http://bmj.com/cgi/content/full/323/7325/1368
BMJ 2001;323:1368 ( 8 December )
Letters
Patients and medical power
More
debate about patient power in NHS is needed
Patient
power requires patient freedom
Issue
of power is almost irrelevant for doctors practising patient centred medicine
More debate about patient power in NHS is
needed
Canter
raises important points about the problematic nature of power and the idea that
it can simply be shifted from one party to another, particularly
given the asymmetries of knowledge and skill that are structurally
inherent in professional-client relationships.1 However,
his challenge to Alan Milburn, the health minister, stops short of
the crucial question about whether a national health service should
seek to achieve a "decisive shift of power in favour of the
patient." The potential implication of this statementthat
doctors should simply give patients what they wantis
fundamentally incompatible with the ethics of taxation.
As Canter's analysis hints but does not explicate, Milburn's statement
implies that doctors should prescribe unnecessary antibiotics, carry
out unnecessary surgery, and make available untested treatmentsall
in the name of patient power. Where does this leave the simultaneous
investment in the National Institute for Clinical Excellence, evidence
based medicine, and medicines management? More to the point, where
does it leave the NHS on the morality of its funding from tax levies?
In an insurance based system I can choose to pay for the level of access
that I want. If I want a consumer driven system that gives me
absolute freedom of choice then I can pay for it, at least to the
extent that I can afford the premiums or can persuade others to join
me in a risk pool where we each agree to fund the others' unlimited
choices.
In a tax funded system we must consider the ethics of compulsorily levying
all taxpaying citizens and whether this can ever be justified beyond
the extent of providing demonstrably efficient and effective care to
those citizens. Doctors are the agents of restraint on behalf of
taxpayers.
As a patient, I may want the NHS to do everything for me that may be of any
conceivable benefit or that will, at least, make me feel good about
it. As a taxpayer, I do not want to see my income sequestered to
indulge the fancies of others when there is a clear medical view
that an intervention has no clear and established benefit. It is a
politician's duty to manage that conflict and the medical
profession's task to produce practical resolutions in individual
cases.
Loose talk about shifts in power is just that and should give way to the
more sophisticated debate that Canter is seeking to encourage.
Robert Dingwall
University of Nottingham, Nottingham NG7 2RD robert.dingwall@nottingham.ac.uk
|
1. |
Canter R. Patients and medical power. BMJ 2001;
323: 414 |
Patient power
requires patient freedom
Canter's
editorial highlighted the formal difficulty in promoting patients' power.1 I see
this in a social context and have summarised some of the problems
here (a longer version of this letter can be found at bmj.com/cgi/eletters/323/7310/414#EL14).
- Medical power is intrinsic to
medicine. It cannot be handed over
- Medical power is a particular
aspect of "experts' power"
- Medical power arises from the
process of socialisation, which induces submission to medicine (we are
born in hospital, vaccinated, surveyed while children, and
screened while adults; medical examinations are requested for
employment and insurance and other purposes; and most of us
will die in hospitals)
- The patient's entourage
undergoes the same process of socialisation, and patients' relatives are a
major source of pressure for medical power to be enforced
- The politicisation of medical
power removes power from the doctor-patient interface and gives it to
higher administrative levels (the government and committees
(health authorities, the National Institute for Clinical
Excellence, etc))
- Lobbying groups, while
requesting more power for patients, result in more power being moved away
from the patient to higher administrative levels
- It is a fallacy that medical
power is handed over to the patient through being more strictly enforced,
with the role of guidelines and protocols being reinforced and
the leeway for personal variance being decreased
- The current discussion cannot
look outside the Western medical paradigm, and medical advice can only be
opposed by even more authoritative medical opinions. Such
opinions are handed over from somewhere further from the
patient (the problem of applying evidence from populations to
particular individuals being bypassed through the unquestioning
acceptance of the said paradigm).
The constraints on patients' power arise from social conditioning to submit
to medicine2
and from political constraints on access to doctors of the patient's
choice. Patients' power cannot be handed down from doctors; it has
to be created anew through freedom to choose the doctor one wants to
see; freedom of access to second or third opinions (not theoretical
access, but economically and socially feasible access); and, above
all, freedom to refuse the medical view of the world and choose
alternative discourses and practices. When will a sick note from a
non-orthodox medical practitioner become acceptable for sick pay?
J Calinas-Correia
16 Roskear, Camborne TR14 8DN j_calinas@yahoo.co.uk
|
1. |
Canter R. Patients and medical power. BMJ 2001;
323: 414 |
|
2. |
Illich I. Limits to medicine. London: Marion
Boyars, 1995. |
Issue of power
is almost irrelevant for doctors practising patient centred medicine
In
the communication skills programme at the Imperial College of Science,
Technology and Medicine, our first year medical students participate
in a session titled "Power and adherence in the doctor-patient
relationship." The issues raised by Canter are debated,
specifically in relation to the models of power that he described.1 Among
other things, the students usually identify the fact that decisions
about medical treatment are rarely made in isolation.
Patients may consult several doctors or other members of the healthcare
team, or both, so that a range of views, at least within the context
of Western scientific medicine, can be elicited. The patient's
decisions are also influenced by his or her world outside the
consultationby
social, economic, religious, and cultural factors. The models of
power tend to assume that only two parties are involved and do not
consider additional influences to decision making.
If doctors are practising patient centred medicine then the issue of power
is almost irrelevant. Patient centredness implies that the doctor
will actively seek to determine the patient's desire to make
decisions about his or her care in the same way that the amount of
information that the patient wants about his or her illness should
be assessed. A patient centred approach to medical care thus assumes
that each patient is wielding the amount of power that he or she
would wish to in the doctor-patient relationship.
Debra Nestel
Faculty of Medicine, Imperial College of Science, Technology and Medicine,
London W2 1PD d.nestel@ic.ac.uk
|
1. |
Canter R. Patients and medical power. BMJ 2001;
323: 414 |
|
Related editorials in BMJ:
Patients and medical power.
Richard Canter
BMJ 2001 323: 414.
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