Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Widening the notion of power.
- J J Waring (24 August 2001)
-
Is patient power such a good idea in an NHS?
- Robert Dingwall (25 August 2001)
-
Political power & Empowered clients
- Ron Law (25 August 2001)
-
Lack of Choices Cause Power Imbalances
- Carol Teasdale (28 August 2001)
-
Power and patient-centred care
- Debra Nestel (28 August 2001)
-
The key is powerless technology!
- Sharon Levy, David Bradley (29 August 2001)
-
Re: Power and patient-centred care
- Pat Davis (30 August 2001)
-
Regimes of Truth , Patients & Medical Power
- Mary Curtis (31 August 2001)
-
Power and concordance
- David Dickinson (31 August 2001)
-
Re: Power and concordance
- Carol Teasdale (31 August 2001)
-
Power and Duty
- Ravi Chinthapalli (7 September 2001)
-
what power for whom?
- J Calinas-Correia (13 September 2001)
-
Patients, Doctors and Power
- Angus W Earnshaw, Philip H M Reilly (10 October 2001)
-
As a patient
- Glynis R Jones (26 January 2008)
|
|
|||
|
J J Waring, Research student University of Nottingham
Send response to journal:
|
Canter's paper provides an interesting, if somewhat old debate on the forms of power and the possibility of changing medical power in a more patient centred NHS. French and Raven's model of power is well utilised, but care must be taken in relying upon a highly individualised notion of power and this reliance is also carried over into the appreciation of Luke's neo-Marxist interpretation of false consciouness. Power is defined at the on set as the ability of an individual to produce behaviour, compliance or change in another, and little attention is given to underlying role of professional and patient cultures, occupational legitimacy and social knowledge. It is disappointing that the paper concludes just as it starts to develop Luke's third dimension and discuss a more discursive appreciation of power at the level of social knowledge. It is at this level that the questionable notion of "handing over" power to patients could be better understood, with particular attention given to Foucauldian theories of knowledge/power. I would therefore suggest that those interested in this subject should widen their understanding of power and address the discursive forms of power both at the level of the individual clinician but also at the level of medical and social knowledge. |
|||
|
|
|||
|
Robert Dingwall, Professor of Sociology and Director, Institute for the Study of Genetics, Biorisks and Society University of Nottingham
Send response to journal:
|
Richard Canter raises some important points about the problematic nature of power and the idea that it can simply be shifted from one party to another, particularly given the asymmetries of knowledge and expertise that are structurally inherent in professional/client relationships. However, his challenge to Alan Milburn stops short of the crucial question about whether a National Health Service should seek to achieve a 'decisive shift of power in favour of the patient'. The potential implications of this statement, that doctors should simply give patients what they want, are fundamentally incompatible with the ethics of taxation. As Canter's analysis hints but does not explicate, taken literally, Milburn's statement implies that doctors should prescribe unnecessary antibiotics, carry out unnecessary surgery and make available untested therapies - all in the name of patient power. Where does this leave the simultaneous investment in NICE, evidence-based medicine, and medicines management? More to the point, where does it leave the NHS on the morality of its funding from tax levies? In an insurance-based system, I can choose to pay for the level of access that I want. If I want a consumer-driven system that gives me absolute freedom of choice, then I can pay for it, at least to the extent that I can afford the premiums or can persuade others to join me in a risk pool where we each agree to fund the others' unlimited choices. In a tax-funded system, we must consider the ethics of compulsorily levying all taxpaying citizens and whether this can ever be justified beyond the extent of providing demonstrably efficient and effective care to those citizens. Doctors are the agents of restraint on behalf of taxpayers. As a patient, I may want the NHS to do everything for me that may be of any conceivable benefit or which will, at least, make me feel good about it. As a taxpayer, I do not want to see my income sequestered to indulge the fancies of others where there is a clear medical view that an intervention has no clear and established benefit. It is a politician's duty to manage that conflict and the medical profession's task to produce practical resolutions in individual cases. Loose talk about 'shifts in power' is just that and should give way to the more sophisticated debate that Dr Canter is seeking to encourage. |
|||
|
|
|||
|
Ron Law, Management Lecturer Auckland University of Technology
Send response to journal:
|
Canter's is an excellent editorial that would benefit from including the significance of connection power, in the practice and politics of medicine. I mean, what career 'advancement' opportunities are there if one does not have the right connections? Patients/clients/citizens are also denied access to certain treatments or therapies based on medical politics giving advice to regulators who make it nigh-on impossible for consumers to access appropriate treatments. For example, the Irish Medicines Board made St John's wort a prescription only medicine based on mostly theoretical evidence of p450 iso-enzyme stimulation. This denied consumers access to such effective and hitherto (and since)safe therapies. Consumers, on the other hand, are not dumb - ie, they are not powerless. They can choose where they spend their money. An increasing number are choosing to avoid the power & politics of medicine and use so-called alternatives. The internet enables individuals to gain not only more knowledge about what disease they have than any general practitioner, but also access to treatment otherwise denied. This means that in effect, the client has the capacity to gain expert/information power. This happened to a friend recently. The friend had terminal breast cancer and was given a month or two to live. They planned their funeral, said good bye to friends and spent most of their time on the couch sleeping. The only outside contact was via the internet which they used to look up information on their disease. To cut a long story short, they discovered three chemo/immuno-therapies, and insisted that their doctor treat them with them. After much debate, the oncologist relented and after only three weeks the person is now up and about and leading a near normal life, including returning to university to undertake masters studies. Power is indeed a two-way street, and unless the medical profession learns that lesson quickly, it may well become the alternative. |
