Attitudes and practices of patients and physicians towards patient autonomy

- Batami Sadan, Ph.D.1* and Tova Chajek-Shaul, M.D.2
1
Division of Information Systems and 2Division of Internal Medicine, Hadassah Medical Organization,
Jerusalem 91120, Israel

Email: < A HREF="mailto:batami@hadassah.org.il">batami@hadassah.org.il

Eubios Journal of Asian and International Bioethics 10 (2000), 119-125.
Abstract

On the surface, it would appear that patients would welcome the opportunity to relinquish their traditional subordination to doctors in therapeutic decision making, and that doctors would be pleased to have partners with whom to share the burden involved in making such fateful decisions. We investigated the attitudes and practices of patients and physicians towards "patient autonomy" in an outpatient clinic of an internal medicine department prior to the enactment of the Patient's Rights Bill in Israel. There were 81 patients randomly chosen from those attending the study clinic and 21 physicians randomly selected from among the physicians treating them. They were all administered the Krantz, the Abramson Health Index, and the Christie Ethical Decision Making pre-tested questionnaires. They were also queried on demographic and background material. The results indicated that the patient sample was neither particularly interested in participating in medical decision making (average score of 3 out of 9 in the Krantz behavioral involvement sub-scale) nor in receiving medical information (average score of 4 out of 7 in the Krantz preference of information sub-scale). The physicians exhibited a willingness to establish equal relations with their patients, and claimed to prefer their taking an active role in decision making. However, when presented with ethical dilemmas, the physicians were not consistent in their attitude in terms of respecting "patient autonomy". The findings of an Israeli survey conducted three years after the bill's passage showed that only one-third of the studied physicians had read the Israel Medical Association booklet's explaining the new law and most of them claimed that the new law had no affect on their daily encounter with patients, meaning that the law did not affect any change in these physicians' pattern of behavior. We concluded that if the Patient's Rights Bill is to achieve its goals, it will have to be accompanied by a widespread educational campaign to encourage the public to appreciate the value and the importance of the autonomy granted to them, and to guide them in exercising this autonomy to its best advantage. In parallel, the medical profession will need to be aware of the importance of achieving the therapeutic goals while upholding ethical and moral values in health care.

Key words: patient autonomy, physician-patient relationship, behavioral involvement, pursuit of information, ethical decision making.

Introduction

Much has been said about the "inequality" in the prevailing relationship between physicians and patients and the desirability to devise a more balanced one between the two parties. However, despite the fact that both physicians and patients strive towards the same goal, their means to the end are based on two different paradigms (Szasz and Hollander, 1956; Siegler, 1981). The physicians represent the objective, rational, scientific and technological perceptions, while the patients are their individualistic, subjective and sometimes non-rational counterparts.

Whether the relationship between the physician and the patient leans toward the paternalistic, or whether it is viewed more as a "partnership", has no bearing on the fact that the patient invariably enters this relationship with reservations, and that his/her requirements and expectations are not always realistic. The patient wishes to be healed, and hopes that the healing process will ameliorate the suffering and the uncertainty associated with the illness as much as possible. Her/she hopes that the physician has it within his/her capabilities to succeed in bringing about full recovery. Both parties are well aware of the gap in scientific knowledge between them, and this is the foundation of the asymmetry in their relationship from the very outset of the encounter.

In the past, the attitude of the physician to this imbalance was patently paternalistic. The physician "dictated" the treatment to be given, with the justification for limiting the patient's liberty of action being given as patient beneficence (Buchanan, 1978)..Today, the growing non-acceptance of this practice was partly solved by the requirements of imparting medical information to the patients and of their signing an "Informed Consent" form. There are several moral and practical justifications for the "Informed Consent". The paramount moral aspect is the principle of "patient autonomy", based on basic human rights in a free society. Autonomy is a form of personal liberty of action in which individuals determine their own course of action in accordance with their own life plans (Siegler, 1981). The rationale behind a patient's signature on an "Informed Consent" form is his/her participation as a "partner" in the therapeutic process. The physician provides the patient with information regarding his/her illness, describes the recommended treatment, and imparts all germane details, including relevant risk factors. The signature on the form confirms the patient's voluntary acceptance and understanding of this information. American courts, supported by legal and ethical commentaries, have articulated a legal doctrine of "informed consent" that requires health care practitioners not simply to seek the consent of their patients, but, through a process of disclosure and discussion, to make such consent "informed" as well. Thus, the law requiring "informed consent" has become an important means by which society regulates relationships between patients and health care professionals (President's Commission, 1982). In Israel, the patient's signature on an "Informed Consent" form received statutory expression when the Patient's Rights Act of 1996 was passed. This law defines the patient as an individual with rights and autonomy, and tries to bridge the gap between information and expectation between the party administering treatment and the party receiving it. The law tries to balance the asymmetry by removing the veil of anonymity of all the parties involved, by requiring the system to provide the information necessary for the patient to be able to make informed decisions (e.g., the working diagnosis, the treatment options, and the risks and benefits involved), and defining under which conditions it is possible to deviate from the spirit of the law. The intention of the lawmakers was to legalize a trend which, in their opinion, was already prevalent and widespread: to involve the patient in decision making and to allow him/her to become an equal partner in the physician-patient relationship.

