Patients and medical power

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7325.1368 (Published 08 December 2001) Cite this as: BMJ 2001;323:1368

More debate about patient power in NHS is needed

  1. Robert Dingwall, professor of sociology (robert.dingwall{at}nottingham.ac.uk)
  1. University of Nottingham, Nottingham NG7 2RD
  2. 16 Roskear, Camborne TR14 8DN
  3. Faculty of Medicine, Imperial College of Science, Technology and Medicine, London W2 1PD

    EDITOR—Canter raises 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 skill that are structurally inherent in professional-client relationships.1 However, his challenge to Alan Milburn, the health minister, 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 implication of this statement—that doctors should simply give patients what they want—is fundamentally incompatible with the ethics of taxation.

    As Canter's analysis hints but does not explicate, Milburn's statement implies that doctors should prescribe unnecessary antibiotics, carry out unnecessary surgery, and make available untested treatments—all in the name of patient power. Where does this leave the simultaneous investment in the National Institute for Clinical Excellence, 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 that 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 when 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 Canter is seeking to encourage.


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    Patient power requires patient freedom

    1. J Calinas-Correia, medical practitioner (j_calinas{at}yahoo.co.uk)
    1. University of Nottingham, Nottingham NG7 2RD
    2. 16 Roskear, Camborne TR14 8DN
    3. Faculty of Medicine, Imperial College of Science, Technology and Medicine, London W2 1PD

      EDITOR—Canter's editorial highlighted the formal difficulty in promoting patients' power.1 I see this in a social context and have summarised some of the problems here (a longer version of this letter can be found at bmj.com/cgi/eletters/323/7310/414#EL14).

      • Medical power is intrinsic to medicine. It cannot be handed over

      • Medical power is a particular aspect of “experts' power”

      • Medical power arises from the process of socialisation, which induces submission to medicine (we are born in hospital, vaccinated, surveyed while children, and screened while adults; medical examinations are requested for employment and insurance and other purposes; and most of us will die in hospitals)

      • The patient's entourage undergoes the same process of socialisation, and patients' relatives are a major source of pressure for medical power to be enforced

      • The politicisation of medical power removes power from the doctor-patient interface and gives it to higher administrative levels (the government and committees (health authorities, the National Institute for Clinical Excellence, etc))

      • Lobbying groups, while requesting more power for patients, result in more power being moved away from the patient to higher administrative levels

      • It is a fallacy that medical power is handed over to the patient through being more strictly enforced, with the role of guidelines and protocols being reinforced and the leeway for personal variance being decreased

      • The current discussion cannot look outside the Western medical paradigm, and medical advice can only be opposed by even more authoritative medical opinions. Such opinions are handed over from somewhere further from the patient (the problem of applying evidence from populations to particular individuals being bypassed through the unquestioning acceptance of the said paradigm).

      The constraints on patients' power arise from social conditioning to submit to medicine2 and from political constraints on access to doctors of the patient's choice. Patients' power cannot be handed down from doctors; it has to be created anew through freedom to choose the doctor one wants to see; freedom of access to second or third opinions (not theoretical access, but economically and socially feasible access); 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 medical practitioner become acceptable for sick pay?


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      Issue of power is almost irrelevant for doctors practising patient centred medicine

      1. Debra Nestel, lecturer in communication skills (d.nestel{at}ic.ac.uk)
      1. University of Nottingham, Nottingham NG7 2RD
      2. 16 Roskear, Camborne TR14 8DN
      3. Faculty of Medicine, Imperial College of Science, Technology and Medicine, London W2 1PD

        EDITOR—In the communication skills programme at the Imperial College of Science, Technology and Medicine, our first year medical students participate in a session titled “Power and adherence in the doctor-patient relationship.” The issues raised by Canter are debated, specifically in relation to the models of power that he described.1 Among other things, the students usually identify the fact that decisions about medical treatment are rarely made in isolation.

        Patients may consult several doctors or other members of the healthcare team, or both, 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 his or her world outside the consultation—by social, economic, religious, and cultural factors. The models of power tend to assume that only two parties are involved and do not consider additional influences to decision making.

        If doctors are practising patient centred medicine then the issue of power is almost irrelevant. Patient centredness implies that the doctor will actively seek to determine the patient's desire to make decisions about his or her care in the same way that the amount of information that the patient wants about his or her illness should be assessed. A patient centred approach to medical care thus assumes that each patient is wielding the amount of power that he or she would wish to in the doctor-patient relationship.


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