INTRODUCTION

The patient's rights movement arose in the late 1960s and began to have an impact on health care providers in the early to middle 1970s. This movement resulted from the fusing of two issues: the demand by consumers for more information about services in general, and the campaign against unethical experimentation of human subjects. The historical genesis of the concern over human experimentation was in the medical experiments conducted by Nazi physicians on the inmates of concentration camps.

As noted in our earlier discussion of liability in the teaching environment, the debate over medical experiments on human subjects has been very emotional. This initially led to great hostility between health care providers and patient's rights advocates. The hostility arose because health care providers did not appreciate the extend to which the patient's rights movement was rooted in patients' fear of not being able to control their own medical care. The health care providers interpreted this fear as an attack on their competence, rather than as an attempt by patients to participate in medical decision making.

The traditional role of the patient in the physician-patient relationship was to accept passively the physician's recommendations for therapy. The patient was not encouraged to ask questions and had little recourse if the proposed therapy was not acceptable. This passive role is best understood by reviewing the nature of medical practice 50 to 75 years ago. Until the late 1800s, medical science had almost no effective treatments. The physician might comfort the patient with various rituals (bleeding was a prime example) but had little positive effect on the patient's well-being. Medicine in this "prescientific" period depended heavily on faith, and faith is not strengthened by asking questions.

As medicine evolved into a scientific undertaking, it began to offer positive benefits to the patient. Effective treatments were developed for conditions that had meant certain death or great suffering only a short time before. The number of conditions that could be treated was still very limited, and few conditions had more than one treatment. There was no reason for the passive role of the patient to be modified, because the only significant medical decisions were diagnostic, not therapeutic. Once the patient's condition was diagnosed, the therapeutic decisions were preordained. Either there was no therapy for the condition, or there was a single therapy. The physician's "take it or leave it" attitude was due less to indifference than to frustration at not being able to offer the patient any alternatives. The persistence of this passive patient role into modern medical practice has led to the present-day conflicts between patients and health care providers.

In the modern practice of medicine, most conditions have several effective treatments. Birth control is an important example. There are several forms of birth control measures available, each with specific risks and benefits. Each woman must balance these various factors in her decision as to which type of birth control measure she will use. The physician may make recommendations, but it is the woman herself who must decide which method is most effective for her. When the physician attempts to make this decision for the woman, it can lead to hostility and may result in unwanted pregnancy due to the failure of the birth control measure for social rather than medical reasons.

The large selection of therapies, coupled with the general expectation that people will get well, has made it important for the patient to be involved in the choice of therapy. This is especially important when there are no clear medical reasons to favor one therapy over another. The patient will be much less likely to sue over a complication of therapy if that patient was informed and consulted in the selection of the therapy.