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The Demise of Paternalism

Traditional medical paternalism was based on the importance of faith in the absence of effective treatments. Physicians occupied a quasi-religious role, providing solace rather than salvation. With the rise of more invasive medical procedures, more finely tuned but highly toxic drugs, and more diseases defined by a medical finding rather than by a patient's symptoms, the underpinnings of this paternalistic role deteriorated. Choosing treatments is no longer the simple exercise of diagnosing the patient's condition and having that diagnosis determine therapy. A diagnosis now triggers a universe of possible actions. The selection of a treatment from this universe becomes a value judgment based on the relative risks and benefits of the various actions. The risks to be considered include patient-specific psychological and social risks.

Physicians may be expert in determining the medical risks of a treatment, but it is only the patient who can determine the relative acceptability of these risks. For example, some patients will risk substantial disability on a chance of a complete cure of chronic pain. For others, chronic but bearable pain is preferable to the chance of disability secondary to treatment. This weighing of risks is idiosyncratic to the patient's individual risk-taking behavior and cannot be predicted by a physician.

Following the paternalistic model, physicians assumed the task of making these risk-benefit decisions for the patients. Problems arose as patients began to question the consequences of these decisions. Once patients realized that there might be more than one way to treat their conditions, they began to question the physician's authority to make unilateral treatment decisions.

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