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Saturday, March 25, 2006

Hofmann on Medical Paternalism

Even in a computer it is possible to misfile things. I recently came across the following by accident, filed in the wrong place. It came in from friend, colleague, health care ethicist, and faithful blog reader Paul Hofmann. It was stimulated by a posting last December titled What Doctors are For.
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In conducting ethics rounds, I continue to see lamentable evidence that medical paternalism is alive and well. Too often, physicians assume their values are shared by patients and/or their surrogate decision-makers. And in some cases, when physicians have determined their values are not shared, they use their professional leverage to impose them on the patient. The basic ethical principle of autonomy is being violated when a patient "consents" to an invasive diagnostic or therapeutic procedure under these circumstances. For example, there are still physicians who insist on aggressive therapy for terminally ill patients despite their preference to the contrary. I am also aware of physicians who have written no-code orders without speaking to patients or their surrogates. What is needed here is not unquestioning deference to the physician's legitimate authority or the patient's legitimate right of self-determination. Instead, we should encourage a process that permits and facilitates an informed discussion of the patient's values and preferences. A physician colleague once told me that most doctors think communication happens when they're talking. Yes, remarkable advances in science and technology have occurred, but unless patients voluntarily and explicitly choose to have physicians make decisions on their behalf, patients should indeed be encouraged to ask the types of questions that permit them to be active rather than passive participants in the diagnostic and therapeutic process.

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