Sharing Vulnerabilities in the Woman Patient/Doctor Encounter

Abstract

This article is an examination of the doctor–woman patient encounter through a vulnerability lens. This relationship has been traditionally been critiqued as a paternalistic encounter in which the remedy was to recognize the patient’s rights of autonomy. In this article, it is suggested that a more helpful approach is to recognize the vulnerability of both the patient and doctor. This encourages an interaction that involves seeking a mutual and collaborative response to the issues facing the patient.

KEYWORDS:

• doctor-patient relationship
• vulnerability
• autonomy
• care ethics
• compassion

Introduction

This article explores doctor/woman patient interactions through a vulnerability lens. The standard presentation of doctor/patient interactions would explain that in the past these were highly paternalistic. The doctor was dominant and determined what treatment the patient needed. The role of the patient, especially a woman, was to be, well, patient, and accept the treatment. However, recent years have seen a welcome change with an acknowledgement of patients’ rights to know of alternative treatments, the risks associated with them and to have the right to refuse treatment. The patient is now seen as a rights holder and co-decision maker with the doctor. And that is to be welcomed.

The move towards collaborative decision-making has much merit, but in this article, I want to explore that relationship in terms of vulnerability. But, not in the way that might be predicted. Of course, the patient is vulnerable, in a myriad of ways, and these have been explored elsewhere (Sossauer, Schindler and Hurst 2019). In this paper, I want to explore the vulnerability of doctors and other medical professionals. The structure of this paper will be as follows. First, it will outline the well-established models of doctor–patient interaction in the literature. Second, it will introduce universal vulnerability theory. Third, it will explain how appreciating the vulnerability of doctors impacts on doctor–patient interactions.

The doctor–patient relationship

Here are four models of the doctor–patient relationship, which appear prominently in various presentations in the literature (Emanuel and Emanuel 1992):

1. The paternalistic model

Few people would nowadays promote a fully paternalistic model in which the patient has no say at all in their treatment and it is the doctor alone who determines what treatment is appropriate. A more modern paternalism would accept that patients have a right to refuse treatment; to ask questions; and to be informed of risks. Nevertheless, it would expect the doctor to ‘take the lead’ and to guide the patient to most appropriate treatment. This is, no doubt, the model sought by many patients. They are seeking out medical expertise and so want and expect the doctor to be diagnosing and recommending the best treatment. If asked for their view on what treatment they would want such a patient might reply ‘I have no idea, what would you recommend doctor?’ Under this model, a patient would be entitled to expect the doctor to recommend the best treatment, which the patient would follow, unless they had some idiosyncratic reason not to.

2. The co-expert model

Under this model, the decision-making process is seen as collaborative. Both the doctor and the patient bring expertise to the process, which are combined to create the optimal outcome. We can see this kind of approach in the most recent guidance from the GMC (2020, para 8):

The exchange of information between doctor and patient is central to good decision making. It’s during this process that you can find out what’s important to a patient, so you can identify the information they will need to make the decision.

But the GMC (2020, para 9) make it clear that ultimately the choice is for the patient. Doctors are told the purpose of the dialogue is threefold:

a to help the patient understand their role in the process, and their right to choose whether or not to have treatment or care

b to make sure the patient has the opportunity to consider relevant information that might influence their choice between the available options

c to try and reach a shared understanding of the expectations and limitations of the available options.

Doctors are warned to remain objective:

You must try to make sure the information you share with patients about the options is objective. You should be aware of how your own preferences might influence the advice you give and the language you use. When recommending an option for treatment or care to a patient you must explain your reasons for doing so, and share information about reasonable alternatives, including the option to take no action. You must not put pressure on a patient to accept your advice. (para 11)

The role of the doctor under this model is to work with the patient. The doctor should not be seeking to force or coerce a patient into receiving a treatment. The model here is close to a negotiation between the two parties, seeking to produce a mutually desirable outcome, while acknowledging that ultimately the patient can refuse treatment.

