What would you do, doctor?

Some ethicists believe that doctors should be like hairdressers. If you ask a hairdresser to shave your head, he or she will most probably do so. Similarly, such ethicists would argue, if a patient asks to have whiskers surgically implanted or his penis enlarged by injecting fat into the shaft (penoplasty), the surgeon should perform the operation once satisfied that this is what the (competent) patient truly wants. Increasingly, medical professionals are involved in procedures that, to most people, are distinctly odd. The principle of respect for autonomy—still gathering moral weight since its modern birth in the 1960s—seems to be constraining doctors' decision making to such an extent that they are no longer sure if they know what is best for patients. When they do know, they wonder whether communicating this is respecting patients' autonomy or violating it.

What does patient centred care—that current buzz term—require? Are doctors wise gatekeepers of medical expertise, adjudicating the reasonableness of patients' requests; or are they unthinking service providers, dishing out medical procedures like the hairdresser does with haircuts? “What would you do, doctor?” is often regarded as an awkward question, because it exposes this current confusion of roles. No doubt in bygone days, when paternalism was not yet called the “p” word, the question was seldom cause for concern.

“What would you do, doctor?” is a recognition of the asymmetry in medical knowledge and experience between doctor and patient. It generally signifies a patient's desire to shift from one model of the doctor-patient relationship—the consumerist model in which the doctor's role is primarily to provide the patient with relevant medical facts—to a conversational model, where both parties are more actively involved in the decision making. Often, it is also a sign of vulnerability and uncertainty, an acknowledgement that the patient is finding the decision difficult and needs help to resolve the problem. Finally, it is a sign of trust—and in particular trust in the value of the doctor's judgment of what is, overall, best in the circumstances.

The question itself is ambiguous. The first meaning relates to what you, another individual, would do if in the patient's shoes. Answering this question requires you to put yourself in the patient's situation: would you have a regional or general anaesthetic for this hip operation? The second relates to what you, the doctor, believe is right for the particular patient: would you say that the best option for me, Daniel Sokol, is a regional or general anaesthetic for my operation? This question requires a deeper knowledge of the patient's values and beliefs than the first, which is mainly concerned with your own preferences.

The first step in answering this question is thus to disambiguate it. To which of the two meanings does the question refer? Howard Brody, in the Healer's Power, suggests that doctors should sometimes “think out loud” when obtaining patients' consent. This suggestion is particularly apposite in this context. The doctor's answer forms part of the informed consent process. It provides the patient with desired information about the various options. The answer, then, could go like this: “Well, if I had to make the decision, I would probably choose general anaesthesia, as I don't like the thought of being awake when it happens, even if this entails a slightly higher risk. But that's just me, and you might have different priorities. If you don't mind seeing and hearing what happens in the operation room—and let me tell you that you'll probably hear the surgeon hammer away when he fixes your bones—then you might choose regional anaesthesia. It's got lower risks, and you'll probably leave the hospital earlier.” If the doctor knows the patient better, he or she may provide a more tailored answer to the second interpretation of the question.

This kind of answer, far from reducing patients' ability to make an informed choice, enhances their autonomy. By showing a willingness to actively engage with the patient's situation and to address the patient's concerns through meaningful personal involvement, it represents good, patient centred care. On the other hand, declining to answer it altogether—“That's a personal decision that only you can make”—is a form of abandonment. Fear not, then, this common question, for it is a trusting invitation to support and advise the patient—who may well be overwhelmed by unfamiliar circumstances—and to fulfil the Hippocratic moral commitment to benefit the sick.

Are doctors wise gatekeepers of medical expertise or unthinking service providers?