Patient autonomy, one of the pillars of medical ethics, now shines brightest of the four pillars in modern medicine. While medical ethics was meant to take beneficence, non-maleficence, justice and autonomy in equal consideration, the balance is now offset by the digital age and an increasingly skeptical population that has hurdled American culture into striving for autonomy above all else.
Patients have begun to correct physicians on the standard of care based on what they read on social media, while other patients influenced by political movements have grown weary of the recommendations made by scientists and physicians.
Patients now opt to see midlevel providers or change doctors in hopes that the next provider will give them what they seek. When expertise is seen as subjective, and the population at large does not look to physicians as the authorities, the doctor-patient relationship suffers and ends with worse outcomes. Radical autonomy is now on the path of concierge and provider-consumer relationships that is far from what health care should be.
Every specialty is touched by this trend; however, psychiatry is a specialty in which paternalism has persisted. With the added complexity of involuntary admissions, use of restraints, therapeutic privilege and lack of capacity in some acutely ill patients, psychiatrists have consistent opportunities to decide on beneficence instead of autonomy with an active-passive model of care.
Psychiatrists also tend to use a guidance-cooperation model or paternalistic approach when treating their patients. Patients with psychiatric diagnoses are, in many ways, a vulnerable population. These patients and their diagnoses are heavily stigmatized. Though there has been more acceptance of mental illness in recent years, this has largely been limited to depression and anxiety. Other diagnoses like schizophrenia and bipolar disorder remain largely misunderstood and stigmatized.
If distrust toward their physician is factored in, this leads to disastrous outcomes when it comes to seeking and continuing treatment.
Psychiatrists may avoid this problem through paternalism, establishing themselves as the decision maker who knows best. Still, an overly paternalistic approach with patients who have the capacity to provide consent and engage in shared decision-making is not always the best approach.
When orders are given without understanding, patients may misuse their medications or may underestimate the utility of psychotherapy alongside their medication regimen. Because shared decision-making and autonomy require the patient to understand before becoming involved in care conversations, the patient will often have greater knowledge of their condition than a patient treated in a paternalistic way in which the patient may be blindly following a decision made by another.
Both radical autonomy and pure paternalism present their own problems. Psychiatry presents additional considerations for patients who may be unable to practice autonomy. But for most patients who present to psychiatrists, there is a better approach to take.
Maternalism is an approach that has been offered as an alternative between the two extremes of autonomy and paternalism. Maternalism is like paternalism, with the physician as the decision maker while incorporating helpful components of autonomy such as shared decision-making and a mutual participation model.
This approach is very relevant to psychiatry, in which patients benefit from feeling that their physician is making the right decisions to take care of them but also cares how they feel about the treatment. With maternalism, there is more patient buy-in, and patients feel more comfortable bringing up concerns and asking questions.
At the same time, a maternalistic physician is still making decisions with beneficence while clearly communicating with the patient. This builds trust with the patient and the understanding that the care decided on is what is best, and the patient still, of course, has the right to accept or refuse treatment. With proper patient communication and the development of this maternal-like relationship, patients will not feel the need to consult with online sources or switch to a different doctor. With a maternalistic approach, it is also possible to discuss the pros and cons of medication, psychotherapy, or a combination to guide treatment preferences.
With a maternalistic approach and a strong doctor-patient relationship, patients will likely stay adherent to treatment and feel more comfortable discussing new or worsening symptoms, with the acknowledgment that the psychiatrist would make the right decision of what to do. With other approaches, the patient may have reasons for not wanting to disclose a symptom due to mistrust, judgment or retribution. Patients who may have issues with trust may feel greater assurance of confidentiality and nonjudgmental reactions during psychotherapy, knowing that their physician can be trusted.
In psychiatry, a strong doctor-patient relationship is essential to the highest quality of care and the avoidance of adverse events. The application of maternalism is especially relevant to psychiatry to draw from the best elements of autonomy and paternalism while achieving the clearest communication with a patient and optimizing trust, confidence and understanding to enhance patient outcomes and quality of life.
Aubrey Jackson is a medical student.