3. The informative model

Under this model, the role of the doctor is to impart information and allow the patient to make the choice between the alternative treatments presented or to decide not to receive any treatment. The doctor would not be seeking to influence the decision but should merely present the patient with the alternatives. The primary role of the doctor under this model is information provision.

4. The deliberative model

This model is more where the role of the doctor is closer to a therapist or advisor. The doctor talks through the issues with the patient, helping the patient think logically. The doctor here is not to tell the patient what to do but to help the patient reach a sensible decision. They are an advisor, helping the patient make their mind up. The doctor is not seeking to tell the patient what to do, but to help the patient articulate their own values and see how these related to the medical decision they are making. Their role is to help the patient reach the right decision for the particular patient given their beliefs and values.

Choosing between these models

It would be a mistake to assume that one of these models is automatically the best in all the cases. No doubt for different people in different circumstances each of these approaches could work well. Sometimes a patient may have a clear view on what treatment they wish to receive while in other medical decisions the patient will feel lost and confused and want a clear lead from the doctor or help in thinking through the alternatives. As Jose Luis Turabian (2018, p. 5) vividly describes, it is more of a dance than adopting one model:

We could say that the ‘good’ doctor–patient relationship is a process where an ‘alliance’ is created: a process in which the doctor adapts to the rhythm of the patient and little by little can help him move towards healthier scenarios; that is, detect ‘what dance the patient dances and like a good dancer, take a step back, another forward, dancing and pacing with the patient. But there is not a single type of ‘good’ or ‘adequate’ doctor–patient relationship; there is not ‘a single dance that the patient dances’. If ‘the doctor has to dance with the patient’, he has to know that there are many types of dance!

Perhaps the important thing is not precisely the model used but the atmosphere of the meeting. Mehdin Shah (2018, p.4) promotes a ‘patient-centered model’ of:

a mutual participation, where two people who do not know each other, are able to feel more at ease through a certain level of intimacy. This sort of interaction requires both the patient and the doctor to accept that they have equal power, mutual independence and equal satisfaction.

Any one of the four models described above could be used to achieve that kind of goal. However, all of them are based on a particular model of decision-making: one based on rationality and facts. The doctor’s role in these is cerebral: to provide tools to enable the patient to reach a rational decision. Be that a clear recommendation; the provision of information; or an assistance in logical thinking. Not only do these elevate rationality to being the key focus of attention, but they all involve the doctor being in a position of power. The doctor has tools which the patient needs to reach a good rational decision. In particular, the doctor has a role in ensuring the patient does not respond to the question in an irrational, emotional or ignorant way.

This view of the doctor as the guardian of facts and rationality reflects the view of Sir William Osler (1927, p. 2), widely viewed as the father of modern medicine, who in his 1912 essay stated: ‘A rare and precious gift is the art of detachment.’ He encouraged doctors to ‘see into’ a patient’s life objectively and neutralize their own emotions so they feel nothing when witnessing emotion. Such an attitude is still prevalent today. As Luke Austen (2016, p. 376) notes:

Now more than ever, the idea of clinical detachment as a prerequisite for scientific objectivity will ring true for health workers. This mindset may also be reinforced by the immense workloads, time pressures, and target-driven cultures of many health systems, factors that would make clinicians more likely to choose the short-term coping benefits of detachment over the patient-centred benefits of true empathy.

The implied danger in such comments is that if a doctor is not sufficiently detached, they may let their own emotions interfere in their role of promoting rationality. I believe this understanding of the doctor’s role is profoundly misguided. In particular, I want to explore how the universal vulnerable theory might add something to our understanding of the doctor–patient relationship, especially by highlighting the vulnerability of the doctor as well as the patient.

