Drawing the line between coercion and persuasion

Is it ever right for a doctor to try to persuade a patient to choose one course of action over another? Some would argue that this is an example of blatant paternalism, even coercion, unethical because it violates a patient’s autonomy. To such people, the doctor’s job is to present unvarnished, unbiased facts: just present the options and let the patients choose. (I would argue that such a position is a repudiation of the whole idea of medicine as a profession, that autonomy viewed in such a fashion makes the doctor not a professional but a shopkeeper, just presenting his wares to whoever will buy. The ethical imperative that is an essential component of a profession is obliterated by such a view of autonomy. But that’s a subject for another post.)

The April 24th JAMA carries a potentially provocative Viewpoint entitled “Evidence-Based Persuasion: An Ethical Imperative” (you can view the abstract and a little over half the article here). The authors classify persuasion under three headings. The first is removal of bias, the correcting of mistaken beliefs or cognitive biases, such as the mistaken belief that the MMR vaccination causes autism; the authors see this as mandatory. The second is recommending options, that is, assessing patients’ values and counseling them regarding which treatment option is most in line with their values; the authors see this as “usually permissible but sometimes inappropriate.” The third is creating new biases, the creating of new mistaken beliefs or cognitive biases in order to persuade a patient to follow a recommended course of action; the authors see this as “normally impermissible but sometimes acceptable in rare cases.” The authors conclude with a discussion of the importance of context, and the statement that “persuasion is an essential component of modern medical practice, and it may be impossible to respect patients’ autonomy without engaging in persuasion.” (!!)

The removal of bias is perhaps the most problematic, because sometimes (often) we find out in medicine that what we thought we knew, was wrong (The short history of medicine: “Ignorance replaced with fallacy”). But I think the authors strike a good balance between ethical and unethical persuasion. The physician-patient relationship is inherently asymmetrical; the patient is exposed (metaphorically and/or literally) and vulnerable, and the physician has great power over the patient by virtue of the trust the patient places in her, power that potentially could be misused for coercion. Absolute dictums regarding where to place the boundary between autonomy-respecting persuasion and outright coercion are impossible; every person, every relationship is too different and complex to make blanket statements that apply to every situation. But the currently accepted absolute dictum that sees the doctor as shopkeeper and the patient as consumer is as destructive to the patient-physician relationship as the coercion it attempts to eschew; and while it may be easier to take a universal, “just-let-the-patient-decide” approach than to make nuanced, thoughtful, difficult, shared, context-driven decisions, it is also contrary to the fundamental nature of medicine as a helping profession.

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Jon Holmlund
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Jon Holmlund

I haven’t read the JAMA piece, but the description here suggests it is indeed a thoughtful and helpful reflection on the doctor’s role in the consent process. I would again remind our writers and readers that, IMHO, we use “coercion” too freely. As the Belmont report and others have pointed out, coercion implies a threat. Better is to raise concern about “undue influence,” either in the form of inappropriate inducements or subtle communications of favor and disfavor. That said, while medical decisions are ultimately the patient’s, I agree with Joe that the doctor’s role is not just to list options… Read more »

Susan Haack
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I read the article and your response with interest. A few comments: first, I agree that we use the term “coercion” far too freely, a fact that seems to be a throwback to our somewhat irrational fears of “paternalism.” Secondly, I find the use of the term “persuasion” a curious one. For in reality, the act to which the term refers is an educational one–the informing and educating of the patient and correction of misinformation. We ALL are subject to misinformation, especially in areas that are outside of our areas of expertise (and sometimes within them!), and at times this… Read more »

Jon Holmlund
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Jon Holmlund

I think all these points are excellent, well taken. I am reminded that “respect for persons” is Declaration of Helsinki terminology.