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This page created August 2000 by Michael Wynne
This page examines the development of paternalism in health care
and its progressive replacement with an ethic of empowerment. The
difficulties in accomplishing this in a market system are considered.
The track record of the market is examined.
Paternalism disempowers. In a world dominated by heirarchical class structures health care assumed the paternalism of its times, as did colonialism. Each person accepted their place in the scheme of things. Paternalism was fostered by cultural differences and a lack of knowledge in the community. It was inseparable from the charitable paradigms which governed the relationship between classes. These paradigms created the context within which medicine was practiced. This is the debris of the 19th century which washed over and coloured much of the 20th.
The continued underfunding of General Practice in Australia and the pressures towards efficiencies rather than humane interaction still creates a context which encourages paternalism. It is more efficient. Ever narrower specialisation and the deification of experts encourages elitism and paternalism. The marketplace has fostered this elitism by marketing expertise and the doctors who supply it - they talk of market differentiation and niche markets. This deification of expertise can occur in National Health Systems. This has been a contributing factor to a series of recent health care scandals in the UK.
Paternalism is external to professionalism. Modern professionalism opposes it. Most of us aspire to an increasingly knowledgeable society that makes informed health care decisions. Dealing with people who are informed is rewarding but much more time consuming. It is inefficient and unproductive in economic terms. Hopefully most of the medical profession has moved beyond the paternalistic behaviour of the colonial era, but they still carry the stigma.
Empowerment is a positive experience both for the person empowered and for those who empower others. It fosters mutual respect and trust. It is something to aspire towards - a civil society in which all citizens partcipate. In our medical schools we encourage doctors to educate, discuss and assist people to make their own decisions. Good doctors, who relate well to people, and who are intent on care rather than profit or efficiency have been doing it all their lives.
The patient's condition does not always permit empowerment. It is not black and white. Decisions have to be made when the patient is unable to make them. We cannot allow people to die or be harmed, because they have not been informed and cannot make a decision themselves. There is a vast grey area between the patient who can comprehend and handle full information and the unconscious patient.
The patient who says "I don't understand Doc - you're the expert - that's your job" can be dealt with in a fraction of the time. This model of care is in the interests of health care corporations. While talking of informed "customers" they have promoted this "expert model". They have marketed themselves and their doctors as experts under the guise of "product differentiation". In contrast doctors who empower patients by spending time with them face "economic credentialling" in hospitals and "delisting" by the managed care companies to whom they are contracted.
Empowering is part of the human side of care. It is time consuming and sits uncomfortably with strong pressures towards greater efficiency. It is satisfying. Mutual trust and confidence are established. This process is disrupted when the patient comes shopping for a health care product. She is now distrusting, suspicious and demanding believing that the doctor will be selling his product over someone elses. I am not suggesting that the patient should not ask or ensure that there is full understanding. She should be assisted to a second opinion if she is doubtful. If another doctor advocates a different form of treatment the patient should be advised of this. This helps to build trust and care depends on it.
One of the major criticisms of managed care and also of the capping of fees for GP's using bulk billing in Australia is that it places great pressure on this increasingly important part of modern health care. Time for discussion and explanation is limited. If the doctor wants to educate her children and pay off the mortgage then she has a problem with long consultations.
Corporate "players" on the level playing field are not interested in empowerment but they want people to trust them. They exploit and misuse the trust which health care professionals have built up over the generations. Dishonesty seems to be the norm. They often seek to restrict the provision of information (eg HMO's and medicare patients) and the freedom of doctors to fully inform. (eg Managed care). Misinformation is very common (eg Tenet/NME, HCA, Sun Healthcare)
An illusion: - Even with a well educated public there is still a very significant imbalance of power because of the patients lack of deep knowledge, emotional involvement and the nature of the illness. Patients may feel empowered and have a reasonable grasp of the situation within their own understandings. This is what we aspire to. It is a misnomer to call this "fully informed". Pretending that this is not so and that patients can be true "customers" with all that word implies is a form of market self delusion. We all want and aspire towards this sort of control of our own lives. Desire, or even demand does not translate into something which is possible. Medicine is not alone in this. However hard I work at it I will never be fully informed when I buy a complex item like a car or a computer. Fortunately my life does not depend on it.
True professionalism recognises, protects, and seeks to empower by informing honestly and with integrity. It strives to protect those who cannot be fully informed from their own weakness and vulnerability. The marketplace, as this www site shows willingly capitalises on the weakness of others when profit can be generated by doing so. Even our author David Malouf recognises this. In his Boyer lectures he talks of "an eye for the weakness of others" when referring to the characteristics which make both a criminal and a successful businessman.
The health care marketplace has an extremely poor record for empowerment. They are very good at inducing people to believe that they selected the best care by paying more for it. One has only to examine the television advertisements of our Australian health care insurers.
Doctors know that a sure way to have a successful practice is to charge twice as much as the next person. Most people will believe that in paying more they are getting the best. Who of us will subject our family to second best care if we can possibly afford the best? A Mercedes or a BMW serve the same purpose . Most doctors know this. Car salesmen know it. Company directors all know it.
Many years ago I pointed out to a friend who was loudly criticising the expensive cars doctors drove that his own doctor drove a Mercedes. He responded pragmatically that he found it very reassuring that his doctor was good enough to aford a Mercedes.
A relative of mine was not allowed to drive anything less than a Mercedes or BMW lest he damage the credibility of the company he worked for. In a strongly commercialised system of healthcare fees go up and doctors borrow to buy Mercedes or BMW's. True professionalism prevents this sort of thing and not many in Australia behave like this. This is how a health care marketplace can and sometimes does operate. I am familiar with it and have seen how successful it can be.
TENET/NME AND DISEMPOWERMENT:- Tenet/NME capitalised on this aspect of the market and charged more than anyone else. Memoranda were circulated instructing staff to meet any criticism of the company's fees by explaining that this was because the company provided superior care.
Marketing by Tenet/NME misinformed susceptible people to induce them to come to Tenet/NME hospitals for assessment. Untrained "assessors" then made every effort to persuade them to stay there for the duration of a course of treatment the length of their insurance cover. People were employed and teams set up to do this. Patients were misinformed of their rights and incorrectly told that if they did not complete the course of treatment then their insurance would not pay. Vast quantities of unnecessary treatments were given over prolonged periods.
In 1992 the Texas government forced the company to put notices explaining patient's rights throughout all its hospitals and made it pay for ombudsmen for all hospitals. Many other corporations indulged in similar practices. This is the competitive marketplace. These are the people who succeed. You cannot empower people or provide care in an environment like this.
MANAGED CARE AND DISEMPOWERMENT:- Managed care perhaps even more than any other form of care in developed countries has misinformed, restricted choice and disempowered people - but only after the patient or their company have paid their insurance. The system of contracting with hospitals now adopted in Australia also restricts choice.