Universal vulnerability

Legal and social discourse promotes a self which is independent, capacitous and rational (Nedelsky, 2014). Such an image of the self, emphasizes key rights, autonomy, bodily integrity, privacy and liberty. Our right to be able to make our own choices over how to act and to only be subject to the responsibilities we choose to take on are seen as central pillars of the economic, social and legal structures. The role of the law in such a model is to protect the individual from unwanted intrusions into liberty and to protect one’s right to pursue one’s goal for life. In short, rights are about keeping other people away from you. Ngaire Naffine (2014, p. 123) writes that the law sees:

human beings as discrete individuals, fully independent of one another and preferring it that way, because others cause worry: they pose a threat to property and personal security. Such nervous, self-isolating beings need law to keep others at bay. They do best—are most autonomous, even happy—when left to their own devices. This way of thinking about persons may seem quite natural because it has been so influential in our Western liberal legal and political tradition.

These are reflected in many of the more modern understandings of doctor–patient relationships. As we have seen, the decision is to be made by the patient. The role of the doctor is to provide the patient with the information and rationality needed, so the patient can decide how they want their life story to go. Hence in Montgomery v Lanarkshire (2015, para. 76) Lords Kerr and Reed emphasize the weight attached to patient autonomy:

patients are now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession. They are also widely treated as consumers exercising choices: a viewpoint which has underpinned some of the developments in the provision of healthcare services.

This is challenged by universal vulnerability theory which, building particularly on the writing of Martha Fineman (2009), promotes a vision of humanity which sees vulnerability as the essence of what it is to be a human being. This view rejects the common understanding of vulnerability: that there are some people or particular groups of people with weaknesses who are labelled ‘vulnerable people’ or

vulnerable groups who requires protection. They lack the essential skills to direct their own lives and protect themselves and so need others to do that for them. Vulnerability on this understanding is seen as an undesirable state, which you should seek to avoid or overcome. That kind of understanding is how the patient, but not the doctor, is portrayed in standard presentations of the clinical encounter. The patient is vulnerable through a lack of information and emotionality, which can be cured by the doctor, who is not vulnerable, undertaking the correct role. That understanding of vulnerability is rejected by the universal vulnerability theory which claims that we are all in our nature equally vulnerable (Herring 2016)

As Fineman (2008, p. 2) has argued, vulnerability is a ‘universal, inevitable, enduring aspect of the human condition.’ So, both the patient and doctor are vulnerable.

To understand universal vulnerability theory a little more, we need to understand what it is to be vulnerable. P is vulnerable if the following three factors are present:

1. P faces a risk of harm.

2. P does not have the resource to be able to avoid the risk of harm materializing

3. P would not be able to adequately respond to the harm if the risk materialized.

Supporters of universal vulnerability theory highlight the fact that the human body in its nature is constantly open to harms and hurts. The health of one body depends on the health of another, as the COVID-19 pandemic has shown all too powerfully. We are literally breakable and woundable. But that is not just true of our bodies. Our emotional, psychological and social selves rely on others, and are at constant risk of distress (Foster and Herring 2018). From our earliest beginnings we are in relationships of dependency and we continue so for much, if not all, of our lives. Sometimes receiving, sometimes giving, care; often doing both. Relationships of dependency are central to our lives.

While universal vulnerable theorists hold that everyone is in their nature vulnerable, there is a recognition that vulnerability is experienced differently because of the different provisions within society (Rodriguez 2017). As Fineman (2008, p. 31) has argued:

While human vulnerability is universal, constant, and complex, it is also particular. While all human beings stand in a position of constant vulnerability, we are individually positioned differently. We have different forms of embodiment, and also are differently situated within webs of economic and institutional relationships. As a result, our vulnerabilities range in magnitude and potential at the individual level. Vulnerability, therefore, is both universal and particular; it is experienced uniquely by each of us.

