Book Review

Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge

N Engl J Med 2008; 359:2851-2852December 25, 2008

Article

Patient, Heal Thyself: How the New Medicine Puts the Patient in Charge
By Robert M. Veatch. 287 pp. New York, Oxford University Press, 2009. $29.95. ISBN: 978-0-19-531372-7

Bioethics has reformed medical practice by elevating patient autonomy over physician paternalism. Robert Veatch was a leader of this movement, but in his view, the transformation has stalled. In this book, Veatch follows patient autonomy to its logical and outlandish conclusion. He articulates a “new medicine,” a truly revolutionary vision of a world in which “literally every decision a physician makes — the pattern of every practice — will have to be altered radically” and “reconceptualized.”

Veatch's proposals are so startling that readers of this review may doubt my characterizations, so I will quote liberally, starting with its excellent title — Patient, Heal Thyself. This injunction captures Veatch's two main points: Patients alone are in charge, and they have no choice but to assume this active role. According to this “manifesto,” doctors “will no longer be seen as capable of determining what will benefit their patients. It is patients themselves who, in the world of the new medicine, have to take charge.”

To defend this astonishing position, Veatch starts from the assertion that “literally every medical choice — no matter how mundane — inevitably requires value judgments,” and says that “physicians make them only by imposing their personal and often idiosyncratic views on their patients.” For instance, nonmedical values influence when a cast is removed and whether cholesterol should be controlled through diet or drugs.

From this premise flow a host of startling conclusions. Hospice care is too value-laden to be covered by health insurance. Physicians “will no longer . . . certify `medical necessity,' or even recommend any treatment, let alone give `orders' or claim they know what is best for the patient.” Even prescriptions are too prescriptive. Instead, doctors will merely document a patient's diagnosis, leaving patients to decide (in consultation with pharmacists) whether to medicate and which approved drug and dosage to take. We will also need to “abandon” informed consent in favor of a menulike process in which doctors laboriously explain all plausible options.

Most radical of all is Veatch's almost total rejection of beneficence on the part of physicians: “even in the ideal case, physicians generally have no basis for knowing what would benefit their patients”; therefore, “doctors often must stop trying to make decisions that benefit patients.” This logic ignores (or brushes aside as false consciousness) the fact that most patients want physicians to take the lead in deciding treatment, as long as they apprise patients of what they are doing and why. Veatch neglects the possibility that patients may seriously regret systematically making uninformed decisions. He never mentions that, in many situations, doctors know (on the basis of their accumulated experience) that patients often falsely predict their own preferences and values.

In calling for a “new” medicine, Veatch wants to sound progressive, enlightened, and postmodern. Instead, his new world seems postapocalyptic to me. It is a barren, isolating world in which sick patients “will have to take charge and heal themselves.” It is a simple, syllogistic world in which anything that is not a proven scientific fact is a subjective value over which physicians have no say and little insight. It is a naively flawless world in which patients almost always know what is best and are rarely scared, confused, or functionally illiterate (“the new patient . . . especially [will be] a whole person”). Veatch contorts autonomy to sketch an autocratic world in which patients may choose not to seek the comfort and care of any physician who has a shred of paternalism.

Veatch does us a real service by mapping such an unappealing world. His articulation of the strongest conceivable version of patient autonomy convinces at least this reviewer of how fundamentally wrong this position is. Therefore, Veatch unintentionally helps to sharpen our appreciation for how medicine necessarily must accommodate more enlightened forms of paternalism than those that prevailed in the past.

Mark A. Hall, J.D.
Wake Forest University, Winston-Salem, NC 27109
hallma@wfu.edu