HUMILITY IN RESPONSIBILITY:

VALUES, INFLUENCE AND SUBDUING THE SELF

To what degree should/do physicians have "social authority" to encourage patients to make certain choices over others, live one way versus another? What is the internal experience of "quieting" (or not quieting) personal values in the clinical setting?

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Physicians are tasked with protecting patients' best interests and promoting health. But "health"—a life's optimal physical, mental, emotional, spiritual trajectory—is not universally defined. Evidence-based medicine (EBM) aims to produce optimal outcomes in terms of longevity, symptom management and other quantifiable measures. "Optimal outcomes," however, can be subjective, varying with individuals’ beliefs and backgrounds, cultures and emotional constitutions. Especially in "a pluralistic society in which people espouse incommensurable values," individuals may harbor vastly different life (and health-related) priorities informed by those values (1). Values are “the frame or the lens with which we see the world, our ambitions for the future and our understanding of the past;” they are ever-present, silently or deafeningly guiding our thoughts and actions, invariably working in the background to inform our identities and ideals (2). In many ways, even "objective" EBM embodies various sociopolitical, economic and scientific values. "Which questions to ask" and "which technologies to develop"—such decisions are made under the influence of some value set, transparently defined or not (2).


Despite the "caricature of the passionless objective...scientist in a white coat," clinicians, too, are value-driven—in both personal and professional settings (2). Values are largely inseparable from identity and person, and a physician is the same person whether interviewing a patient, suturing a laceration, planning a family vacation or arranging their parent’s funeral. The patient-physician relationship is thus “value-laden” in nature, and physicians may occasionally find their values—whether directly informed by EBM or not—in conflict with those of their patients (3). It is well-established that in such situations, medical providers generally “set aside…personal and cultural preferences in order to provide effective [and safe] patient care”(4,*). Physicians are asked to “engage their patients in evaluative discussions of health issues and related values,” offering opinions grounded in science and experience without imposing personal values as such (1). Inappropriate value imposition by clinicians may not only undermine patient autonomy, but has potential to cause patients and families harm (5,6).

*We recognize that there are countless scenarios in which providers or other caregivers may be required to make decisions “for” a patient. A patient may lack mental capacity, for instance, and a caregiver might step in to make choices ideally in line with the patient’s previously expressed values (7). In emergencies, medical decisions can occur rapidly without knowledge of patient or family values. Or patients may request procedures clearly outside the bounds of clinical indication/standard of care. We do not address such "extreme" cases of value clash here; such extreme examples require much more nuanced dissection and discussion, as well as a detailed understanding of the specific scenario at hand. For our purposes, we assume a) full mental capacity of all involved parties; b) time and space for involved parties to contribute to decision making; and c) discussion of varied, yet not overtly dangerous, approaches to health, life and living.

Illustrative scenarios:

  • A pregnant patient seeks counsel from her physician around family planning options. She asks for help making “the right decision for her.”

  • A patient regularly smokes marijuana recreationally. He does not experience any negative side effects. He presents for an annual physical, and discloses his drug use when asked. The physician is against any substance use in his personal and family life. 

  • A patient comes to a physician about a cough. During the visit, the physician finds out that the patient has not completed high school, stopped studying for the GED, and has not been able to secure a job. The physician wants to encourage this patient to "think big" and “be motivated." The patient says she is “happy with how things are.”

 

References

  1. Emanuel LL and Emanuel EJ. Four Models of the Physician-Patient Relationship. JAMA. 1992;267(16).

  2. Kelly MP, Health I, Howick J et al. The importance of values in evidence-based medicine. BMC Medical Ethics. 2015;16.

  3. Hoehner PJ. The Myth of Value Neutrality. AMA Journal of Ethics, Virtual Mentor. 2006;8(5):341-344.

  4. Dyer C. Doctors must put patients’ needs ahead of their personal beliefs. BMJ. 2008 Mar 29; 336

  5. Tremayne-Lloyd T. Doctors' Religious Beliefs Shouldn't Trump Patients' Rights. Huffpost. January 28, 2015.

  6. Genius SJ. Dismembering the ethical physician. Postgrad Med J. 2006 Apr; 82(966): 233–238.

  7. About Mental Capacity. Office of the Public Advocate. http://www.opa.sa.gov.au/page/view_by_id/21