|||
|
|
|||
|
Carol Teasdale, N/A N/A
Send response to journal:
|
Dear Sir, Power is always afforded to an organisation or individual, which has dependants. Unfortunately, unlike the family unit where the child knows that one day it can grow away from it, the work place where people can leave, or a Government we can vote out, our same medical system stays with us. How good is it for people’s well being for doctors to only have one governing body to choose from, or to have well qualified alternative practitioners unable to order diagnostic tests? Should I be able to ask those questions, and the many more I could ask, of a modernised medical system designed to empower? Lack of choice is power’s greatest tool, and it’s certainly no accident that in this day and age people are having their choices restricted. Power is worth far more than a pay cheque, or the individual health of a patient, it’s what makes work rewarding and for some is the reason they choose the work in the first place. It’s just a shame that the people who are most vulnerable are the most disempowered by, and dependant on, the system. I propose that handing over power to the patient is about offering choice first and foremost, not only in medications where it is economically viable, but also in the use of practitioners. Giving this kind of choice to patients would mean that other ‘professionals’ would have to be recognised as equals in the work they do, and I think that this would be too hard for many medical professionals. Choice means that ‘everyone’ is empowered with options they don’t have at the moment. So, why haven’t we got choices? Is the problem really a matter of whether power can be shifted over to the patient, or whether shifting it to the patient is what is actually wanted? I also propose that a system that keeps people waiting so long for appointments feeds the self importance of the few, who use their power to satisfy their own prejudices. For example; sending a patient in need of medical treatment to a dietician because they are overweight, instead of investigating physical causes for the ill health first. Doctors can get away with doing such a thing simply on the basis that people need treatment, more so after a long wait. Having the choice to walk out into another option may no longer be viable, or feel viable by then. Therefore, more choice, if it ever comes, must go hand in hand with reduced waiting times, not just to consultants, but to all primary care staff too. |
|||
|
|
|||
|
Debra Nestel, Lecturer in Communication Skills Imperial College of Science, Technology & Medicine
Send response to journal:
|
In the Communication Skills Programme at Imperial College, our first- year medical students participate in a session titled, Power and Adherence in the Doctor-Patient Relationship. The issues raised by Richard Canter are debated, specifically in relation to the models of power described. In addition to the content of the other responses to the article, the students usually identify the fact that decisions about medical treatment are rarely made in isolation. Patients may consult several doctors and/or other members of the health care team so that a range of views, at least within the context of Western scientific medicine can be elicited. The patient's decisions are also influenced by their world outside of the consultation - social, economic, religous and cultural factors. That is, the models of power tend to assume that there are only two parties involved and do not consider additional influences to decision-making. The second element is that of patient-centredness. If doctors are practicing patient-centred medicine, then the issue of power almost becomes irrelevant. Patient-centredness implies that the doctor will actively seek out the patient's desire to make decisions about his/her care in the same way that the amount of information a patient wants about his/her illness should assessed. That is, a patient-centred approach to medical care assumes that each patient is wielding the amount of power that he/she would wish to within the doctor-patient relationship. |
|||
|
|
|||
|
Sharon Levy, Research student/Professor of Mechatronic Systems School of Science and Engineering, University of Abertay, Dundee, David Bradley
Send response to journal:
|
Canter discusses the idea of handing over power within the UK National Health Service from healthcare (nee medical) professionals to their patients, where in fact we believe this should read their clients. This subtle change in terminology reminds us that it is patients as clients, rather than professionals, who are at the heart of the healthcare process. Consumerism as a philosophy in healthcare, where service users are seen as the customers of care, places responsibility for health management on informed individuals by giving them the power to act as they deem appropriate. Healthcare professionals who argue that patient’s interests can only be defined and assessed by those with the “right” knowledge, while de-emphasising the patient’s right for autonomy, self- determination and full involvement in their care, may be seen as guarding against a loss of power. However, patients can only share in the decision making process if they are given access to relevant