Patient Choice and Consumer Choice
The tensions between traditional medical values and those of business make for coherent policies in health care, and Western governments now encourage patients to see themselves as consumers of health care.
Thus patient choice is stressed, but there is serious ambiguity in the conception of patient choice. The ordinary conception of choice enters medical practice via a term more commonly used in health care — consent, a foundation principle of medical ethics and treatment. Briefly, the doctor must provide adequate information on the treatment; suggest alternatives; and outline a possible action plan. Responsibility is therefore divided: the doctor takes responsibility for providing the information, the alternatives, and the action plan, while the patient takes responsibility for choosing or consenting to an offered action plan (Mason and McCall Smith 1994: 218-37).But if patients adopt the role of consumer, they may wish to suggest their own alternatives. This can create three problems. The first is that of funding; however, I shall not develop this important issue, because although it raises serious problems for states and other providers of health care, funding is not one of the basic values of medicine. But the second problem is central to the medical ethos, that of the ownership of the knowledge base and the treatment options. Traditionally, medical knowledge was a preserve of the profession: influenced by the ethos, doctors would offer what they considered to be the best evidence-based treatments. But the internet has provided a challenge to this, and contemporary patients, as consumers of health care, may make suggestions or indeed demands concerning the treatments they want. Ownership of medical knowledge may therefore be disputed. The third problem concerns the locus of responsibility. In terms of the traditional ethos, the doctor was responsible for offering the treatments and the patient for consenting; but if the patient insists on having a certain treatment, the patient must take on the moral responsibility for that choice.
If the patient’s choice of treatment has been reached after discussion with his or her doctor, this change can be seen in a positive way, as creating a partnership between doctor and patient. But it certainly challenges the traditional medical ethos (Downie and Randall 2007: 182-185).A consumerist-type problem can of course arise if there is disagreement between patient and doctor on optimum treatment. The UK and the United States seem to differ on this issue. In the UK, the Court of Appeal ruled that the courts could not require a medical practitioner to offer a treatment that the practitioner thought was contra-indicated. Lord Justice Balcombe went as far as to say: “[he] could conceive of no situation where it would be proper to order a doctor to treat a patient in a manner contrary to his/her clinical judgment” (Re J 1992: 625). On the other hand, in a survey of the literature in the US, it was claimed that doctors will almost always continue treatment if requested by patients or relatives, even if they regard it as futile (Paris et al. 1993). This view was supported by many US ethicists throughout the 1990s. Thus, Veatch and Spicer maintain that a physician is obliged to supply requested treatment, even if the request “deviates intolerably” from established standards or is in terms of the doctor’s judgment “grossly inappropriate” (Veatch and Spicer 1992). I do not know what Veatch and Spicer mean by saying that a physician is “obliged” to supply “grossly inappropriate” treatment: such an obligation seems in direct conflict with the moral duty of a physician. But it is in accord with the consumerist maxim, “the customer is always right.”
The point here may emerge more clearly if attention is drawn to the ambiguous term “best interests.” It can be said that one merit of a consumer-based system is that it enables patients to achieve their own best interests. The assumption here is that patients know their own best interests, whereas traditionally, doctors decide what is in the patient’s best interests and take responsibility for that decision.
But there is a confusion here that arises from an ambiguity in the concept of “interest,” an ambiguity between a psychological and a normative sense. “Best interests” in the psychological sense refers to choices arising from what people actually want to have: “autonomous choice” is usually interpreted in this way as expressing what the patient wants. But “best interests” in the normative sense refers to what a patient ought to have, whether he or she in fact wants the offered treatment or not. For example, it might be in a person’s best interest to take some exercise or cut down on sugar, but he or she might not want to. As we say to the relative reluctant to accept the treatment, “It’s for your own good.” But in the framework or value-base of consumerism, the psychological and the normative senses will run together, for a person’s best interest in such a framework or value-base is simply the satisfaction of his/her wants. On the other hand, in the framework or value-base of medicine, the psychological and normative senses of “best interests” are quite separate, and the doctor’s professional duty is to offer treatments from the normative interpretation of“best interests.” This normative view will have two components: a duty to promote the health of patients where possible, and a duty to take responsibility for the suggested treatment. Of course, the patient is entitled in law to refuse the doctor’s offer of choices based on this normative view of best interests, even in cases where life-prolonging treatment is involved (British Medical Association 1999). But the central point is that the psychological sense of“best interests” expresses the value-base of consumerism, while the normative sense expresses that of medical professionalism. In other words, there is a conflict between two sets of collective values.This conflict between the values and attitudes of medicine expressed through medical practitioners, and those of the free market expressed through management structures, can result in poor care for patients. For example, the management imperative to meet targets in the name of efficiency can conflict with the medical desire to spend time with patients, and thus care can be minimized to achieve through-put of patients. But the situation can become more confused when, as I shall go on to suggest, the solidarity of medical attitudes is in harmony with the solidarity of management attitudes with the aim of covering up serious mishaps.
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