Issue 40 / 24 October 2011

WESTERN society’s view of doctors has changed substantially in the past few decades. What might previously have been regarded as special expertise and judgement is now seen as arrogance and paternalism.

As more of the general population has access to education about their health, it is only appropriate that orthodox medicine should adapt by providing more information, expressing uncertainty where it exists, and involving the patient in their care decisions. There is no doubt that this happens more than ever — and rightfully so.

Paradoxically, however, as orthodox medicine has become less paternalistic and increasingly based on evidence, more people are turning to practitioners who offer certainty in the guise of choice and empowerment.

At its worst, the outcomes of this “empowerment” can be devastating, as was the case in WA, when a woman was “influenced by misinformation and bad science” and refused orthodox medical treatment. The WA coroner was reported as saying that if the woman had not spent a year seeking the advice of a naturopath rather than seeing a doctor, she may have survived.

Maybe this case is an example of that fact that, while culturally we have turned away from “elitism” and moved towards the concepts of autonomy and choice, something in our humanity still seeks reassurance and certainty.

Perhaps some part of our lives as responsible adults longs for the security of childhood. How else can we readily accept the idea that modern life is full of dangerous toxins and stresses when longevity and health outcomes are better than ever?

Consider, then, the allure of the practitioner who allows you plenty of time (for a fee), validates your sense of autonomy, allows you to feel a general sense of dissatisfaction with the world and offers a solution — a very tempting solution based on time-honoured traditions with low risk of adverse effects.

If the therapy doesn’t work, there are usually simple reasons — you didn’t have the right attitude, you didn’t follow the instructions correctly. Again, the satisfying illusion of it being your choice and you being in control.

However, having gained your confidence, would this practitioner tell you frankly that they just “don’t know” why you are ill or why the therapy didn’t work? Or that there is a chance that your problem is too complex for them to resolve and you might need another opinion?

Would they go through the evidence with you, explaining what their diagnosis and treatment is based on? Would they ever consider that in reality you are doing just fine, and don’t need to see them again? Or would they just rely on you trusting them and their decisions?

A bit paternalistic, don’t you think?

Dr Sue Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management. She also runs the health system consultancy SI-napse.

Posted 24 October 2011

9 thoughts on “Sue Ieraci: Paternalism’s new practitioners

  1. Dr Paul Dunne says:

    Cannot but agree with you. My view of alternative practitioners is unfortunately clouded by 40 years of medical practice the last 20 of which have been in Palliative Miedicine. The extent that desparate people and their families will go to try to avoid reality is often heartbreaking to witness and we all stand impotent in the face of death. A failing of the medical profession is often neglecting to take an adequate history of the patient’s beliefs and use of alternative medicine (and practitioners) and working with rather than against the belief systems. Communication is often the solution to these situations.

  2. Anonymous says:

    Please indicate where is your evidence for this trend (“orthodox medicine has become less paternalistic and increasingly based on evidence”). Surely would like to see the source.

  3. Therese says:

    I am not aware of any evidence per se. Certainly the style of medical education has moved significantly away from the ‘paternalistic’ medical role to a more inclusive educational one where the patient participates in and understands the treatment decisions made.

  4. Sue Ieraci says:

    Anonymous – there are a multitude of sources that illustrate these trends. Firstly, in the development of medical education: curricula, selection processes, post-graduate courses, change in workforce demographics (feminisation, broader social and cultural strata). In relation to the greater use of medical evidence, the very fact that the term “evidence-based practice” exists, the Cochrane collaboration (for all its limitations), greater openness in declaring conflicts of interest (for example in publishing research).

    The very nature of professional behaviour includes ongoing questioning and updating of practice and policy as new information becomes available. On the other hand, ideology does not change in the face of evidence.

  5. Coco says:

    I find the idea that paternalism is dead in medicine laughable after 1.5 years of being treated for breast cancer. The worst – absolute worst – were the radiation oncologists who as a group seem to have never encountered to have any personal commitment to the concept of informed consent for adult women with their faculties intact and were positively hostile to giving me pertinent medical information I asked for. Like how precisely would radiation extend my life. Relevant stuff. I also found they were carefully manipulating the verbal stats quoted to me so as to confound – when I drilled down to specifics of overall survival of course I finally got to the truth which was in my case radiation would not extend overall all cause survival and in fact could very well detract from it. Getting pertinent medical information out of them was like prising teeth from a bear. A long time friend who is qualified in the area later told me they are trained not to impart information as in their experience the more information a patient has the less likely they are to agree to radiation.

  6. Cris Kerr says:


    What is needed is reliable data on individual patient experiences and health outcomes… to balance the scales and act as a buffer against data that’s been influenced by ‘conflicts of interest’.

