Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice

doi:10.1059/0003-4819-125-9-199611010-00010

Physician Recommendations and Patient Autonomy: Finding a Balance between Physician Power and Patient Choice

Timothy E. Quill, MD; and
Howard Brody, MD, PhD

From University of Rochester School of Medicine and Dentistry and Genesee Hospital, Rochester, New York; and Michigan State University, East Lansing, Michigan. Acknowledgments: The authors thank Geof Williams, Richard Ryan, and Ed Deci of the Rochester Motivation Group for helping conceptualize the distinction between autonomy and independence. Requests for Reprints: Timothy E. Quill, MD, Department of Medicine, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607. Current Author Addresses: Dr. Quill: Department of Medicine, The Genesee Hospital, 224 Alexander Street, Rochester, NY 14607. Dr. Brody: Department of Family Practice, B-100 Clinical Center, Michigan State University, East Lansing, MI 48824.

Abstract

Medical care in the United States has rapidly moved away from a paternalistic approach to patients and toward an emphasis on patient autonomy.At one extreme end of this spectrum is the “independent choice” model of decision making, in which physicians objectively present patients with options and odds but withhold their own experience and recommendations to avoid overly influencing patients. This model confuses the concepts of independence and autonomy and assumes that the physician's exercise of power and influence inevitably diminishes the patient's ability to choose freely. It sacrifices competence for control, and it discourages active persuasion when differences of opinion exist between physician and patient. This paper proposes an “enhanced autonomy” model, which encourages patients and physicians to actively exchange ideas, explicitly negotiate differences, and share power and influence to serve the patient's best interests. Recommendations are offered that promote an intense collaboration between patient and physician so that patients can autonomously make choices that are informed by both the medical facts and the physician's experience.