A case for bringing back paternalism?

Paternalism has become a bad word in medicine. The physicians of old are caricatured as stern unapproachable male figures who commanded their patients to take the treatments they prescribed without any explanation. The patient’s own opinion didn’t seem to come into it at all. The term ‘paternalism’ also evokes the idea of a stern unloving father figure who rules the home with an iron rod and doesn’t hold back on punishment when his child misbehaves.

I’m not going to defend the old style of medicine  – nor would I want to defend the sort of strict uncaring style of parenting that gave no room for the child to develop.

Good parenting requires a progressive ‘evolution’ in parental behaviors and attitudes. The younger the child the more directive the parental advice and the briefer the discussion or explanation will be. The caring parent will provide a safe environment for the child by making decisions for them – with their best interest at heart. As the child grows and gains education and maturity they will be able to have an increasing role in decision-making until they are fully independent.

I would argue that doctors need to understand where their patients are on the continuum between the passive or less well informed patient and the patient who has a comprehensive knowledge of their disease and its treatment. In the case of rarer diseases the patient (perhaps with the help of online resources) may even build up a knowledge base that is superior to that of their specialist. The doctor should help the patient become better informed by guiding them to reliable sources of help and sometimes warning them where the sources are unscientific. Some would argue that a doctor’s job should be to dispassionately offer the information and leave the patient to make the choice (e.g. between two or three different Disease modifying drugs for arthritis). I think it is quite cruel to leave patients on their own to make these important decisions and not to use your skills of persuasion to help them to make the decision when they are afraid to do so, perhaps because of a particular side effect mentioned on the information leaflet.

I would argue that most patients want and expect expert help, guidance and advice from their doctor. Most patients expect us as specialists to have sifted the information and to speak from experience. It is not wrong to present them with a preferred choice and coax them into going along with our proposal – perhaps we should call this characteristic ‘benevolent paternalism‘.