and timely information. Yet consumerists maintain that information and choice are easily mixed up, and that there can be information without choice, whereas there cannot be choice without information. We believe that the introduction and use of a range of healthcare technologies has the potential to facilitate a shared decision making process and thus to lead to a redistribution of ‘legitimate power’ among providers and their clientele. Used in this way, technology can empower patients by providing them with information tailored to their needs, in an interactive forum which delivers up-to-date healthcare information detailing treatment options and potential outcomes. Consider a situation where individuals can access a full range of healthcare information from their home. In future, a use of information technology to control and manage self-care reduces the reliance on consultation with healthcare professionals. However, in this scenario technology serves to transfer ‘power over’ from healthcare professionals to their clients while losing the ability to gain from a such professionals ‘power to’ facilitate appropriate human centred care. Alternatively, clinical information systems, while supporting the efficient management of resources, may shift the current reliance on communication with patients to a reliance on data and information about patients. Healthcare professionals may thus come to perceive accurate, scientific and ‘real time’ data as a high added-value tool for disease management, while neglecting the holistic needs of the person who suffers from the disease. The failure of technological innovations to impact on ‘power to’ may ultimately promote ‘power over’ whereby the pre-existing ‘provider centred’ culture is reinforced. Technology which provides the means and medium for knowledge sharing and open communication must therefore be perceived by its users as powerless. In this way, a power paradox in which both users and providers are using access to information and knowledge as ‘power over’, is resolved. The achievement of a nil ‘power currency’ attributable to healthcare technology can only be accomplished by ensuring that all stakeholders are educated as to role of such technologies in facilitating patient centred care. A failure to accept power sharing in a system which embraces technological advances, may lead to the decline of a service which was created to protect the most vulnerable in society. |
|||
|
|
|||
|
Pat Davis, Thyroid Group Helper
Send response to journal:
|
I have to wonder which cloud cuckoo land the writer of this article is on !!!!!!!!! The day that patients are considered as important by doctors is the day that a huge number of illness figures will take a nosedive The current abject failure to correctly diagnose much less treat a vast range of ill health is a disgrace Thyroid patients being at the forefront of the illtreatment The failure of the establishment to ratify research which PROVES that Thyroxine far from being beneficial to Hypothyroid patients is actually causing a whole host of furthur disease and that undiagnosed Hypothyroidism is the true cause of Breast Cancer, Heart Diseae, Arthritis , etc etc is a damming indictment of a blinkered health system that cares more for Medical Egos than patients False claims by Drug companies for medications like Thyroxine are doing immeasurable harm to thousands of patients left struggling to exist on Incapacity Benefit of £68 a week when the return of the use of Armour Thyroid could cure them and see them back at work |
|||
|
|
|||
|
Mary Curtis, Head of Education & Training Cornish Hospices & Palliative Care Services Mount Edgcumbe Hospice
Send response to journal:
|
Firstly, it is good to see senior medical personnel engaging with literature outside biomedicine. This is to be encouraged since medicine is increasingly defined by people outside its realm and the sooner medical professiojnals get to grips with the arguments the better will they be able to fight their corner. Despite Waring's comment about the debate being somewhat old, I think further explication of Luke's conception of power would not have been amiss for those without knowledge of the model to which Canter refers, for, as we shall see, it continues to have relevance in contemporary culture. Luke's (1987) model can be describes as having three faces. 1) decision making (Canter's first dimension), which is self explanatory, 2)non-decision making (Canter's second dimension) involves using power to prevent issues being discussed or decisions about them being taken (think government for expert evidence based practice at this! along with bio medics of course!) and finally, 3) shaping desire by means of manipulation Canter's third dimension. This latter is a favourite with advertisers, bio medics amongst others, as well as the apparatus of the state. From Luke's perspective, those interested in power are concerned with, the difference that is made, i.e. outcome, and, the making of that difference, so interest is in the locus of power. The purposes for which power is being sought will often be thoughtfully and extensively hidden by carefully constructed discourse. The above model and Government Rhetoric is steeped in the Enlightenment tradition which saw the human as possessing some essence of freedom or liberty which is constrained by social practices (Jean-Jacques Rousseau - 'Man is born free, but everywhere he is in chains'. By changing the social practices (abolition of slavery, abolition of monarchist rule in the French, American and Russian revolutions, emancipation of women and children, decline of colonialism leading to independent governance, personal autonomy, shift of power from doctor to patient etc) we liberate the person from constraints. I will now take Waring's request to widen the notion of power a stage further. Foucault's 1979) ideas help us to reverse the above way of thinking. He did not believe that some utopian situation of 'freedom' can be achieved, because 'freedom' itself is a product of a discourse that is historically and culturally determined. Ironically, 