Health Paternalism

I think a lot of health and medical professionals take themselves too seriously.

When I read through research articles, almost every one ends on a note that goes something like this:

“The referenced study indicates such and such a problem is very serious and warrants closer consideration by medical professionals and public policy people”

It’s become so common place that I think a lot of authors put it in there because a paper might not be taken seriously without it.

You get the impression that the people doing the writing feel like it’s their obligation to take care of the helpless peasants that are afflicted with one thing or another. But I have doubts that their perception is shared by the afflicted.

 For instance, The Wall Street Journal has an interesting article about pharmaceutical sales in Japan:

What persuades doctors and patients to use a particular drug, it turns out, is local.

In the U.S., doctors tend to focus on a new drug’s clinical trial results–the medicine’s safety and effectiveness. But doctors in Japan often have other interests, too, particularly the biology behind a new therapy’s development, industry officials say.

Japanese physicians also want to know how it performed specifically in Japanese patients. “That’s a significant hurdle upfront, because they’re hungry for evidence,” says Tony Alvarez, Merck’s Japan chief.

However, the need for doctors to understand the truth about their medicine is not passed onto their patients. Medical paternalism is a strong cultural ethos in Japan.

Reading more about the Japanese led me to this curious bit about doctors attitudes towards cancer disclosures:

Despite the increasing concerns of truth disclosure, most cancer patients are not told the truth about their disease in Japan…….

Results showed that 72% of patients and 83% of clients wanted to be told the truth, but only 33% and 34% of them thought that the truth should be told to cancer patients. These attitudes of patients and clients regarding truth disclosure were more positive than those of the general public and health care workers in previous studies. At present, 13% of doctors inform cancer patients of their disease. These trends indicate that the Japanese attitude toward avoiding truth disclosure stems primarily from paternalism but is also influenced by social characteristics including insufficient understanding of this issue. 

However, the doctors might want to give their patients a little more credit. In another survey, 85% of patients said they’d want an active or collaborative role in the decision making process for illness:

 The overall proportions of respondents who preferred active, collaborative, and passive roles were 12%, 71%, and 17%, respectively……

Our study suggested that a majority of Japanese patients have positive attitudes towards participation in medical decision making if they are fully informed. Physicians will give greater patient satisfaction if they respond to the desire of patients for participation in decision-making.

Admittedly, these preferences were not as strong for cancer. However, the same overall point was true. And other evidence suggests there are pervasive mismatches in preferred information sharing.

This result is not unique to Japan. In America there are also large discrepancies between what doctors think their patients ought to know and what cancer patients want to know:

Across all cancer types, patients wanted more participation than what actually occurred. Research to date documents a pervasive mismatch between patients’ preferred and actual roles during decision making.

At Nutrition Unplugged, there was a discussion about how dieticians should fight the war on obesity. One of the participants in the debate framed the issue like this:

We’ve lost the war on obesity. Fighting fat hasn’t made the fat go away. And being thinner, even if we knew how to successfully accomplish it, will not necessarily make us healthier or happier. The war on obesity has taken its toll. 

Do fat people view the issue the same way? How many of these people “fighting the war” are obese themselves? 

I don’t want to throw sand on the motives of the people doing the talking, but I sometimes think framing the issue this way makes things worse. Our obsession with diets and weight loss causes anxiety and confusion over what we eat. Maybe the expressed paternalism by health professionals distorts the layperson’ decision making as well.

3 thoughts on “Health Paternalism”

  1. You’re right about your “paternalism” remark, to a degree. However, a large number of patients aren’t very well informed about health care matters, they aren’t aware of research, they tend to want the “quick fix,” a pill. Getting a history, doing an exam, getting appropriate labs and imaging studies, making a working diagnosis, prescribing, treatments and medications are all difficult to do. Medical education commonly lasts 7+ years AFTER medical school. And, it requires recertification, state licensure and continuing medical education.It’s one thing to redo your home’s wiring if you’re an electrician, or have had lots of supervised experience working with electricians. It’s very different, and dangerous rewiring your house if you have very little background or knowledge and lack basic skills.


  2. Thom,Excellent points. I think the point I was getting at wasn’t that Doctors don’t have a large knowledge advantage over their patients, obviously they do.But would health outcomes be better off if health professionals ceded more decision making authority to their patients on the margin? I suppose the best answer would be to look at studies that tried to answer that question. Maybe material for a future post.


  3. Hi, Jon,Thanks for the reply, I appreciate it.That’s something we can discuss.  I posted to your site (and answered thru Mech Turk), under this alias.I’m actually an MD on the East Coast.  I skimmed some of your other posts and thought that they were pretty good.Actually, there are studies going back at least thirty years showing things like: patients find their visits with a doctor unsatisfactory, regardless of the outcome, unless the patient gets a prescription. A recent study shows that there’s NO link between vaccinations and autism.  Other studies show that by not getting one’s children vaccinated, it puts those children at risk (measles, mumps, whooping cough, tetanus, etc.), it puts other children at risk (the contacts of the unvaccinated children) may put the children’s parents and other adults at risk, increase the risk to the vaccinated elderly and the immunosuppressed.  Yet there are hundreds of thousands of parents that refuse vaccination, believing that mercury, thimerosal, etc. in vaccines can cause autism.There are people out there who are doing chiropractic manipulations and craniosacral therapy on INFANTS.  Even physicians who do craniosacral therapy will not do it on infants.  A classmate of mine was a chiropractor and then went to medical school.  He’s appalled at chiropractors doing manipulations on kids and can’t believe that that they’d even attempt it on infants.I’m not defending all doctors in general.  There are some out there who are reprehensible:Octomom having a huge number of children (that one was both a patient and physician disaster).Michael Jackson’s death – another one that probably has both Michael and his doctor to blame.Obviously, I’m citing some negative things that people opt for than can be extremely harmful.  Ultimately, in most cases the choice is the patient’s – does he want to accept the diagnosis, get the additional tests and imaging studies, take the prescribed medications, seek out another opinion, see a specialist, etc.  Another issue in the paternalism question is one of malpractice suits.  In the electrician analogy I posted on your site, if the homeowner refuses the electrician’s advice, does the wiring himself, then his house burns down, the electrician doesn’t get sued.  However, if the physician recommends treatment and the patient declines it, gets some other form of treatment that has a less-than-satisfactory result, it’s NOT uncommon for the physician to get sued by the patient.   Most recent statistics that I’ve seen show that over 2/3 of doctors will get sued during their professional lives, many more than once.  And while the majority of these suits are dismissed, it can cause a great deal of damage to the doctor: loss of patients, loss of patient TRUST, loss of time, legal fees, stress and many other negative aspects.Sorry, Jon, didn’t mean to go into lecture mode.  It’s just that there are several issues related to paternalism that often aren’t considered.  Ideally, if I had a well-informed patient, who had researched his disease, treatment, outcomes, medications I’d have no problems with giving him much more control over his options.  Unfortunately, many patients use Aunt Bertha as a reference (I have carpal tunnel because I have the same symptoms Aunt Bertha had), their information about their disease comes from a commercial website that is promoting a supplement (SuperAcai tablets work really well for carpal tunnel, I won’t need surgery or a support for my wrist), treatment (the electromagnetic splint causes the carpal tunnel to enlarge naturally), spiritual cure (I’m getting my wrist prayed over), has no peer-reviewed data on the success/failure of its product (“our studies show”), etc.  The well-informed patient seems to be a rarity though.BTW, never heard of Nova Scotia dulce.  I’ll have to check that one out.  Thanks!Mark


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