The new subjective medicine: taking the patient's point of view on health care and health
Section snippets
Introduction: from saving lives to improving lives
While the ongoing social transformation of American medicine is well recognized, a parallel transformation of medicine's clinical goals and scientific method is less well recognized. Bioethics has pointed to the importance of the patient's point of view in health care decisions through its call to respect patient autonomy. Facts known only by physicians need to be supplemented by values known only by patients. Outcomes research has pointed to the importance of the patient's point of view on the
Informed consent for research
Gradually after World War II, it was recognized that physician good will was not sufficient guidance in clinical research or clinical care of patients. Bioethics grew up around the insight that respect for patient autonomy was an essential part of respecting patients. Patients were not just bodies to be studied and healed however benevolently, but persons with values and the capacity for choice. But it has been a hard fought battle to bring patient subjectivity into medical decision making.
It
From costs to effectiveness to outcomes
Outcomes research grew from many seeds. I will mention only a few important ones from the late 1980s. William Roper, head of the Health Care Financing Administration (HCFA) in the late 1980s, was interested in improving the efficiency of Medicare. He explained in 1988 that the first decade of Medicare had been about increasing access, the second decade about decreasing cost, and the third decade was going to be about increasing value. He argued that medical care quality assurance needed to move
From objective to subjective health
Through clinico-pathological correlation, modern medicine has strived for a fully objective view of death and disease. This view was claimed to be so unbiased as to represent a “perspectiveless” view. Philosopher Thomas Nagel (1999) has called this scientific ideal “the view from nowhere”. To advocate patient-centered outcomes as the primary measure of medical interventions is to accept “perspective” as unavoidable in clinical medical science. It is to reject the ideal of completely objective
Conclusion: accepting perspective in medicine
Modern medical science has been anchored by death. Death has provided medicine a “value-free” enemy. Society monitored medicine's progress with mortality reduction rates. Medical research has focused on conquering the diseases that cause death (Callahan, 2000). Death also provided a “value-free” and objective perspective on patient illness. Death revealed the definitive objective diagnosis through the autopsy and clinico-pathological correlation. Disease could be observed through death's eyes
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