The issue we are investigating in this article is whether the law really does give voice to the practices and attitudes of both physicians and patients on the subject of patient autonomy. We also sought to determine if the parties involved are disposed towards a change in the system. We believe that without laying the necessary foundation for the respect of the goals involved on the part of all parties concerned, the mere passing of legislation would not be likely to bring about the desired changes in behavior. This was clearly borne out by the findings in a recent Israeli survey that had been carried out three years after the bill's passage which showed that only one-third of the studied physicians had read the Israel Medical Association booklet's explanation of the new law. Most of those who did claimed that it had no affect on their daily encounter with patients, meaning that it did not influence their pattern of behavior (Tabenkin et al. in press).

Current requirements for "informed consent" are based on law, but the values underlying these requirements are not merely legal artifacts. "Informed consent" stems from respect for the individual and, in particular, for each individual's capacity and right both to define his or her own goals and to make choices (President's Commission, 1982).

The findings of the preliminary study we conducted on the issue of patient autonomy raised doubts as to whether patients and physicians are, indeed, capable of internalizing the value of "patient autonomy" and if they know how to utilize it appropriately without a proper educational campaign.

The study described herein is a preliminary one, aimed at investigating the attitude and practices of patients and physicians in the Outpatient Clinic of the Internal Medicine Department at Hadassah Hospital, Jerusalem, as they relate to the ethical question of "patient autonomy" from the point of view of the two principal partners, the physician and the patient.

How "Patient Autonomy" Is Measured

The word "autonomy" is derived from the Greek "autos" (self) and "nomos" (law, rule). The term includes the following values: self-definition, independence, personal choice and privacy. It can also be expressed with a negative connotation: an "autonomous" action is one which is neither supervisable nor governed by other coercion (Beauchamp, 1989). In other words, the principle of autonomy emphasizes the right to non-interference and, as a consequence, stresses the right of not limiting an independent action.

In view of the lack of symmetry in the division of knowledge between the professionals (physicians) and the patients, inherent in the principle of autonomy is the moral duty of the former to convey information to the latter, to ensure understanding and freely given consent and to adopt and maintain a suitable decision making process. Before carrying out any sampling for this study, we searched the literature for objective measures by which we could delineate and present the practices and attitudes of physicians and patients on the issue of "patient autonomy".

The Patient's Perception

The doctrine of "informed consent", anchored on the principle of respect for patient autonomy, is predicated upon the desire of the patient to have knowledge (information) and to participate in decision making (President's Commission, 1982).

To date, the published literature related to this subject (Szasz and Hollender, 1955; Ballard-Reisch, 1990; Deber, 1994; Cassileth et al., 1980; Ende et al., 1989; Greenfield et al., 1985; Lerman et al., 1991) has presented two distinctly delineated dimensions of "patient autonomy", the patient's desire for involvement, and the patient's desire to receive information.

There are several works that offer measurements and tests for these two indicators, mainly from the patients' point of view (Krantz et al., 1980; Ballard-Reisch, 1990; Deber, 1994; Cassileth et al., 1980; Ende et al., 1989; Greenfield et al., 1985; Lerman et al., 1991). For our study, we chose the Krantz questionnaire (Krantz et al., 1980). These authors developed a scale for determining the two indicators of "patient autonomy" based on a questionnaire which measures patients' preferences for "more or less active involvement" during the medical treatment process, and their preferences for receiving "more or less information" during that process. The Krantz scale yields a total score and two relatively independent sub-scales that measure the two above-mentioned preferences. The questionnaire includes 16 items, with which the subject could agree or disagree. These items are divided into two scales:

