A common argument is that an important aspect of the doctor-patient relationship is that of information asymmetry. That is, while a patient can chronicle her symptoms, her history, her preferences over treatment, she lack the medical knowledge that her doctor has acquired over years of training through schooling, residency, and fellowship. Her doctor has a technical degree of knowledge about the body and about pharmacology that will be unmatched in that relationship. Thus, there is a power relationship: when one is sick and vulnerable, we defer to expertise in the management of technical detail, risk, and uncertainty. The physician can then use that informational advantage to recommend certain treatments, and their assessment of medical necessity or lack thereof can also help to moderate potential concerns of moral hazard given insurance coverage (see, e.g. Arrow 1963).
Concessions to expertise are the subject of much of scholarship on the American bureaucracy (and of course other fields outside my own area of expertise). Rather than take on the immense and impractical task of itself carrying out enforcement in technical policy domains, and rather than engage in the transaction costs associated with crafting longer and more detailed legislation to address the complexities before which the nation is faced, the legislature delegates to the agency given its technical expertise. The political principal (in this case, Congress) acknowledges that the agent (conveniently in this case, the agency) is better equipped to handle the matters of implementation, though there are information asymmetries of course in that only one party has the detailed knowledge of the given policy and how best to carry it into effect.
Such concessions to expertise occur throughout all of our lives in ways both great and small. We assume that the local mechanic will better ensure that our car gets fixed than will we. We assume that the local carpenter will better address home repairs. The list goes on. The catch is that in the context of medicine, rather than resulting in needing to take the train instead of driving, or having a less aesthetically pleasing apartment for some period of time, the stakes are life and death, and the relationship between doctor and patient becomes critical.
How physicians relate to their patients obviously need not – and indeed, should not exploit information asymmetry, but rather should work in as accessible a way as possible to reduce that asymmetry to facilitate the making of informed decisions that are collaborative rather than a paternalistic system in which the physician acts as an overly domineering principal toward their agent, the patient.
What seems to be a distinction between the nature of care for physical health and care for mental health (which is far more divided than it should be) is the additional layer of asymmetry added to the mix: cognitive asymmetry. That is, while physical and mental health are in many ways inextricably linked, mental health’s focus on cognitive capacity – the ability to process information, to maintain perspective in light of current and past events as well as future prospects, to make reasoned and rational decisions – are compromised, or at minimum are compromised with a probability high enough sufficient to compromise the patient’s credibility to work with care providers on remotely equal footing.
That is, in a world that values and requires informed consent, if a person does not want to receive medical treatment in a hospital, they may sign an AMA form (against medical advice), but such a form does not apply in a psychiatric emergency room. The flexibility of canceling a therapy session amid an emotional crisis may be reduced relative to the decision to postpone a physical exam. While patients will not be forced to take medication, the playing field is far less even, and in hospital settings can be infantilizing even among patients who, outside the context of that illness, are intelligent and successful. Of course, that is one of the many central challenges of such an illness, which is that it targets the reason with which one would otherwise be navigating the world and serving as an advocate for their own care and well-being.
It is unclear to me whether there is a solution to better managing these relationships in ways that level the playing field with respect to both information and power (which of course are not independent), to maximize patient autonomy while also protecting well-being. But in thinking more critically about opportunities to better advocacy, it is important to recognize the dual dimensions of heightened vulnerability experienced by this patient population as they work to navigate the already fragmented healthcare system.
Concessions to expertise are the subject of much of scholarship on the American bureaucracy (and of course other fields outside my own area of expertise). Rather than take on the immense and impractical task of itself carrying out enforcement in technical policy domains, and rather than engage in the transaction costs associated with crafting longer and more detailed legislation to address the complexities before which the nation is faced, the legislature delegates to the agency given its technical expertise. The political principal (in this case, Congress) acknowledges that the agent (conveniently in this case, the agency) is better equipped to handle the matters of implementation, though there are information asymmetries of course in that only one party has the detailed knowledge of the given policy and how best to carry it into effect.
Such concessions to expertise occur throughout all of our lives in ways both great and small. We assume that the local mechanic will better ensure that our car gets fixed than will we. We assume that the local carpenter will better address home repairs. The list goes on. The catch is that in the context of medicine, rather than resulting in needing to take the train instead of driving, or having a less aesthetically pleasing apartment for some period of time, the stakes are life and death, and the relationship between doctor and patient becomes critical.
How physicians relate to their patients obviously need not – and indeed, should not exploit information asymmetry, but rather should work in as accessible a way as possible to reduce that asymmetry to facilitate the making of informed decisions that are collaborative rather than a paternalistic system in which the physician acts as an overly domineering principal toward their agent, the patient.
What seems to be a distinction between the nature of care for physical health and care for mental health (which is far more divided than it should be) is the additional layer of asymmetry added to the mix: cognitive asymmetry. That is, while physical and mental health are in many ways inextricably linked, mental health’s focus on cognitive capacity – the ability to process information, to maintain perspective in light of current and past events as well as future prospects, to make reasoned and rational decisions – are compromised, or at minimum are compromised with a probability high enough sufficient to compromise the patient’s credibility to work with care providers on remotely equal footing.
That is, in a world that values and requires informed consent, if a person does not want to receive medical treatment in a hospital, they may sign an AMA form (against medical advice), but such a form does not apply in a psychiatric emergency room. The flexibility of canceling a therapy session amid an emotional crisis may be reduced relative to the decision to postpone a physical exam. While patients will not be forced to take medication, the playing field is far less even, and in hospital settings can be infantilizing even among patients who, outside the context of that illness, are intelligent and successful. Of course, that is one of the many central challenges of such an illness, which is that it targets the reason with which one would otherwise be navigating the world and serving as an advocate for their own care and well-being.
It is unclear to me whether there is a solution to better managing these relationships in ways that level the playing field with respect to both information and power (which of course are not independent), to maximize patient autonomy while also protecting well-being. But in thinking more critically about opportunities to better advocacy, it is important to recognize the dual dimensions of heightened vulnerability experienced by this patient population as they work to navigate the already fragmented healthcare system.
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