Where, therefore we see people appearing to be independent and self-sufficient, this is due to the allocation and resources and power without which they would be as vulnerable as the norm (Herring 2019). The dependence which is a core aspect of humanity is often unacknowledged. As Simo Vehmas (1999, p. 61) puts it:

non-disabled people tend to forget their own dependence on services, such as the provision of the water that comes out of the tap – an obvious obstacle to their independence. The concept of independence is clearly defined according to society’s expectations about what people normally do for themselves and how they do it … . It seems, therefore, reasonable to conclude that people are best described as interdependent since `people are sometimes autonomous, sometimes dependent, sometimes provid­ing care for those who are dependent

We must therefore recognize the position that doctors hold is not the product of their innate invulnerability, but a special position within society; and that does not remove their baseline of vulnerability.

Generally, vulnerability is portrayed as a bad thing. People who are vulnerable need help and support, typically to help them escape from their vulnerability. However, we should see vulnerability as a good thing. It is key to human nature and is a desirable characteristic (Bedford and Herring 2020). It requires us to be welcome and open to our interconnection with others and the wider world. It warns us against puffing ourselves up or judging each other harshly. It encourages co-operation; a looking out for each other; a working together to find solutions to the problems we all face. Because we cannot look after ourselves, we need to offer and receive help from each other. We need to reach out to others and be open to them if we are to need and others are. A recognition of our mutual vulnerability which leads to empathy and understanding, is essential (Feder Kittay 2011). That creates intimacy and trust. As Carse (2006, p.48) puts it: ‘Our vulnerability is inextricably tied to our capacity to give of ourselves to others, to treasure and aspire, to commit to endeavours, to care about justice and about our own and other’s dignity.’

There is much more that could be said about the claims of universal vulnerability to fully develop the theory (see Herring 2019, ch. 2), but I want to focus on the issues that are relevant to the doctor/patient. Our starting point in considering the doctor–patient relationship must be that we have two vulnerable people coming together. Of course, we are not used to seeing doctors as vulnerable, but the statistics are clear. There are considerable stresses and pressures in being a health care professional (Brooks, Chalder and Gerada 2011). One survey for Mind, of more than 1000 GPs found that 40% of those questioned said they were currently experiencing a mental health problem such as depression, anxiety, bipolar disorder or post-traumatic stress disorder (MIND 2018). A study by the Medical Protection Society found 85% of doctors had experienced a mental health issue at some point. Of those 13% talked of experiencing suicidal feelings. Indeed, the rates of suicide among doctors are between 2 and 5 times the rates of the general population (Gerada 2018). Clare Gerada (2018, p. 167) in her international survey finds ‘In most healthcare systems (whether privately or publicly funded), and across all ages, genders, specialties and seniority, doctors have higher rates of depression and anxiety compared with the general population and other professional groups.’ COVID has demonstrated the particular vulnerability of health care professionals to catching viruses from patients. Nurses and care home workers topped the lists of professions and occupations recording deaths due to COVID (Office for National Statistics 2021).

I wish to explore here particularly how that impacts on the understanding of the doctor–patient interaction and want to emphasize three points in particular.

1. Care is relational

Once it is understood that humans are universally vulnerable the importance of care becomes obvious. Caring relationships are essential to our survival; our understanding of ourselves; and to the things we value. As Feder Kittay (2019, p. 168) writes:

A world without care would not only be a dismal world, it would be a world in which great harm would be done. A world in which nobody cared about anyone else would be a world in which needs of those who could not attend to their own needs (and that is all of us at some point in our lives) would be neglected.

More widely we see that our value lies not in ourselves as isolated egos but in our caring relationships. As Reinders (2011, p. 435) puts it:

Being loved by someone is what matters most in our lives. What we do not often think about, however, is the logic of this statement, and this logic is what I ask you to contemplate for a moment. If ‘being loved’ is the most important thing in our lives, then the most important thing is something we cannot do by ourselves or on our own. It’s not a goal we can strive for, it is not something we can achieve. To be loved by someone implies that the most important thing in our lives is something we can only receive as a gift.

