The Doctor as Parent, Partner, Provider… or Comrade? Distribution of Power in Past and Present Models of the Doctor–Patient Relationship

The grand narratives of the evolution of the doctor–patient relationship almost always start with what philosophers have referred to as “paternalism” since the 1960s and 1970s [6, 18]. The age of paternalism has been claimed to span between “many decades” [14] to “thousands of years” [54]. Etymologically, paternalism derives from the Latin word for father. This metaphor, then, aligns the relationship between doctor and patient with the relationship between benevolent father and ignorant child. The patient-child is regarded as a dependent of the doctor-father; just like the child of the father, the patient-child is not really actively involved in deliberations about his or her medical encounter. Belonging to the same cluster of metaphors is the so-called “priestly model” of doctor–patient interaction, which has designated more or less the same thing [63]. In terms of ethical principles, a paternalistic stance implies that the principle of beneficence often, or always, trumps the principle of patient autonomy [8, 62]. Thomas Szasz and Marc Hollender’s famous text about the doctor–patient relationship puts forth two distinct paternalist metaphors which correspond to two different types of doctor–patient interaction: the parent-infant and the parent-adolescent relationship. In the first, the doctor-parent is active, and the patient-infant is a completely passive recipient of the doctor’s actions. It is even questionable if it can be called “interaction” at all, as the action goes only one-way. It is a completely appropriate orientation in the treatment of emergencies, but not much else. The second parental metaphor, between adult and adolescent roughly designates a form of paternalism that partially recognizes patient subjectivity. In contrast to the infant, the adolescent is conscious. The adolescent can cooperate, or at least obey. Although critical of this model, Szasz and Hollender admit that there are scenarios when also this mode of interaction might be warranted, or at least commonly occurring: “it is employed in situations which are less desperate than those previously mentioned […]. Although the patient is ill, he is conscious and has feelings and aspirations of his own.” Their own suggested example of this is “acute infections” [57].

Despite the heterogeneity of the attitudes that huddle under the umbrella of paternalism and familial metaphors, there is one feature that unites them, and which is important for the progression of the main argument in this article. The doctor is the one in charge, with power to influence the decisions. The main characteristics “pertains to power, and to its actual or potential use. The more powerful of the two (parent, physician, employer, etc.) will expect […] cooperation of the other member of the pair (child, patient, employee, etc.). The patient is expected to ‘look up’ and to ‘obey’ his doctor” [57].

The standard account of the doctor–patient relationship during the last century is a story of the abandonment of paternalism for something else [54, 57, 62]. The beginning of the end of the era of medical paternalism is often set around the end of the Second World War. Although the effective causes for the death of the hegemony of paternalism are notoriously difficult to pin-point, and separation between causes and effects are tricky, the changes in general attitudes are somewhat easier to follow. For example, an American survey in 1961 showed that 90% of the responding doctors preferred not to fully disclose a cancer diagnosis to their patients. About 20 years later, the response was completely reversed: 97% indicated a preference to tell their patients they have cancer [45]. For the medical ethicist Howard Brody, among others, this rapid change in information disclosure possibly represented a paradigmatic shift, leaving behind the “history of routine deception and withholding of information for fear that frank truth would frighten or harm the patient” [8].

There are several suggestions as to what superseded medical paternalism. One category and cluster of metaphors used to designate the new relationship emphasizes its equal and cooperative character [2, 15, 19, 63]. Doctor and patient are more like parties of a contract of sorts, both in the form of a business contract but also as a holy covenant, a marriage [63]; Others have suggested that the bond is analogous to friendship [19]. The common denominator of these models and metaphors can be summarized in a few points: 1. The flow of information between doctor and patient is more symmetric; less an interrogation and more a conversation; 2. An open deliberative approach to whatever means and ends are appropriate for the treatment of the patient; the ends of medicine are not presupposed, as in the paternalist case. In terms of power, they are all identical, as Szasz and Hollender put it: “It is crucial to this type of interaction that the participants […] have approximately equal power” [57]. A crucial common denominator for many who employ the metaphor (some cited above) is the relative indifference to power structures outside of the doctor–patient dyad. The power vested in doctors and patients is assumed to entail a high degree of actual influence over the ends of the medical with negligible apparent involvement by external forces. A corollary of this assumption is that the doctor and patient are the main (or sole) entities involved in deliberating and making decisions about the goals set in the confines of the doctor’s office. The negotiation is, hence, directed inwards [2, 8, 14, 15, 19, 48, 57, 63].

