Faced with a life-changing decision and a great deal of uncertainty, do patients prefer to decide for themselves after being given all the facts? Or do they prefer a nudge in “the right direction” by their physician?
In medicine’s recent past, Dr. Welby could be counted on to dispense sage fatherly advice. Fast forward a decade or two, and Dr. Grey often lays out the options while addressing their and their patient’s angst. During the interval, the thought leaders of medicine have pointed out that acting paternalistically (or maternalistically) robs the patient of their autonomy, one of our ethical standards. As a result, much like the din over pain being the fifth vital sign, subsequently contributing to the opioid crisis, our medical theoreticians have pushed for more patient information and less patient guidance. A new study suggests that like their thinking on pain, this may be one of the paths to perdition.
The researchers conducted a series of experiments in which patients were given various medical scenarios, the constant being that patients faced a difficult decision with at least two good options. In one situation, they were given all the relevant information, in the second, all the relevant information, as well as a recommendation by the physician. Participants receiving recommendations perceived the physician as more competent, more helpful, and were more likely to recommend them to others and to return for additional care.
They tried varying the conditions, offering patients two opinions, one with and the other without recommendations. Patients preferred recommendations, and they preferred physicians making them. They made the advice, solicited or unsolicited, with no change; patients preferred physician guidance. They tried to see whether it was the additional effort at providing a recommendation that was a determinant; again, it wasn’t the perception of an “additional effort” on the part of the physician, although that did have a small effect, it was that physicians provided recommendations.
Despite their best efforts, patients valued guidance from their physicians over the autonomy of making their own decision. And this held for scenarios involving finance and workplace management. Despite the claim of “medical ethicists and philosophers,” autonomy in the setting of uncertain, difficult decisions is not what people want; they want and need help in choosing the correct path for themselves.
Interestingly, in an earlier pilot study, the queried employed, youngish, physicians, a majority of whom were also medical researchers. They couldn’t decide whether patients would favor autonomy or paternalism, being split pretty much 50-50. While the best approach was unclear to these physicians, and I would claim that they were less clinically experienced or focused, the patients, as the results show, were pretty adamant in seeking advice. In another small pilot study involving financial planners, and presumably, these individuals do rather than study financial planning, there was concordance – they knew that offering advice made one seem more competent and helpful, and would increase satisfaction.
As you might suspect, as the decision became less complicated, with less downside risk, and less uncertain, the strength of advice in framing attitudes towards physicians diminished. I would argue that most clinicians, the frontline community physicians, already know these ideas to be correct, implicitly, or explicitly. It is our thought leaders who need to be better grounded in medical reality. As the authors conclude,
“Normative ethicists who make clear that autonomy is the normative gold standard have influenced prevailing rhetoric and practice regarding autonomy and paternalism. However, normative ethics should be informed by the psychology of the advisees; it is important that we understand the reactions, emotions, and preferences of those that normative theories are designed to protect.”
Perhaps it is only me, but I hear a sigh of resignation in that statement. I return, once again, to that eminent thought leader, #8, Yogi Berra, “In theory, there is no difference between theory and practice. In practice, there is.”
Source: Decisional autonomy undermines advisees’ judgment of experts in medicine and in life Proceedings of National Academy of Science DOI: 10.1073/pnas.191-572117
