Patients and medical power
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7310.414 (Published 25 August 2001) Cite this as: BMJ 2001;323:414All rapid responses
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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
Founder, Prostate Cancer Support Association
Philip H M Reilly, MA, Dip Psych
Patient Advocacy Service
Manager
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
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:
1) Hierarchial observation, i.e. sites where individuals can be observed.
The design facilitates observation.
2) Normalising judgement, attributes/actions of each individual are
compared with attributes/actions of others. This permits a norm to be
established.
3) Examination, combines normalising judgement and hierarchial
observations. Here the individual subject can be assessed and corrected.
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.
Competing interests: No competing interests
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
Competing interests: No competing interests
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.
Competing interests: No competing interests
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.
Competing interests: No competing interests
As a patient
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
Competing interests: No competing interests