There is a third mode of doctor–patient relationship that has gained traction later than the partnership model: the consumer model.¹ In the United States it can be traced back to the 1960s [7]. In a European welfare state context, the transition might have occurred later, during the (re-)commodification, privatization and marketization of healthcare around the 1980s (with considerable individual differences between countries, of course) [27].

Even though the model can be categorized as a realist offshoot of the partnership model, they differ in terms of power. The autonomous and sovereign patient-consumer constitutes the essential core of the metaphor. The professional role correlating to the patient-consumer is more passive: a provider or “engineer” [63], or a “seller” [7] of a service. At its most reified extreme, physicians are the services or objects they provide: mere products. Hence, the relationship is more asymmetrical than the partnership model, and can in some respects be conceived as the “polar opposite” of the paternalist model [7]. Analee and Thomas Beisecker have elegantly summarized the consumer metaphor in the doctor–patient relationship in the following bullet points: "Consumerism focuses on rights[;] consumerism assumes the doctor is self-centered[;] consumerism replaces trust with accountability[;] consumerism presumes that the patient's health care values dominate[;] consumerism may require third-party supervision" [7]. The fundamental assumption that forms the base of the consumer model is that the interests of the physician and the patient diverges, and the only person genuinely interested in the health of the patient is the patient. Most importantly, for the aims of this article, the specific distribution of power rests in the hands of the patient: “In a consumerist relationship, the seller has no particular authority; power rests in the buyer who can make the decisions to buy or not to buy as he or she sees fit “ [7].²

In working through the different metaphors of the doctor–patient relationship, I have implicitly ordered them in two ways. Firstly, there is the question of historical order in which the metaphors of the doctor–patient relationship appeared. Although there is good reason to be critical of grossly oversimplifying statements, I believe there is some truth to the specific order in which the paradigms are assumed to have appeared: that is, during the twentieth century in the West, paternalism was superseded by other models for the doctor–patient relationship, namely the partnership model and the consumer model.

Then there is the question of ordering the models and metaphors in terms of the specific power distribution they each represent. This categorization of models and metaphors is by no means an unprecedented endeavor. For example, Felicity Goodyear-Smith and Stephen Buetow have suggested something similar. In their meta-model, there are mainly three unique distributions of power: In paternalism power resides with the doctor, in consumerism with the patient, and in contemporary society both doctors and patients are empowered, but with “each exercising different but equally important sources of power”. They then proceed to problematize this last position of “equality” or “mutuality” of power. Both doctors and patients can misuse their powers; doctors have multiple allegiances to other stakeholders outside of the doctor–patient relationship which adds a good deal of complexity to the partnership model [24]. However, there is one possible configuration of power they do not explore, namely, the disempowerment of both physician and patient and the peculiar interaction it engenders.³

The same historical and ideological conditions that brought forth the consumer model are also the ground for this fourth model: marketization, public sector cutbacks and a businesslike management of healthcare that remained public, all driven by a neoliberal frame of reference [38, 39]. The partnership model and the consumer model both presuppose that the unit of doctor and patient (regardless of the internal distribution of power) contains a high degree of control and power over the course of the medical encounter. Current conditions of power have in reality empowered neither doctor nor patient. Not only is the equal disempowerment of doctor and patient conceivable; in contemporary healthcare, I argue, the equal disempowerment of doctor and patient is becoming paradigmatic. As far back as 1985, and possibly a bit untimely, Mark Siegler declared the arrival of what he called the “age of bureaucratic parsimony” in healthcare. For Siegler, the distinctive feature of this age was that the relationship between doctor and patient had ceased to be the impenetrable dyadic bond it once was: “The physician will be accountable to multiple interests including employers (health maintenance organizations [HMOs], hospital corporations), hospitals, insurance companies, and government. The physician in the age of bureaucracy will have divided allegiances” [54]. The condition of possibility of the equal disempowerment of doctor and patient is this multiplication of stakeholders in healthcare, and that power resides elsewhere.