    Patients could be given enhanced capacity to ‘participate’ (as per UN recommendations) in their own health journey through self-reporting their health experiences and outcomes. They could do this through an ehealth system purpose-designed to capture meaningful data on symptoms, treatment outcomes, medication side effects, etc… to enhance ‘transparency’ of ‘actual treatment outcomes’ as opposed to ‘anticipated treatment outcomes’.

    The long-held insulting argument that patient experiences/anecdotes have no value would no longer hold when the data collection grew sufficiently to achieve ‘volume value’. Data matching by the numbers would validate legitimacy as a reliable aspect of health outcomes evidence.

    Over time, this innovative and valuable source of ‘transparent’ data on actual health outcomes experienced by patients could be weighted and used to inform treatment guidelines and clinical decision-making with a view to increasing the number of successful treatment outcomes, whilst minimizing the number of unsuccessful treatment outcomes.

    This repeatable and sustainable system would result in a continuous cycle of health improvement that would also build our collective knowledge of long term health treatment outcomes. A world first.

    National productivity would be enhanced, health inflation would be reined in, patients would suffer less from ineffective treatments and avoidable hospitalizations, scientists and researchers would gain access to new and valuable sources of data. The world would want access to it. Win, win.

    Unfortunately there has been strong opposition to this proposal and it has not been adopted for inclusion in Australia’s new Personally Controlled Electronic Health Record (PCEHR) system (launching in July 2012).

  7. Anonymous says:

    Two issues are raised by this article. One of them is that medicine is science-based practice – which is a myth – and that paternalistic attitudes are disappearing from medical practice – which is a fallacy.

    The profession has an image problem that can be diagnosed as a severe case of narcissism. Symptoms include pompous, generally vague speech, and in general references to itself as ‘art’. When specific questions are asked that appear to question or challenge self-prescribed authority, symptoms can get worse.

    I doubt that medical professionals are really in a situation where they can gauge where the paternalism trend stands. It is hard to imagine this encounter as a meeting of equals in any sense, when information asymmetry plays a part. It happens in every profession, yet, the implications in a medical setting have a different bearing.

    I am not quite sure where this belief (pun intended) that medical practice is science-based comes from… It is enough to read the mainstream media (that is well courted by the profession, by the way), and MJA, MJA InSight on top of that to get a sense that it is perhaps an image the profession is desperately trying to project. But there are plenty of numbers from insiders including former BMJ editor BMJ Richard Smith (only about 15% of medical interventions are supported by solid scientific evidence), Professor David Eddy, of Duke University (only 1% of the articles in medical journals are scientifically sound and many treatments have never been assessed at all), the BMJ (of 2404 treatments surveyed, only 15% are rated as beneficial, while 47% are of unknown effectiveness – 1991; 303: 798–799) and Rinaldo Bellomo in a recent issue of the MJA (on the dangers of dogma in medicine – 2011; 151: 280-284).

    When it comes to paternalism there are two typical responses from medical professionals when asked a pertinent (informed) question. The first one is: “well, aren’t you a smart lady”, which is patronising, chauvinistic, paternalistic response, and generally fails to deliver an answer matching the question. The second: they bite their tongue and give a vague response. The less information the patient has the better. That way it is easier to defend any position taken. It is NOT true that the profession wants well informed patients! And the concept of informed consent is a farce in many settings/procedures: “…professionals may adopt unreasonable practices. Practices may develop in professions, particularly as to disclosure, not because they serve the interests of the clients, but because they protect the interests or convenience of members of the profession.” (Safety and Ethics in Healthcare: A Guide to Getting it Right, By Bill Runciman, Alan Merry)

  8. Sue Ieraci says:

    Anonymous – your quote about “scientific evidence” shows a misunderstanding of the true science-base of orthodox medicine – it is based on the CLINICAL SCIENCES: anatomy, physiology, pathology, pharmacology. These are the basic sciences that underpin medical diagnosis and treatment. You will not find papers on anatomy in modern journals because the human body has been studied at all levels – from macroscopic to electron microscopic detail. From the science of physiology, we know how the renal tubules work, what stimulates secretion of various hormones, we can measure these things. New knowledge is arising in the area of genetics and inherited disease – all science-based.
    Contrast some of the “alternative” therapies such as homeopathy. What science underpins the theory that undetectable amounts of a pathogen diluted in water or alcohol can do anything to alter the body? And lastly, anonymous, if the doctors you encounter are condescending towards you, why not choose another doctor. You say there are “two typical responses from medical professionals”, but how have you established that these are “typical”? Definitely not a science-based conclusion.

  9. Anonymous says:

    Dr Ieraci, your response just proves my point.
    If your way of defending orthodox medicine is by pointing out how much less/non-existent science there is in “alternative” therapies, that helps very little your argument. (BTW I was not talking about alternative therapies.) And lastly: you are absolutely right: “ideology does not change in the face of evidence”

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