'freedom' is achieved through putting into place 'practices' of freedom, not by removing constraints. While such practices of freedom offer an illusion of emancipation, they in fact set up a series of subtle controls to maintain the idea that autonomy has been achieved. Such practices of freedom, as practices of 'self' are viewed by Foucault as articulating an ethos that offers power relationships allowing a minimum of domination. Now, professional dominance of certain occupational groups is clearly grounded in the possession of a body of knowledge which is a crucial feature of the exercise of professional power, (Turner, 1995). Medicine, like most of the sciences, is knowledge transformed into power. The theoretical aspects of medicine, constitute the rational experimental foundations of a science which is then applied by the practitioner. The doctor - patient relationship is complex, not readily analysed and influenced by a myriad of cultural factors. I suggest that discourse surrounding and within this relationship is the most important factor influencing the character of this relationship because it is here that other influencing factors are given form or ignored, depending on the 'regime of truth' predominant in a given historical period, Foucault, 1984) (Witness current debate surrounding MMR vaccine to work out how the latter operates). Discourse then, is a domain of language use unified by a set of
common assumptions which provide ways of representing a particular kind of
knowledge about a topic, e.g. biomedicine. Here, power rather than facts
about reality make things true. Power and knowledge fit as glove to hand,
always implying one another, discourse being one of the systems through
which power operates. Power, based on control of information (can you hear
Luke's conception in the background here?) may be Administrative or
Disciplinary. Working at the level of the individual and of the
population, through regulatory controls, knowledge of bodies is produced.
The 'known' become 'subject'. Disciplinary power refers to the way bodies
are regulated, trained, maintained, understood. (Most evident in
institutions, hospitals, prisons). Disciplinary power works at two levels;
(1) Anatomo-politics of the human body (individual bodies are trained and
observed), (2)Regulatory controls, a bio-politics of the population
(Concurrently populations are monitored). Knowledge of bodies is thus
produced. There are three main instruments of disciplinary power:
The medical encounter according to this perspective or how bodies are controlled by discourse. Clinical examination is one of the apparatuses of disciplinary power. Body is both target and effect of power. Each individual equals a 'case' (the subject and object of knowledge). Talk of medical dominance is inappropriate. Patient's self-talk provides opportunity for the medical gaze to be directed towards them. This therefore, offers subtle, individualised means of surveillance and social control. Power in this relation is diffuse, a form of social organisation by which social order and conformity are maintained by voluntary means. Therefore, power is not only repressive, but also productive. Discipline occurs through punishment (lose weight or we won't operate etc) and gratification via the rewards and privileges for good conduct (discontinue smoking and you can have the treatment). Both doctor and patient believe in the importance of medical testing, constant monitoring and invasive, embarrassing investigative procedures in the interests of the patient. Explicit coercion is not needed. The patient voluntarily gives up the body to the medical gaze because that is what people are socialised to expect. So, control occurs through (A) Cultural values and norms: Power is everywhere, enforced as much by the individuals unconscious self- surveillance as by authority figures. (B)The use of language and practices: the patient is incited to speak, allowing invisible power relations to take place within a framework in which the patient is encouraged to take responsibility for their own behaviour. (Recall the flurry of policy documents in the 1980s & 90s propounding the role of disease prevention?). According to Lupton, (1995) 'the dialectic of public health is that of the freedom of individuals to behave as they wish pitted against the rights of society to control individual bodies in the name of health'. She asserts that, 'disciplinary power is maintained through the mass screening procedure, the health risk appraisal, the fitness test, the health education programme invoking guilt and anxiety if the advocated behaviour is not taken up'. In other words, health persuasion techniques, Beattie, (1993) or indeed, Lukes (1987) third face of power, shaping desire by means of manipulation, and his second face, that of non-decision making, because, after all, individuals are unaware that such discourse is disciplinary because health is portrayed as a universal right and the source of the discourse as benevolent. 'Power relations are rendered invisible, and are dispersed, being voluntarily perpetuated by subjects upon themselves as well as upon others, and thus produced are not simply the imposed results of alien, coercive forces, the body is internally lived, experienced and acted upon by the subject and the social collectivity' (Grosz, 1990:65 cited in Lupton 1995. In conclusion, Enlightenment humanism (the liberal humanist view) sees knowledge (education) as a potential to liberate from power, where power is seen as distorting 'true' knowledge (e.g. Marx's alienation, Durkheim's anomie, Hegel's development of Spirit, humanism's authentic self etc). Foucault sees power and knowledge rather as intimately tied. Knowledge is formulated through power relations. Liberal humanism does not remove power (Liberation) but merely re-inscribes it, or offers techniques of 'liberty' and 'autonomy' that are subtle forms of power relations. Foucault does not perveive 'power' as merely a coercive, negative, controlling force, but as an integral part of human relationships, which changes in quantity and quality from one situation to another and within situations. 