A warranted objection is that the doctor–patient relationship never existed in isolation, that external stakeholders and actors (such as family members or social insurance agencies) and more impersonal, abstract, power structures (such as class, culture, market, gender, etc.) always have conditioned and influenced the patient-doctor interaction [1, 35, 54, 58, 64]. These constitute a dimension of external force behind all the enumerated models, that can be large or small, depending on the circumstances. For example, does the partnership model not already contain the possibility of an even distribution of whatever power there is (be it a lot or very little), reducing a distinction between an even distribution of power and an even distribution of powerlessness to a category mistake? As mentioned above, characterizations of the partnership model usually exclude the possibility that powers of doctors and patients might be severely constrained by external forces. Secondly, the partnership model deserves a distinct category as its normative claims are laudable, despite its limited descriptive value in this particular conjuncture. Thirdly, although the partnership model and the model I propose both formally share an even distribution of power, the experiences they produce are qualitatively different. Whereas the partnership model mainly brings to the fore inward negotiation, my suggested equal disempowerment model is dominated by negotiation strategies directed towards the structures in which the doctor–patient interaction is embedded. Hence, another difference is that schematic partnership models allow a bracketing of outside forces without losing grasp of the interaction between doctor and patient as partners (be it for ideological or pedagogical reasons). The main characteristics of how disempowered doctors and patients act and interact, on the other hand, cannot even be comprehended without reference to its outside.

The novelty of my proposition, I believe, is that this relatively new condition of healthcare creates not only problems, but also possibilities. It is not despite the characteristics of this age, but because of them, that a new kind of bond can be established between doctors and patients. Following philosopher Jan Patočka (which I will return to below) one can also say that being on the receiving end of the cracking whip of domination creates a sentiment between former adversaries—a solidarity of the shaken [46]. Similar to philosopher Rahel Jaeggi, I will call the subjects of this new solidarity comrades in order to distinguish it from other forms of solidarity.⁴ In the remainder of this text I will explore what this new kind of solidarity is and how it manifests in a concrete case.

The processes delineated above could certainly be interpreted as expressions of a general loss of trust and solidarity, which have been superseded by a universal logic of suspicion [40, 61]. It could easily be assumed that doctors follow suit and act equally suspicious towards their patients and their sickness benefit claims. However, that does not seem to be the case. Physicians are not just standing idly by. Some of them mount elaborate forms of low-key everyday resistance against the attempted power grab of the SSIA, its stricter standards of sickness benefit eligibility, its logic of austerity and suspicion. One such way of resistance has been documented through interview studies with Swedish GPs. In writing the sickness certificate, they employ “techniques” aimed at making the certificate appear as if it adheres to the stricter standards. For example, as the SSIA demands documentation of “objective signs” for cases where such signs are hard to come by (such as psychiatric disease, some forms of chronic pain, etc.), the appearance of such data is fabricated on the fly. Hence, parts of the anamnesis (the patient’s own account) might be presented as if it was an objective finding: an account of a depressed mood is “translated” to a clinical sign (“patient has a lowered mood” or “psychomotor retardation”). In the interview study, the motives declared by physicians for doing so were multiple: writing sickness certificates in an evasive fashion was not motivated solely by self-interest, nor by pure altruism. The doctors saved time, so they could do more clinical work instead of paperwork, and defended their medical autonomy and discretion. The patient could recuperate and enjoy income protection [52, 53].

In both the experience of and resistance against the bureaucratic disregard for professional judgment, the absurdity—that is, the contradictions and senselessness—of bureaucracy appeared in between the lines of the interview study of Swedish GPs. For example, one doctor lamented that the SSIA forced her to use buzzwords which paradoxically lowered the medical precision of their certificates:

I write ‘cognitively impaired’, because I’ve learnt that they [the SSIA] want to hear that particular phrase. It’s not enough to write memory and concentration loss; for some reason the word ‘cognitive’ must be used [52]

Furthermore, this perceived absurdity was commonly communicated between the doctor and patient. The doctor could be frank with the patient about the weirdly Kafkaesque and common predicament of theirs, exemplified here:

I’ve even told the patient: “Maybe this wasn’t exactly what you told me, but to be certain that you’ll get your sick pay, I will have to write it like this.” [52]

The dynamics between doctors and patients in the sickness certification process, the transition from adversaries to comrades in and through their common powerlessness, can be understood in terms of philosopher Jan Patočka’s idea of a “solidarity of the shaken”.⁷ In an essay in his Heretical Writings (“Wars of the Twentieth Century and the Twentieth Century as War”) Patočka develops the idea that the horrors in the trenches of the First World War revealed something very important regarding human coexistence. Through depictions of the front-line experiences, he highlights a special type of coexistence, enabled by the limit-experience of war, of death, and violent conflict. The experience was utterly destabilizing and frightening: “The first phase, which few can transcend, is the experience of meaninglessness and unbearable horror. The front line is absurdity par excellence”. One of the main consequences of this fundamental shaking is that the “adversary”—the one with whom we have nothing in common but conflict—becomes a “fellow participant in the same situation”, through the absurdity of war, and through the brush with death. This is what Patočka calls “the solidarity of the shaken for all their contradiction and conflict”. Whichever trench we happen to crouch down in, German or British, in the role of doctor or patient, we come to the insight that “ultimately, all are subject to the crack of the whip” [46].

