Academic journal article The Hastings Center Report

What Health Care Providers Know: A Taxonomy of Clinical Disagreements

Academic journal article The Hastings Center Report

What Health Care Providers Know: A Taxonomy of Clinical Disagreements

Article excerpt

Some assume that respecting patient autonomy means clinicians should refrain from expressing opinions about what's in a patient's best interests. But depending on the kind of medical decision the patient is making, a clinician may have expertise vital to the patient's best interests--and even if she doesn't, she may still know what is best.

Consider the following case: Horace Johnson is a forty-year-old, wheelchair-bound patient who has been suffering for the past ten years from type 2 diabetes mellitus. He has wet gangrene on his fifth toe. He doesn't visit the outpatient clinic for care of his diabetes and infection as he is scheduled to. The infection is so severe that his physician, Dr. Garcia, concludes that the toe cannot be saved and that if it is not amputated, Mr. Johnson could die. Mr. Johnson has been seen by a psychiatrist, who finds him eccentric but believes that he has no evidence of mental illness and must therefore be declared competent to make his own health care decisions. (1)

What is Dr. Garcia to do in this case? Given that Mr. Johnson is competent, almost everyone will agree that she cannot hospitalize him against his will. (2) Competent patients have the right to make choices about their own care, and their clinicians are, other things being equal, duty-bound to defer to their wishes concerning treatment options, even if doing so is not best for the patient. (3)

Even so, we might feel that Dr. Garcia is well positioned to tell Mr. Johnson what is best for him. She sees--as surely we all do--that choosing to die rather than lose a baby toe is bad for Mr. Johnson. In this case, we might be tempted to say that Dr. Garcia knows best. Even if she cannot make Mr. Johnson do anything, she can try to persuade him to have the toe amputated, confident in her assessment of what is best for him.

But is that really so clear? For who is Dr. Garcia to say that Mr. Johnson is wrong to prefer death to living without his baby toe? Perhaps, given his view of life and the importance of bodily integrity, dying with ten toes is more important than living with nine. If that is what Mr. Johnson thinks, are we still so sure that Dr. Garcia knows what is best for her patient?

I will not try to directly answer these questions on behalf of Dr. Garcia. Instead, I will develop a model for understanding disagreements in a clinical setting that illuminates the different types of disagreement that can take place between a health care provider and her patients (or more broadly, her patients' families). In doing so, I hope to give health care providers some guidance in understanding their role in such situations. More specifically, I aim to offer insight into what clinicians can and cannot plausibly be said to know about what is best for their patients, particularly in cases of disagreement.

I do so by developing a taxonomy of clinical disagreements. I maintain that this taxonomy helps us to see that health care providers can legitimately lay claim to knowing what is best for their patients in many cases. It reveals that, in some cases, clinicians can lay claim to having special expertise regarding treatment options, while in other cases, they can lay claim to knowing what is best for their patients, even if they cannot do so in their role as clinicians.

The second point depends on distinguishing between the idea that clinicians often do not have special expertise regarding what is best for their patients, and the idea that they do not know (or are unlikely to know) what is best. These ideas are not the same. Moreover, we cannot infer the second from the first, for reasons I discuss below. Keeping these two ideas distinct can help someone like Dr. Garcia decide how to proceed in a case like that involving Mr. Johnson.

But beyond the inherent interest and, I hope, helpfulness in providing a taxonomy of clinical disagreements, this paper has a subsidiary aim: to combat a kind of skepticism about the role of the clinician in determining patient care that can be found in the work of Robert M. …

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