'Power' than, is a productive network which runs through the social body, much more than as a negative instance whose function is repression. 'Knowledge' (related to what Foucault calls 'trugth-games') is constructed through power relationships. The 'subject' is a good example of a site of power/knowledge relationships, for the 'subject' is not only agent but also object (one is subject to, or subjected to) The subject is constituted by a number of social practices variously in different historical periods. The subject is formulated through 'games of truth' or validated and invalidated forms of knowledge and Foucault suggests that subject/truth relations are the central concern of power/knowledge relations, as humans have constructed various techniques of the self (care of the self) through history. So we ask, following Foucault, (a) how are practices and knowledge established through social discourse, and (b) whart are the particular relationships between power and knowledge and the subject and truth in any historical epoch? References Foucault, M. (1973) The Birth of the Clinic, London Tavistock. Foucault, M., (1979 & 1984 "Truth and Power" in (Ed) P. Rabinow, The Foucault Reader, Penguin. Lukes, S. (1987) Power, Basil Blackwell. Lupton, D., (1995) Medicine as Culture, Sage, pp 31,32. Turner, B., (1995) Medical Power and Social Knowledge, 2nd Ed, Sage. |
|||
|
|
|||
|
David Dickinson, Editor, Connect: the concordance newsletter London
Send response to journal:
|
The range of responses to Canter's stimulating editorial shows the gulf between the interested parties. There are those who have called for a more rigorous analysis of the nature of power, those who call for more patient-centred techniques - and then there are patients themselves (or their close advocates) for whom fine gradations of power are out of cloud cuckoo land. Like others in the field, supporters of concordance (myself included) recognise the difficulty of handling transfers of power. On a workaday level, the first step may be to address the related difficulty of effective, two-way communication (as Nestel suggests). Excellent work by the GKT Concordance Unit has shown broad gaps in post-consultation understanding between patients and GPs - gaps which may be seen reflected in the responses listed here. Speaking personally, I find it helpful to imagine power being pooled between patients and professionals, in order to make decisions and reach solutions that might not otherwise be reached. [Others argue, with more severe logic, that power is a zero sum game]. The concordant approach is not exactly meant to favour the patient, though it would be a huge leap forward for most. It's not even patient-centred – concordance broadly suggests that the 'centre' of partnership in medicine taking lies between the patient and the professional. It is born of understanding, and talking honestly to, each other. If professionals need to set the process in motion, reflecting on Canter's editorial is a good place to start. |
|||
|
|
|||
|
Carol Teasdale, N/A N/A
Send response to journal:
|
Dear Sir, With respect to Mr Dickinson's comments about concordance. Concordance, as it is in my understanding, is a mutual agreement. This does not address an imbalance of power, as reaching an agreement could be a perception, and is almost certainly determined by the personal attributes of individual doctors and their powers of persuasion. Also Mr Dickinson's comment that some patient's views on the matter come from 'cuckoo land' are insulting, especially as there were relatively few 'patient' opinions on this matter. So statistically there is a high chance I am one of those patient's he is referring to. He seems to be of the opinion that the patient's views, derived from experiences, are not to be valued. If he were a doctor, his attempt to ridicule, would be a classic example of an imbalance of power. If the system is not working for patients because of an abuse of the power within it, then it has to be changed radically. Radical changes involve looking at the constructs within the system and the way they work, or not as the case may be, and then making adjustments. It is a simple fact that on many occasions choice could be offered to a patient, yet it is not. This is most likely because of the personal choices of the doctor, the written material a doctor adheres to, or convenience. There is also indications that there is a distinct lack of choice because it suits the power model within the medical profession. For Mr Dickinson to disprove this he would have to satisfactorily explain why; relatively cheap drugs, such as natural thyroxin, are denied to patients, mothers have been denied separate vaccinations for their children, well qualified alternative practitioners do not have the means to carry out tests and make referrals to consultants, women can't self refer to a gynaecological clinics, and patients with injuries cannot self refer to physiotherapists if they feel there is a need. Of course I could go on with this list. To try to demean patients by inferring that their views come from 'cloud cuckoo land' is despicable and can only add distance between the 'problem' and the patient. I do not think that Mr Dickinson fully understands the nature of 'power' and how an imbalence of it can disempower another person. |
|||
|
|
|||
|
Ravi Chinthapalli, Consultant Paediatrician Princess Margaret Hospital, Swindon
Send response to journal:
|
