Fast Takes

Ezekiel J. Emanuel and Linda L. Emanuel.  "Four Models of the Physician-Patient Relationship." JAMA 267:2221-6, 1992.

Emanuel and Emanuel are concerned that in rejecting medical paternalism, today's medical ethics might appear to support a dry and limited conception of patient autonomy.  They believe that they can defend a model of patient autonomy which allows the physician a very active role in counseling and persuading the patient. 

The authors discuss (but almost immediately dismiss) a "paternalistic model" of the physician-patient relationship.  Thus for our purposes, their "four models" actually amount to three non-paternalistic models.  Still, the paternalistic model is useful as a way to better understand the other three models by noting the relevant contrasts. The four models are analyzed as follows:

Model Patient values Physician's duty Concept of patient autonomy Concept of physician's role

Paternalistic

Objective, shared by physician and patient Promote patient's well-being regardless of patient's current preferences Assenting to objective values Guardian
Informative Fixed and known to patient Provide factual information Choice of, control over medical care Competent technical expert
Interpretive Vague, conflicting, requires elucidation Provide factual information and help to elicit and interpret patient's values Self-understanding relevant to medical care Counselor or adviser
Deliberative Open to development and revision thru dialogue Provide information, elicit and interpret values, articulate and persuade re: most admirable values Moral self-development relevant to medical care Friend or teacher

The authors believe that the informative model reflects most discussions of informed consent and capacity to make medical decisions today, but that it is a very limited model in its minimalist interpretation of the physician's role and the patient's autonomy.  (That is, they suggest that many if not most patients want their physicians to be more than mere technical experts.)  Different medical circumstances (including how many times the physician has seen or will be seeing the patient) make different models ideal in different settings and with different patients.  But the authors feel ultimately that on average, the deliberative model is the "ideal" doctor-patient relationship.  They defend this model against possible objections that it is merely a form of disguised paternalism.

[For our purposes in this week's discussion, you may want to consider whether you agree that the deliberative model is ideal.  You may want to compare this discussion with Miller's four senses of autonomy.  And you may want to compare these three models with: 1) how Dax's physicians appear to have wanted to relate to Dax; 2) how Dax's physicians seem actually to have related to Dax.  For purposes of this last question you may want to add back the paternalistic model and talk about all four possibilities, not just the three models shown in the table.]

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