But there is much in contemporary society that seeks to reduce care to the performance of tasks. This is particularly so in a world in which care has become increasingly contractualized and commodified; where we seek to put a price on each activity of care. This activity model of care has writing been criticized by disability rights activists. Jan Morris (1997, p. 54) has argued that care itself is a form of oppression against disabled people:

The only way to empower disabled people is to throw off the ideology of caring which is a form of oppression and an expression of prejudice. Empowerment means choice and control; it means that someone has the power to exert choice and therefore maximise control in their lives (always recognising that there are limits to how much control any of us have over what happens in our lives). Care – in the second half of the twentieth century – has come to mean not caring about someone but caring for in the sense of taking responsibility for. People who are said to need caring for are assumed to be unable to exert choice and control. One cannot, therefore, have care and empowerment, for it is the ideology and the practice of caring which has led to the perception of disabled people as powerless.

True care is not doing an act to someone, but living with them. It is a relationship of care (Wildemann Kane, 2016).

And this raises an important point which is relevant to considering the doctor–patient relationship. In all caring relationships there is a giving and a taking. An intermingling of interests, often bodies and emotions. A breaking down of boundaries. Caring relationships are multi-directional. That care is not done as an abstract activity or task but is rather part of the dynamic giving and taking of care (Rockwell 2012). Caring involves investment in another’s well-being (Clarke et al. 2020). Good care challenges the divisions that can be created between ‘them and us’; ‘the competent and the not competent’; ‘the adult and the child’; the ‘vulnerable and the non-vulnerable’; the doctor and the patient. It means that we should recognize the doctor–patient relationship is not simply about the doctor doing something to the patient; but is about being together.

Doctors need not set themselves above the patient: be that as the fount of all knowledge; the wise counsellor; or a breathing Siri. They have their own fallibility, weakness and vulnerability to influence that they bring to the relationship. The decision is not just the patient’s. What happens to the patient will impact on the doctor too. The pain of the doctor impacts on the patient; and the pain of the patient impacts on the doctor. The nervous doctor can be reassured by the calm patient. The depressed health care assistant can be cheered by the friendly patient. None of this is recognized in the standard presentation of doctor–patient encounters.

I will highlight three aspects of the doctor–patient relationship in particular. First, it challenges the concept of ‘professional detachment’ that is often seen as the ideal perspective for a doctor. As Angeliki Kerasidou and Ruth Horn (2016, p. 15) write

In many Western countries, there is a tendency to favour the technically skilful, rational, and emotionally detached physician rather than that of the compassionate or empathetic doctor. The active expression of compassion in medical care is often seen as a supererogatory requirement or even perceived as weakness

Yet good care cannot be found with this detachment. I should be clear I am not saying that doctors should be expected to demonstrate high emotion in each medical encounter. The caring thing to do may be to appear detached. But that is very different from being detached. As a parent may need to appear brave to a frightened child, even if the parent is not feeling brave, the doctor may need to take on a formal detached role. But that is working together, drawing on each other, to get through the challenge.

Second, seeing care as a relationship helps explain why a patient cannot demand treatment which a doctor believes is inappropriate (Burke v GMC [2005] EWCA 1003). To require a doctor to provide inappropriate treatment, treatment which will not respond to the needs of the patient, will not be promoting a caring relationship. It will be one where the doctor is the ‘tool’ of the patient.

Third, I think this gives us a good reason to respect the rights of conscience. A caring relationship requires respect both ways. The doctor must respect the right of the patient to refuse treatment, but the patient should respect the doctor’s right not to give the treatment if that infringes their conscience. Neither party can ask too much of another, otherwise it loses its quality as a caring relationship. Of course, where that treatment is treatment that is appropriate under the NHS the patient has a right to that and another doctor should be found to do that. A good example of this in practice is the case of Re B (2002) where a woman who had become paralysed had been cared for by the medical team ‘with devotion’ (para 97). The clinicians had become ‘emotionally involved’ and ‘a relationship had built up’ the nursing team. Although the woman wanted to have the ventilation removed, the team were unwilling to do this. Butler Sloss in her judgement, while acknowledging the woman had a right to have the ventilation removed, and ordering that to happen, acknowledged that the team should not be expected to do this. This respect for their feeling was not built on some of the high-minded arguments based on conscience, but an acknowledgement that the depth of caring relationship and the emotional investment of the team had to be acknowledged and valued.