Dear Sir It was interesting to read the editorial and the subsequent rapid responses on transfer of power from doctors to patients. I think that the word and meaning of power has been taken out of context. A different interpretation would be that it is not a mere manifestation of power when a doctor influences a patient in what he believes is right, but rather that it is the doctor’s duty to do so. A doctor is duty-bound to explain the choices and failing to do so would be falling foul of GMC regulations. That such regulations exist, means that such power is not in a doctor’s hands but elsewhere. Of course, the doctor can only explain the choices as he understands them. That is why it is the doctor’s responsibility to keep his knowledge continually up-to-date, by keeping abreast of the latest research, guidelines, and practices. This is again determined by the GMC and the various Royal Colleges. Patients have power not only due to informed consent (which compels the doctor to explain the alternatives, risks, and benefits of a procedure – and rightly so), but also by being able to request a second opinion before and after treatment. If anything should be unsatisfactory in the conduct of the physician or the care given, then the patient is always able to complain. Many research articles have shown the power of a complaint in modifying a doctor’s behaviour. This is after the consultation, but even so it shapes future behaviour. As for the conventional biomedical framework Richard Canter mentions, that has always been inherent in doctors’ approach to treatment and care. Patients know that they will probably not be offered so-called complementary medical alternatives (hence their name), and they are also free to use those therapies if they wish. Whether other paradigms should be considered is a matter for Alan Milburn, and the governing bodies to determine. Conventional medicine is nothing more than medicine that has been scrutinised carefully for its effect, and proven to have a beneficial effect. Whether the complementary medical alternatives should be included, depends solely on their merits, and unless there is evidence of their benefit, doctors will naturally be reluctant to include them in their list of choices. Doctors will always exhibit this kind of ‘third-dimensional power’ in any personal interaction, as in a consultation. However I do not think it is fair to say doctors control the world as the patient sees it – as though it is deliberate. It is true that third-dimensional power can be hard to recognise and can be abused, but in the majority of the profession, it is not a sinister attempt to lure the patient into believing what we want them to. The doctor will give information impartially to the best of his ability, but, as with any human, it will inevitably be slightly coloured by his own views, beliefs, and attitudes. This is going to be inevitable in any interaction in which one person is imparting information to another. An analogy would be that of taking a car to the mechanic. The mechanic will explain the problem briefly and go about fixing the car. Yet we do not complain of power in this situation – we do not expect the mechanic to take into account our opinions, or to offer to phone a second garage so that we can be sure he has correctly identified the problem. And if new garages are set up on the belief that cars can be repaired using psychic powers, then we do not expect the mechanic to take account of that alternative theory of repair. We just want a working car at the end. Naturally this is tongue-in-cheek, and medical interactions are more complex, but some of the basic principles about power still apply. A shift in the balance of power ‘decisively in favour of patient’ favoured by Alan Milburn, sounds laudable, but in essence means nothing. A doctor has more knowledge (and also obligations to the taxpayer – as Robert Dingwall mentions), and that is the source of his power. In a consultation, doctors should strive to have a mutual relationship, in which patients understand all of the issues regarding their treatment, and if that aim is met, both parties should be satisfied. Even achieving this, in the present NHS, when consultations are only a matter of minutes, is by no means an easy feat. |
|||
|
|
|||
|
J Calinas-Correia, medical practitioner Cornwall
Send response to journal:
|
There is this idea that medicine is in the process of reassessing the balance between the power of the doctor and the power of the patient. Richard Canter [1] expressed very well the difficulties involved. The power of medicine - the power of the doctor - comes from the ownership of the model of reality where the life of the patient is to fit. The consultation is the process of rewriting the patient's history - life history - from lay into medical jargon. This process implies the primacy of the medical view of the world, and the patient's acceptance of that primacy, otherwise it makes no sense for the patient to consult the doctor. The primacy of the medical view implies the upper hand is with the doctor. This cannot be changed without destroying the core of medicine itself. To deny the legitimacy of the medical rewriting of the patient's history is to deny the capacity for medicine to interpret and to act upon that life, and ultimately is to deny the legitimacy of medical intervention itself. And to accept the medical version of the patient's life implies the power of medicine upon the patient, exercised by the doctor. To consult an expert is to accept this state of affairs, be it a doctor, lawyer, engineer, teacher, and so on. The expert is supposed - in fact called upon - to reinterpret our problem according to his or her expert knowledge, not accessible to the non-expert (a point also made by Chinthapalli [2]). An expert is by definition a person of authority on the field of expertise considered. With authority comes power. Whenever one hears authoritative advice, power is obviously present. It may be about fire alarms saving lives, or speed limits, or smoking, or neighbourhood watchers, it doesn't matter. Those who fail to follow authoritative advice are guilty of something, and if they suffer the consequences of not following advice, they become doubly guilty. Imagine the man whose house burns down after he attended a session on fire alarms, or runs a child down at 35 mph after a session on road safety, or gets lung cancer after years of ignoring his doctor's advice, or gets robbed after refusing to take part in a neighbourhood scheme: isn't he somehow more guilty than those who had not been given authoritative advice? To understand what exactly makes the power of a doctor different from the power of an engineer, a lawyer, or