Is There Still a Place for 'Paternalistic' Doctors?

Arthur L. Caplan, PhD; Barron H. Lerner, MD, PhD


July 08, 2014

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When Doctor Knew Best

Arthur L. Caplan, PhD: Hello. I'm Art Caplan, at the Division of Medical Ethics at New York University (NYU) Langone Medical Center. Welcome to Close-Up. This is an interview program during which I have a chance to talk with thought leaders from all over the world about social and ethical policy questions in medicine and healthcare. I am very pleased today to have as my guest Dr. Barron Lerner, who is a historian and an ethicist at NYU Langone Medical Center in the Department of Population Health. Thanks for coming.

Barron H. Lerner, MD, PhD: My pleasure.

Dr. Caplan: Let's shift talk to your new book, which is an interesting challenge to prompt people to think about this. Your book is called The Good Doctor: A Father, a Son, and the Evolution of Medical Ethics (Beacon Press, 2014). It's an interesting look at the shift in ethics from the time when your dad was a doctor back in Cleveland to your own practice today, what you learned about ethics, and how your father believed you ought to practice. I gather your dad was somewhat paternalistic?

Dr. Lerner: Yes, he was the quintessential paternalist doctor, like most doctors of his era.

Dr. Caplan: When was this?

Dr. Lerner: He went to medical school in the 1950s, started practicing in the 1960s, and retired in the late 1990s. He made it into the bioethics era, but his heart was back in paternalism. He was of the "doctor knows best" school. It was a doctor's job to learn as much about the patient's illness as possible, to know the science, to know what was best, and to know the patient as well as possible. This meant spending time with them, getting to know them as people, understanding their values, and using all of this scientific information and knowledge about patients to guide patients and tell them what to do.

Dr. Caplan: We still hear of paternalism today. We think of it as bad, but it was more beneficent paternalism, right? Trying to do what you knew -- from experience and training -- to be best for your patient.

Dr. Lerner: Absolutely. Paternalism is a dirty word these days, but this came out of a different mindset, in which it was the beneficent duty of the doctor to do what was best for the patient. Why would a doctor not want to use all of his or her knowledge to do the right thing for someone? Some of what went on in my dad's practice was manipulation. He told people some things and he concealed the truth. Sometimes he involved the family but not always.

Dr. Caplan: I can hear the lawyers gasping.

Dr. Lerner: But it was all to get patients to take the treatment that he thought was the most likely to help them.

Full-Tilt Into Patient Autonomy

Dr. Caplan: Let's put the focus on you for a minute. How do you see the pendulum swinging from the way your dad practiced -- a kind of benevolent paternalism -- to today's emphasis on patient autonomy? Who do you think is right in this debate?

Dr. Lerner: When I started medical school, it was the early years of bioethics. Bioethics, to some degree, was a reaction against paternalism -- and not just paternalism, but often the arrogance of doctors who participated in such things as the Tuskegee experiment. The bioethics folks came in and said, "You know what? Doctors do not do a good enough job of policing their profession, and they are making all the decisions. Patients are silent and not empowered. This has to change." As I became a doctor, that was in the forefront. We were learning that it was not our job to tell people what to do. It is our job to inform them and then let them make the decision. This was very much the rise of patient autonomy. As I became a doctor, we were rejecting the exact philosophy that my dad had based his practice on for so many years.

Dr. Caplan: It is nice to say that families (patients) should make decisions. In my experience, however, there is a fair number that do not want to. Owing to a lack of education or the trauma of being diagnosed with a disease and the unexpected calamity, they can't do it. Should patients still be treated as if they were autonomous, or are all those philosophers and ethicists overestimating what people in the real world are capable of when they face illness and disability?

Dr. Lerner: To get to the point, somewhere in the middle we had to go through a phase of truly embracing autonomy. It was a reaction to some of the problems of the past. We went full-tilt, at least in language, to support informed consent and patient autonomy. You did everything you could to get the patient to make the decision. All along, however, some of us were thinking, "This isn't working in some cases; not everybody wants this." Nevertheless, it was an important exercise, and now we are coming back to some of the issues that you are raising. Some patients don't want to make decisions. Some patients aren't capable of doing it. How do we empower these people and at the same time help them to make the right decisions? These are the issues I am trying to get at in the book.

Does a Happy Medium Exist?

Dr. Caplan: What would your dad say if he read your book? Would he say, "I was right -- I told you so"? What would he draw as a lesson from reading the book?

Dr. Lerner: He was glad that I was working on the book. We had had friendly disputes over the years as I was pursuing ethics and coming into conflict with some of the beliefs that he held over the years. This was an open debate between us. He was probably thinking, "This young whippersnapper thinks that autonomy is going to solve everything" and that we had our heads in the ground. He knew, to some degree, that people were going to come back a little bit in this direction and say, "Let's not throw out the wise doctor who tries to get to know his patients and guide them. There still is a place for that." That's where we are now.

Dr. Caplan: I hear many doctors complain, "I don't have enough time, my patients don't know me, I am like a stranger." How do autonomy and benevolent paternalism play out in the world we are in today?

Dr. Lerner: It makes it harder. If we had all the time in the world -- my dad had a lot more time -- it would be easier to gain the trust of patients and forge a relationship. It's harder now because everything is very brief. You could honestly ask yourself, "If I was the patient, why would I trust this doctor, who barely knows me, to make decisions?" That is why we are not going back to paternalism. In fact, some doctors today wouldn't be good enough at making those sorts of decisions. They wouldn't feel comfortable making decisions for patients.

The challenge is, with such short periods of time, trying to use other people on the team (besides doctors) to have meaningful interactions and to build up some trust between doctors and patients, and try to forge relationships for making productive decisions.

Dr. Caplan: That ought to be part of the health reform debate, to build that environment. Who would you want to be your doctor if you were sick? I don't mean by expertise, but by moral stance.

Dr. Lerner: I would like a doctor who has been through the autonomy informed-consent educational process. We have wound up in an era in which that is crucially important. That is good. On the other hand, I would also like a doctor who is willing to spend a little extra time to listen when I am talking, to ask whether I have questions, and even in that limited time to get to know me in some way. I am more than happy to ask advice; and I might ask, "What would you do?" I am not uncomfortable with that, and in general, patients shouldn't be uncomfortable with that. They should just know that, ultimately, it is their decision. They can ask for advice, but they shouldn't simply follow the doctor's direction because the doctor said this or that.

Dr. Caplan: Thank you so much for being with us. Get the book. I am sure it will prove to be a fascinating read. I am Art Caplan for Close-Up. Thank you for watching.


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