  1. Information - which measures the subjects' desire to ask questions and to be informed about medical decisions regarding their illness. Of the seven items included in this scale; four are in the "negative" form, whereby agreeing to them would point to a preferred avoidance of information. The resultant score is labeled "the number of items to which the subject's answer pointed to a preference of information". This scale ranges from 0 to 7.
  1. Behavioral involvement - which measures the subjects' attitude regarding self-treatment and behavioral involvement during the medical treatment process. This scale is comprised of nine items, six of which are in the "negative" form. The final score is called "the number of items to which the subject's answer pointed to behavioral involvement". This score ranges from 0 to 9.
The Physician's Perception

While several previous studies have suggested various measurements and tests for "Patient Autonomy" from the patient's point of view, there are far fewer studies on the physicians' perception of the "patient autonomy" issue (Beisecker and Beisecker, 1993; Peters, 1994; Childress and Siegler, 1984), and none has yielded an acceptable measure for examining this question.

We chose a questionnaire developed by Christie et al (1987) which contains 6 simulated case scenarios, each of which posing an ethical dilemma. Physicians were asked to select the most appropriate course of action for each scenario and to explain their choice. The simulated case questionnaire was developed to assess the conflict between the value of respecting patient autonomy and the value of unchallenged professional judgment intended for promoting patient welfare. The authors expected that a preference for the value of patient autonomy would be manifested in decisions that favor patient control of courses of action and outcomes over physician control, and vice versa. Three of the simulated cases dealt with a "control of information" issue. Two other simulated cases raised the issue of how extensively a physician "may intervene in a patient's lifestyle" when that lifestyle jeopardizes the patient's health, and one additional case presented a potential family problem. This original study was conducted among general practitioners in Canada, the United Kingdom and the United States (Christie et al., 1987, 1989; Hoffmaster et al., 1991, 1992). For our study, we selected four of the six cases (two did not apply to the specialty field of the study physicians): two dealing with "control of information" and two with "life style intervention" (summarized in Table 1).

In each of the cases, the physician's ethical attitude was investigated in the following manner:

a. Scale of Physician Control-Patient Control

Stage one: The physician was requested to answer the following question pertaining to each case: "If you were the treating physician in this case, what course of action would you consider most appropriate?" Each of the five actions was graded on a scale of 1-5, with 1 representing full patient control and 5 representing full physician control.

  1. Considerations for Choosing Patient Autonomy (PA) or Patient Welfare (PW) Stage two: For each of the above cases, the physician was presented with six considerations which may have guided him/her to decide on the course of action to be taken. Two of them dealt with the potential conflict between two values - preserving the patient's autonomy (PA) on the one hand, and the concern for his/her welfare (PW) on the other. The other four were deliberately irrelevant to the issue of ethical values. Table 2 lists specific details pertaining to PA and PW considerations in each case.
For each case, the physician was asked to indicate which of the six considerations is foremost in importance, which is second and which is third.

Methods

Subjects and Procedure

Eighty-one patients and 21 physicians participated in the study. The patients were randomly chosen from those attending the Internal Medicine Outpatient Clinic of the Hadassah Ein Kerem Hospital. The physicians were randomly selected from among the physicians treating these patients. Questionnaires were distributed to the patients as they emerged from the physician's office, and it took them about one hour to fill them out. The physicians received detailed instructions for filling out their questionnaires and were requested to complete them at their convenience and return them by mail. Both physicians and patients signed Informed Consent forms to participate in this study and all the questionnaires were anonymous. The study received the approval of the Institutional Helsinki Committee.

Table 1: Cases Included in the Questionnaire (Christie et al., 1987)

Case A: Young woman with possible multiple sclerosis.

A single woman in her 20s who has had one episode of temporary blindness is examined by her family doctor with no physical findings. He refers her to an ophthalmologist, whose report is negative.

Case B: Male smoker with bronchial asthma

A 17-year-old male has been in the hospital four times recently for asthma, which is not well controlled despite medications, including cortisone. Regardless of the doctor's efforts, the patient continues to smoke two to three packs of cigarettes a day.

Case C: Post-menopausal woman with vaginal bleeding

The patient, on cyclic hormones, develops vaginal bleeding. The doctor wants her to have a D&C to rule out cancer of the endometrium: the hormones could be discontinued to see if the bleeding stops.

Case D: Young woman with a positive anal swab

A woman in her mid-20s comes to her family doctor because her boyfriend has venereal disease, although she has no symptoms. Cultures for gonorrhea are taken from the urethra, cervix and anus. A positive culture is only obtained from the anal swab.

THE PATIENT'S SAMPLE

The Evaluated Variables

1. Demographic

2. Health

3. Patient involvement and pursuit of information.

4. Physician-relationship (actual and desired)

These four major categories included the following items:

Demographic

The subject's age, country of birth, father's country of birth, sex, whether or not the subject is presently working, whether he/she is living alone or with any permanent cohabitant, the extent of religiousness (se/religious), level of education.

