You’re the doctor. Be a paternalist

Screen Shot 2016-04-29 at 08.52.09Dalrymple writes that when he has been in need of treatment,

I have wanted the doctor to decide what to do and do it, without any intellectual input from me (a doctor). The last thing I wanted was to hear a disquisition on the various possible courses of action the doctor could take, with all their possible disadvantages, and then to have to make up my mind.

But, he says,

this attitude is rather against the temper of the times: it smacks of a return to paternalism. What we want is information, more and more of it, to help us decide what is best for us.

The problem is that

there are many questions in medicine that are without a definitive answer. Is it worth running a small relative risk of a major side-effect to obtain relief from a non-life-threatening condition?

Perfectly sensible people

may give different answers to the same question, according to their own scale of values.

Unfortunately,

people don’t like living with uncertainty. For them, intellectual honesty has its limits as a virtue. They (or perhaps I should say we, because we are most of us the same in this respect) prefer living with a sense of certainty, at least about our illnesses, even if this certainty is not well-founded. We want the doctor to act as if he were certain, even if he is not certain. And this desire is not completely without rational justification, because faith in the doctor has a healing quality. It is hard to put one’s faith in a man who presents us with a series of insoluble dilemmas.

A patient comes to Dalrymple with somewhat raised blood pressure.

I conscientiously told him that there was a small statistical chance that treatment would do him a lot of good, but a large statistical chance that it would do him no good. Did he want treatment or not? He looked at me as if I were mad. He hadn’t come to the doctor for this, but to be told what to do. He had never thought of medical treatment as a game of roulette: treatment either worked in every case or it didn’t. ‘I don’t know,’ he said. ‘You’re the doctor. Do what you think is best.’ What he meant was, be a paternalist.

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