2. Compassion

At the heart of good care is compassion. Joshua Hordern (2018, p. 22) explains

Compassion is an attribute of a person’s affective understanding, which aims to enable, so far as possible, shared experiences of the world’s ills and some alleviation of those ills’ effects. As an attribute of human affective understanding aiming at shared experience amidst life’s illness, compassion is cognitive, participative and alleviative. As an affection, compassion is not reducible to mere sensation, although it may coincide with physical expressions such as weeping or reassuring touch. Rather, compassion is centrally an affective attitude towards someone’s suffering, a core dimension of the ‘partnership-working’ crucial to patient–practitioner relationships

Compassion involves coming alongside the person who is suffering and seeking to do what you can to support and help them. Compassion cannot be detached. Compassion renders the doctors vulnerable. It is emotionally toiling and opens up to sharing the grief, disappointment and sadness of the human condition. Martha Nussbaum (2011, p. 301) defines compassion as ‘the painful emotion occasioned by the awareness of another person’s undeserved misfortune’ Jazari and colleagues (2014) suggest that compassion involves:

 … a multidimensional process comprised of four key components:

(1) an awareness of suffering (cognitive/empathic awareness),

(2) sympathetic concern related to being emotionally moved by suffering (affective component),

(3) a wish to see the relief of that suffering (intention) and

(4) a responsiveness or readiness to help relieve that suffering (motivational).

Compassion requires an ability to relate to what the patient is going through (Crawford et al. 2014). It requires more than a recital of a diagnosis and treatment options, but an imaginative leap and sharing of feelings. Here the doctor will have to rely on their own experiences (Novack et al. 1997). This requires the doctor to acknowledge their own vulnerability and to share the benefits of their vulnerability for the good of the patient (Malteru and Solvang 2005).

One particular area of controversy is whether a doctor should disclose to a patient that they have been in a similar situation to the patient. No doubt there is no ‘right or wrong’ answer that applies in all cases. But it must be appropriate to draw on doctors own experiences to advise and care for the patient (Warrender 2020). Self-disclosure is controversial among medical professionals with some concerned that it fails to respect appropriate boundaries or that it can lead to a shift in focus away from the patient (Mann 2018). There are studies indicated that such self-disclosure is common (Arroll and Allen 2015) and clearly there are doctors who find it can, in some contexts, be helpful.

3. Relational autonomy

The traditional Kantian approach to autonomy emphasizes the importance of rationality and information. The ideal decision maker under this model will be the academic alone in their study weighing up in a rational way the different pieces of evidence. Under this model, what the patient needs from the doctor in order to have autonomy is the provision of information which is accurate and relevant; and assistance to ensure they make decisions based on rationality, rather than emotion. We see this in Montgomery v Lanarkshire (2015), with Lords Kerr and Reed emphasize the importance of patient autonomy and the role of the doctor in that:

The doctor explains the options to the patient, setting out the potential benefits, risks, burdens and side effects of each option, including the option to have no treatment. (para. 73)

However, universal vulnerability theory indicates that information alone is insufficient.

This is helpful, but it can only be a small part of what is needed for this interaction to be a productive one. The focus on rationality underplays the worries, prejudices, unwanted desires, ambivalences fears and crucially relationships that are central to human experience.

Relational autonomy offers a different way of understanding autonomy. At the heart of relational autonomy is the argument that the image of the autonomous man is a fiction. Lorraine Code (1991, p. 78) writes that

Autonomous man is – and should be – self-sufficient, independent, and self-reliant, a self-realizing individual who directs his efforts towards maximizing his personal gains. His independence is under constant threat from other (equally self-serving) individuals: hence he devises rules to protect himself from intrusion. Talk of right, rational self-interest, expedience, and efficiency permeates his moral, social, and political discourse. In short, there has been a gradual alignment of autonomy with individualism.

