http://bmj.com/cgi/content/full/323/7310/414
BMJ 2001;323:414 ( 25 August )
Editorials
Patients and medical power
Shifting power in favour of the patient
may not be so straightforward
Power is the means by which A gets B to do something, and many models exist
to explain how A might do this. The medical profession sees itself,
and is seen, as expert in understanding and managing disease.
However, expert power is only part of the picture. The concept of
power also includes reward, coercive, legitimate, and charismatic
power.1
Individual clinicians may exercise elements of each of these types
of power in different proportions so that each has his or her own
distinctive consultation style.
Perhaps Mr Milburn really means that the medical profession should become
more charismatic and less coercive in its approach to patients. At
first sight this may seem more desirable in a consumerist society,
but coercive power is easy to recognise while charismatic power is
not. Charismatic doctors may do great harm to a population of
patients who remain grateful to them. Perhaps the full report on the
murderous general practitioner Harold Shipman will illustrate this
point.
Current thinking is that the analysis of power is far more complex than this
simple model suggests. Lukes has proposed a threefold description of
power that might be relevant here2: first
dimensional power, in which A forces B to do something; second
dimensional power, in which A controls the agenda in any interaction
with B; and third dimensional power, in which A controls the world
as B sees it.
First dimensional power is akin to the coercive power in the older model.
Such power might be exercised appropriately in emergencies, in
certain acute psychiatric states, or when patients are extremely distressed
or anxious and do not want to debate choices. Second dimensional
power is exercised when the conversation is deliberately steered
away from or towards certain topics that influence the outcome. The
advantages of a treatment, or its complications, may be emphasised
in a way that influences the patient's apparent choices. Exercising
power in this way also includes the power to silence through lack of
clinical time, poor ambience, poor listening skills on the part of
the doctor, and a host of other ways that make it difficult for
patients to ask questions in a clinic.
Many doctors might argue that they do not operate in either of these ways
but simply "present the facts to patients in an unbiased
way" and allow them to make their own choice. This is how they
would shift power decisively in favour of the patient. Lukes' model
would suggest, however, that A has constructed for B a worldview of
disease and treatment, in which B believes he or she moves
autonomously but in fact B's actions are shaped by the flow of
medical knowledge (supplied by A) that underpins these choices.
Similarly, A may believe that B moves autonomously, because both may
be the subject of a world view of another agency.
Consider the situation faced by a patient with malignant disease of the
larynx who has to make choices about the treatment options of
palliation, radiotherapy, chemotherapy, surgery, or combinations of
each. The encounter begins by the clinician setting the clinical
problem in a conventional biomedical model. A discussion will follow
looking at the effectiveness of each of these treatment options
based on the physician's understanding of results reported in the
medical literature together with his or her experience of previous
cases. The patient might then make a "choice," but the
whole encounter is located firmly within a conventional biomedical framework
where there is no place for other frameworks, such as herbal
medicine, acupuncture, osteopathy, or other complementary medical
alternatives. Indeed, in this example even the mention of
alternative medicine may strike many readers as odd. Because third dimensional
power is so pervasive and bound up with knowledge itself, it is
difficult to recognise. Both A and B may be largely unaware that
their worldview is shaped by the prevailing paradigm.
The reasoning then is that all forms of knowledge, including medical
knowledge, produce images of the world that then operate as if they
are true.3
There is therefore a powerful argument that when the exercise of
clinical power shifts from crude, but easily recognisable, coercive
or first dimensional power to the more subtle and harder to
recognise third dimensional power, the reality is that nothing may
have changed.
What then can be done to encourage a more "patient centred"
healthcare system? Firstly, a little more honesty on the subject wouldn't
go amiss. Healthcare professionals must recognise that they do not
hold a privileged position from which they alone recognise all
medical truths. Medical paradigms come and go, and medicine often
develops new paradigms to support the continuation of certain practices
when faced with conflicting data.4 Secondly,
the argument seems to be about the power model appropriate to the
clinical situation. Perhaps healthcare workers should be taught to
keep some basic frameworks in mind to enable them to be more sensitive
to power in all its manifestations. At the very least a debate that
goes beyond the rather naive idea that power should be "handed
over" needs to begin, for at the heart of this proposal is the
very nature of medical knowledge itself.
Richard Canter
Royal United Hospital, Bath BA1 3AG
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1. |
French JR, Raven B. The bases of social power. In:
Cartwright D, ed. Studies in social power. Ann Arbor: University of
Michigan, 1958:150-167. |
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2. |
Lukes S. Power: a radical view. London: Macmillan,
1974. |
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3. |
Guba EG, Lincoln YS. Competing paradigms in qualitative
research. In: Denzin N, Lincoln YS, eds. Handbook of qualitative research.
Thousand Oaks, CA: Sage, 1994. |
|
4. |
Kuhn TS. The structure of scientific revolutions.
Chicago: University of Chicago Press, 1972. |
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Rapid Response responses to
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responses
Widening the notion of power.
J.J. Waring, Research student , University
of Nottingham
bmj.com, 24 Aug 2001 [Response]