Likening mundane clinical encounters to life in the trenches of war may seem implausible, even tasteless. However, metaphors of war are commonplace in portrayals of healthcare, even though their use can be problematic. It has been claimed that they stigmatize the ill and shift focus “from fighting the disease to fighting the patient” [42]. Yet, there are some fundamental similarities between war and the clinical encounter that warrant a comparison aided by Patočka’s solidarity of the shaken. The concept constitutes a critique of the senseless killing of war and is therefore less prone to reproduce the negative impact of warfare tropes; it might even counter such effects. The three fundamental similarities are the following: (1) Both war and the clinical encounter can involve severe suffering and death. Through illness as the reminder of the finitude of life, death figures at least to some extent in the background of many clinical encounters. Havi Carel, an influential thinker in the field of phenomenology of illness, goes further and establishes death as a transcendental-existential condition of illness as such: “Death is positioned on the existential horizon of illness, and therefore makes up part of the illness experience” [12].⁸ Furthermore, for the doctor, there is the limit-experience of being overworked to the brink of fatigue. It is a form of “self-sacrifice” and an “endurance in the face of death”, not exclusively in relation to the patient, but also through an ever accelerating production process [46]; (2) Both war and clinical encounters in the era of bureaucracy are in some respects absurd: In war, the horror of death is its necessary condition. In healthcare, this may occasionally be the case. There is, however, another dimension of existential loss of meaning or ground that springs forth not from facing death in itself, but from confronting nightmarish bureaucratic inflexibility. This holds true for war as well: while the horror of death is necessary, it is not a sufficient cause of that specific type of absurdity. Rather, it is the horror of death in conjunction with the destruction of human bodies on an unprecedented industrial scale, initiated by impersonal state structures and carried out by opaque chains of command. Hence, the absurdity in question is not only of the transcendental Sisyphean variant, but simultaneously a worldly and historically specific subspecies often emphasized in the works of Franz Kafka.⁹ When internal ends of healthcare are increasingly colonized and replaced by external goals of efficiency and austerity, a similar kind of absurdity emerges, that may lead to losing and being forced to find new ground. In the case of the absurdity of the sickness certification process (mentioned above), that new ground is the solidarity between physicians and patients; 3. There is a procedural similarity between the solidarity of soldiers in war and the encounters between doctors and patients in late capitalism. In contrast to the solidarity of, say, factory workers who start out from a relation of mutual indifference to showing solidarity with each other, the starting point of this other form of solidarity is not indifference, but antagonism, from which they transition over to solidarity.¹⁰ In a way, the foundations of this new kind of solidarity were built by the metaphors and models of partnership and consumerism. The abandonment of the paternalist paradigm also meant that the interests of physicians and patient could not be assumed to automatically overlap. In the superseding framework of partnership their interests often appear as subject to negotiation, and in the framework of consumerism the participants even appear as mutually suspicious adversaries, whose interests must not only be negotiated, but sometimes even fought for [24]. Antagonism is essential to market mediated relations, even if they do not always appear as such. Irrespective of the use-value of whatever is changing hands, the goal is nevertheless for one to buy cheap and for another to sell high. However, the argument of a foundational antagonism between doctor and patient is independent of the conceptual content of the partnership and consumer models. For example, the relationship between doctors and patients in the sickness certification process does not embody any specific doctor–patient relationship model. Even if the logic of mistrust pervades the entire field, in Sweden it is not directly a commodity relation because the Social Insurance Agency is state-run and can only indirectly be understood in terms of the consumer model. Due to the institutional framework, the doctor and the patient have still been cast into the pit of sickness certification as adversaries, as “gatekeeping” the resources of the social insurance system is one of the main roles that the Swedish doctor is expected to assume [60]. Given current circumstances, that role unfortunately amounts to being the guardian of austerity [4].

In addition to these points, which make Patočka’s (ontologically) negative take on solidarity relevant for our purposes, the concept is also distinctly negative in one further sense. Whereas Steinar Stjernø believes that the lack of “a common vision of society” between physicians and patients automatically disqualifies their relation as being solidaristic, this apparent lack is an essential feature of Patočka’s solidarity: “The solidarity of the shaken can say ‘no’ to the measures of mobilization which make the state of war permanent. It will not offer positive programs but will speak, like Socrates' daimonion, in warnings and prohibitions” [46].