This is rejected by those who support relational autonomy. Our lives are bound up with other lives. Hence there are no decisions which are just ours and few decisions which we make alone. Eva Feder Kittay (2019, p. 18) argues that one must always ‘construe oneself and others as selves that are always selves-in-relationship’

The image the self as in its nature governed by rationality, self-direction and self-sufficiency has been said to represent a ‘male’ image of the self. It means that caring work and relating to others were subservient aspects of the self. As Willett and Anderson (2002) put it: ‘To identify the self with the rational mind is, then, to masculinize the self.’ They go on to explain:

The masculine realm of rational selfhood is a realm of moral decency – principled respect for others and conscientious fidelity to duty – and of prudent good sense – adherence to shrewd, fulfilling, long-range life plans. However, femininity is associated with a sentimental attachment to family and friends that spawns favoritism and compromises principles. Likewise, femininity is associated with immersion in unpredictable domestic exigencies that forever jeopardize the best-laid plans and often necessitate resorting to hasty retreats or charting new directions. By comparison, the masculinized self appears to be a sturdy fortress of integrity. The self is essentially masculine, and the masculine self is essentially good and wise.

Under a relational autonomy model, the self is understood as emerging from relationships and the emotions that govern those relationships. We need to recognize that for most patients, the question is not simply ‘What is best for me?,’ but rather ‘Given the responsibilities that I owe to those in relationships with me and the responsibilities owed to me by others, what is the most appropriate course of action?’ Patients may well be far more worried about how their family will respond to their illness, than the impact on themselves. They need comfort, support, empathy as much, no more than, the provision of information or risks or side effects. Decision-making in the real world is not the analytic philosopher in his study carefully assessing the competing arguments, but is instead had over a cup of tea; in chats; in tears; in fear. Important decisions are rarely if ever just ours and rarely, if ever solely rational.

This means if the doctor is seeking to assist the patient’s autonomy, they must move beyond the mere information provision and rationality promotion commonly presented as at the heart of the decision. Comfort, encouragement, empathy, emotionally insight are all key to making the decision together. Under the relational autonomy approach relationships, connections and interactions with others, far from challenging autonomy, are necessary for it. It is in mixing and sharing autonomies that decisions can be made. Of course, relational autonomy supporters are all too aware of the fact that relationships can undermine autonomy as well as enable it. So the role of the doctors is to ensure that relational context is such that the intermingling of autonomies is not oppressive of one of the parties. Susan Dodds (2000, p. 214) has argued that applying relational autonomy to doctor–patient interactions means the physician should offer care and support ‘to better promote autonomy both in decision-making and in the patient’s capacity to learn to accommodate or respond to the changes in their health, so they can learn to live with, resist, or accommodate their altered circumstances.’ This requires more than a focus on medical ‘facts’ but also the emotional and relational experiences of the patient.

In a helpful discussion on relational autonomy, Natalie Stoljar (2011) considers a woman deciding whether to take hormone replacement therapy (HRT) for menopausal symptoms:

Such a woman is likely to be given all of the relevant medical facts. However, the decision-making process will likely be influenced by factors in addition to a weighing up of the medical evidence that is presented to the woman, including her education, race, and class; her conception of herself and her unique experience of menopause; cultural norms such as that looking young is attractive and valued whereas looking old is unattractive and devalued; the attitude of family members to the symptoms of menopause; the support of family members for the woman’s decision; and so on. The complexity of all these factors and the uncertainty experienced by the woman in weighing them up may lead to diminished self-trust. Informed consent, as an opportunity concept, is inadequate to ensure that agents exercise their preference formation with the required subject-referring attitudes. The process of preference formation that we call informed consent is therefore not sufficient for autonomy.

With these concerns in mind, Stoljar advocates that health care professionals should be alert to the social conditions and expectations which impact on a patient’s capacity for autonomy. They may need to ‘counteract’ these effects and enable patients to feel authorized to speak for themselves.

