their own knowledge and experience and rely on the best and highest level evidence available to guide their recommendations. The doctor must also defer to the client in areas where the core issues are those of values rather than medicine, while of course still staying true to their own ethics and understanding of appropriate standards of care.
These negotiations between the interests and competencies of the parties involved are complex and situational, and they require explicit, clear communication, thoughtful self-reflection, and a willingness to consider and integrate factual information with sometimes contrary interests, values, and perspectives. This all makes the activity both difficult and sometimes frustrating and also richly rewarding.