a teacher, one has to revisit Illich [3]. It isn't the power endowed on the expert that makes the difference, but the social pressure to surrender to the expert. One may decide to ignore advice from most experts without incurring social punishment, but that is not so when it comes to medicine. For once, no one can be properly sick without the sickness being legitimated by a doctor. Without it, particularly if refusing to submit to it, one is assumed to be malingering, to be displaying antisocial behaviour, to be taking advantage on others who will have to support the malingerer. But more pervasive, more intimate than that, is the conditioning all of us are exposed to, that one should not cope, that coping is only admissible within the medical world. Outside medicine, coping is malingering, or sheer stupidity, or ignorance. Anyhow, the one who copes outside medicine will be said to lack something socially important (this is the result of current socialisation, as pointed by Curtis [4]). The issue is that one ought to see the doctor, and this 'ought' is much more imperative regarding medicine than the 'should' we use for other experts. Having said this, what is really at stake in this power struggle? More than the balance between patient and doctor, it seems to be the balance between doctor and the entourage of the patient. This entourage may consist in relatives and loved ones, or it may consist in patient advocates, solicitors, employers, and many other parties. In fact, the patient seems a pawn in this struggle, instead of an actor. The patient is the voice I seldom hear in those discussions. I hear politicians trying to calm down lobbying groups, and I hear pressure groups trying to wind-up politicians. To devolve power to the patient does not involve giving it to someone else but the patient. This power is the power to ultimately decide for or against the advice received. This power is the power to say no to medical advice. The ones restraining the patient's power are not doctors, but that same society who will brand as malingerer, stupid, or ignorant, the patient who says no to medical advice. The most effective promoter of the power of the doctor is the public voice for conformity with the expert's opinion acting as peer pressure upon the patient. The current status of affairs justifies caution against medical advice. The doctor may give less than optimal advice, as doctors are no longer independent advisers, but advisers employed to promote the excellence of their employer - the NHS. Compare this with the rules for financial advisers. Doctors are submitted to regular and compelling propaganda by their employer, and economically driven decisions are seldom explained as such. One has just to remember how long we waited for the government to own up to its rationing policies. Or the post code lotteries for many treatments, from IVF to Interferon or Riluzole. When the doctor is the sole expert, how can the patient refuse less than optimal advice, from within a strong peer pressure for conformity? The right to refuse less than optimal advice can only be gained through the right to refuse any medical advice. And the doctors are not the ones trying to constrain the patient here, but the patient's peers, conditioned, with the patient, by an 'experts' culture'. Usually, this implies that medical advice can only be declined in favour of some other medical advice... and this circle does never extend outside medically legitimised power. Interestingly, what will happen if the patients are given, by the politicians, the right to consult with specialists of their own choice for second opinions? Are we forgetting that General Practice's gate-keeping role is a politically imposed way of rationing medical advice? The pride placed on "the envy of the world" went from resting on being exceedingly good into being exceedingly cheap. It is difficult to see those who extol the virtues of the cheapest national health service in Europe financing patients' education to focus on questioning their submission to a politically effective agency. Centrally controlled medicine is a political weapon used to normalise and constrain. Why would the central control forgo such a useful weapon, effective as it is? Particularly if the doctor can be used as scapegoat? It seems much more politically competent to shift power from doctors to the central control itself, invoking the sanctified notion of accountability. Obviously, it means accountability to the centralised control, not to the patient. Instead of giving less than optimal advice because of the uncertainties inherent to medicine, doctors can now deliver less than optimal advice because the guidelines say so. It is worrying that the only doctor taking the trouble to reply to Canter sees medical power as being already away from the doctors [2], in some agreement with Dingwall: “Doctors are the agents of restraint on behalf of taxpayers.” [5]. It seems that the patient's name is being invoked to remove the real power farther and farther away from the patient. Instead of facing the source of power in the consultation room, the patient is more and more facing a facade, standing for a centralised, removed power, for whom a patient is a statistic. Doctor's power resides on the acceptance by the patient of the validity of the medical view of their problem. You cannot take the doctor's power away without destroying medicine, and doctors power is supported by the legitimacy of medical knowledge: the patient has no support to receive that power. However, the constraints on patient's power arise from social conditioning towards submitting to medicine [2], and to social and economic constraints on access to doctors of their choice. All are politically determined, and much can be done about them without destroying what benefits medicine may offer. Quoting Curtis [4], “freedom is achieved through putting into place practices of freedom”. Patient’s power cannot be handed down from doctors, it has to be created anew through the implementation of its practices: freedom to choose the doctor one wants to see, freedom of access to second or third opinions (not theoretical, but economically and socially feasible), and above all freedom to refuse the medical view of the world and choose alternative discourses and practices. When will a sick note from a non-orthodox medicine practitioner become acceptable for sick pay? 1 Canter, R. Patients and medical power: shifting power in favour of the patient may not be so straightforward. BMJ 2001;323:414 2 Chinthapalli R. Power and duty. Electronic response to Canter R #11 3 Illich, I. Limits to medicine. Marion Boyars Publishers, London 1995 (enlarged edition) 4 Curtis, M. Regimes of truth, patients & medical power. Electronic response to Canter #8 5 Dingwall, R. Is patient power such a good idea in an NHS? Electronic response to Canter #2 |