None of this can be done in a detached way. It is a long way from the suggestion of one NHS manager I spoke to, who had decided that the message from Montgomery was that patients facing surgery should be put in front of a DVD which would set out the risks and side effects of their treatment. That way, he thought, we could make sure patients were told of the key risks. True, but not in any significant way that promotes autonomy. A relational approach to autonomy sees the value of emotional support; comfort; talking through things; putting the issue in a relational context. All of this is far from the more limited role that doctors are normally stereotyped with as being detached providers of information and rationality.

As already indicated, the promotion of a rationality-based decision-making promotes ‘male’ ideals, which work in the world traditionally populated by men. However, it is also relevant in the reality of the doctor/patient interaction. There is evidence from the UK that female doctors involve patients more in decision-making and consider psychological issues more than male doctors (Sandhu et al., 2009, p. 355). Generally, female doctors spend more time with patients, especially in female doctor/female patient consultations. The gender of the patient matters too with female patients being given less jargon, but more information. They also ask more questions and give a more detailed history (Bertakis 2009). Harbinder Sanhu and colleagues (2009, p. 355) report:

These differences reflect established relationships between gender, power and communication, where male talk has been identified as predominantly task-orientated; and where men are more likely to communicate in ways which are louder; more forceful, dominant, and competitive; and where they interrupt others more frequently. However women’s communication is more likely to be emotional, subjective, polite, and self-revealing; and to show more concern and awareness of the feelings of others.

We might therefore be concerned at men failing to get some of this support. Relational autonomy, however, also adds some important protections. The first is that we know domestic abuse, particularly coercive control, impacts far more women than it does men. Being alert to this relational context is very important. The second is that as Stoljar highlights above, societal pressures to conform to feminine stereotypes, be that in terms of body image; conceptions of ‘beauty’; expectations around care, can impact adversely upon women. Thirdly, there may be conditions or life cycle issues in relation to women, particularly around the menopause, which also impact negatively on decision-making. All of these require a nuanced and deeper interaction than a detached form of medical encounter. They also cannot be reduced to simply a matter of facts and rationality.

Conclusions

The traditional models of doctor–patient relationship are based on a detached model for the doctor. These are reflected in the legal requirements of the doctor. These are to ensure that the patient is given the necessary information and is sufficiently able to understand and process it to reach a decision. This article has highlighted two pre-suppositions behind this approach. First, it assumes that rational thinking based on facts is the only valid form of decision-making. Second, it assumes that doctors have a detached role in providing information and ensuring the patient is acting rationally. Neither of these acknowledges the importance of our universal vulnerability.

This article has highlighted the extensive feminist writing on universal vulnerability – how we are all in our nature vulnerable, both patients and doctors. This is a considerable resource (Malterud, Fredricksen and Haukaas Gjerde 2009) which requires an acknowledgement that both doctors and patients come to the medical encounter with significant vulnerabilities. It is by sharing our resources and experiences in working together that we can overcome the challenges we face. In particular, it has been argued first that care should be understood as a caring relationship, rather than an activity and one that is required by acknowledging our universal vulnerability. Second that compassion is key to good care and this requires both parties to come alongside each other and share in the emotional journey. Third, that autonomy should not be understood in individual terms but in relational terms. It is in the joining together and working through things that true autonomy is found. Sharing tears and sharing fears is at least as important as the sharing of information in the medical encounter.

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Notes on contributors

Jonathan Herring

Jonathan Herring is the DW Wolf-Clarendon Fellow in Law at Exeter College and Professor of Law at the Faculty of Law, University of Oxford. He has written extensively on issues around family law, medical law and ethics, care law, and criminal law. His books include Law and the Relational Self (Cambridge University Press); Law Through the Life Course (Bristol University Press); Caring and the Law (Hart Publishing); Older People and the Law (Oxford University Press); and Domestic Abuse and Human Rights (Intersentia).