|||
|
|
|||
|
Angus W Earnshaw Prostate Cancer Support Association, Philip H M Reilly
Send response to journal:
|
Dear Sir/Madam, Patients, Doctors and Power A friend of ours, who is both a doctor and a cancer patient, has sent us a copy of the article 'Patients and medical power' in your issue of 25th August 2001. We are grateful to Richard Canter for his analysis of the ways in which A (the doctor) is able to influence the balance of power between her/him and B (the patient). We would like to look at the role of B in this relationship, and those of C and D also. When presented with the diagnosis of a life-threatening illness, such as cancer, both patient and partner are assailed by powerful emotions: crippling fear, rage and grief. How they deal with them depends, of course, not only upon their individual psychological make-ups but, also, upon the extent and manner in which the information about diagnosis, prognosis and the effects, both beneficial and adverse, of treatments are conveyed. The authors recognise that the patient may be overwhelmed, want the doctor to take charge and to decide which treatments to provide. But what can be done about doctors who always take this approach, regardless of the patient's wishes? Training in listening skills, as well as communication skills, would be a good start. And what can be done to encourage patients to empower themselves? Patients need to be valued, acknowledged as individuals rather than as a set of symptoms on legs, and actively listened to - to be encouraged to tell their stories - and to be given full and frank answers to all and only the questions they ask. Doctors simply don't have the time - but C (another patient/support volunteer) may well do. It was for these reasons that one of us, a cancer patient, founded a national charity The Prostate Cancer Support Association (PSA) in 1997. There is a helpline and local groups to listen to, inform and support callers, whether patients, partners, family members or friends. One should never under-estimate the immense affirmation that can result from being actively listened to. But there is, not infrequently, the need for a fourth person D (a patient advocate) whose function is not only to support the patient in deciding what s/he wants from health and other services but also in expressing those needs clearly and effectively. One of us has set up and manages an Advocacy Service for patients with mental health problems. On many occasions, cancer and other patients could also benefit from access to such a service. Unfortunately, health service workers often, initially, look upon patient support groups and patient advocacy services with distrust and suspicion, viewing their activities as likely to undermine their professional standing. Later, they frequently come to appreciate how they can complement and facilitate their roles. If Alan Milburn really wants power to "shift decisively in favour of the patient", then he should establish a Patient Advocacy Service for all patients which is truly independent (unlike PALS). He should also initiate a review of mental health service delivery that goes far beyond simply re-framing the Mental Health Act 1983. The review would do well to consider the contracts of consultant psychiatrists and their relationships to the Trusts for which they work, their colleagues and, not least, their patients. Both the national shortage of psychiatrists and the nature of their contracts ensure that they are highly autonomous and largely unaccountable to anyone. This situation is thoroughly unacceptable because it plays directly into the worst aspects of the model delineated by Richard Canter; it leaves patients reliant upon their consultants' goodwill and their ability to reflect upon both their own practice and those of their junior doctors. In too many instances, both these qualities are almost completely lacking. We heartily agree with Richard Canter's statement that "a little more honesty on the subject wouldn't go amiss". Make that a lot and add a measure of humility. And it applies to us all: patients, doctors, nurses, health service managers and, last but not least, politicians. Yours truly, Angus W Earnshaw, BSc
Philip H M Reilly, MA, Dip Psych
|
|||
|
|
|||
|
Glynis R Jones, N/A None
Send response to journal:
|
After having read all of the responses on this board I would like to say that for some illnesses, patients are regarded as being equal or even in control of their care. For instance, if I were diabetic, would it not be my responsibility to watch my diet and administer my medication? Why then is it such a huge jump to patients with other illnesses, short or long term, having control over their care and medication? When are doctors going to realise that they are a part in the healing process and not the whole thing? I am hypothyroid, I am sick, tired and demoralised that doctors won't even listen to me when I explain the pain I am in or the difficulty in attempting to live a normal life. I have had responses from, not even listening to me, to telling me I am lying, to telling me that I am mentally ill. What hope has any patient if doctors are not trained to accept that the patient needs to be able to get information on their condition and to have a major stake in their treatment? Competing interests: I am a hypothyroid patient |
|||