Health

The subject's state of health was presented through two scores:

1. The need for permanent medical treatment (yes, no).

2. The health index as expressed by the sum of answers to Abramson's health questionnaire (Abramson et al., 1992). The questionnaire included 5 questions, to which the subject could give one of three possible answers to each: able; able but at a slow pace; unable. Here, the score varied between 5 and 15 (5 indicating inability to function and 15 indicating ability to function).

Patient Involvement and Pursuit of Information

1. Approaching Professional Health Resources

The subjects were asked whether they had approached one or more of six possible sources of medical assistance for the same current medical complaint (family physician belonging to the patient's sick fund, nurse, private physician, outpatient clinic in another hospital, practitioner in alternative medicine,

Table 2: Patient Autonomy (PA) and Patient Welfare (PW) Considerations for the Four Cases (Christie et al., 1987).

Case

PA

PW

Multiple Sclerosis The patient's right to know that she might have multiple sclerosis. The patient's ability to cope with the anxiety of knowing she might have multiple sclerosis
Smoking The patient's freedom to choose his own life style The probable consequences to the patient's health from his smoking
Bleeding The patient's right to make decisions concerning her own medical care The patient's ability to cope with the anxiety of knowing she might have cancer
Sexual Disease The patient's freedom to engage in whatever sexual behavior she desires The effect of this behavior on the patient's emotional well being.

Table 3: Pearson Correlations Between Number of Approaches and Number of Information Sources and Between Information and Behavioral Involvement (Krantz Questionnaire, Krantz et al., 1980).

Krantz Scores

Information

Behavioral Involvement

Number of Approaches

.20*

.11

Number of Information Sources

.29**

.01

*p <.05; **p <.01

Table 4: Percentage of Respondents in Each Combination of Actual and Desired Situations (n=81).

Desired

"Physician More Influential

"Patient more Influential or Equal Partners"

"Physician more Influential"

18.2

18.2

Actual

"Patient more Influential or

Equal Partners"

13.0

50.6

Table 5: Associations Between Receiving an Explanation and Its Importance and Between Continuous Involvement Variables

Explanation

Importance

Number of Approaches

-.02

.04

Number of Information Sources

.12

.02

Krantz "Involvement"*

-.12

.09

Krantz "Information"*

.04

.02

*The current study

Table 6: Percentage Distribution of the Course of Action in Each Case in Comparison with Studies Conducted in the UK (Christie et al, 1989) and The USA (Hoffmaster et al., 1991)*

* A - Multiple Sclerosis

(Control of Information)

C - Smoking

(Interference with Life-Style)

B - Female Bleeding

(Control of Information)

D - Sex Disease

(Interference with Life Style)

The Sample

Ours

UK

USA

Ours

UK

USA

Ours

UK

USA

Ours

UK

USA

N

20

690

663

20

686

621

20

682

666

20

675

645

Patient Control

(1 + 2)

55

44.0

78.9

10

93.1

68.6

25

45.6

55.2

35

47.7

44.3

(3)

5

14.8

2.7

5

4.7

16.4

15

2.8

17.1

10

37.2

39.4

Physician Control

(4 + 5)

40

41.1

18.4

85

2.2

15.0

60

51.7

27.6

55

15.1

16.3

M

2.80

3.90

3.55

3.05

SD

1.91

0.97

1.47

1.43

*Notations as in original researches.

another physician at Hadassah). The scoring for the "number of approaches" varied between 0 and 6: it was assumed that the higher the number the greater was the patients' involvement in their illness.

2. Sources of Information

The subjects indicated whether any one of seven choices was a source of information (e.g., the attending physician, nurse, reading material, etc.).

The "number of sources of information" was scored on a scale of 0-7: it was assumed that the higher the number the greater was the patients' desire to receive information.

3. Pursuit of Information and Behavioral Involvement - According to Krantz et al. (1980). As mentioned earlier, this involves the two sub-scales, preference of information and behavior involvement.

Physician-Patient Relationships

1. Models in Physician-Patient Relationships

The possible answers to the questions considered as being indicators of these relationships fell into 3 categories:

  1. The physician is more influential (actual and desirable).
  1. The patient is more influential (actual and desirable).
  1. Both are equal partners (actual and desirable).
2. Physician's Explanations - Content and Extent

These questions pertained to nine areas relating to the patient's medical problem and its treatment: 1. The nature of the illness; 2. What could have caused it, 3. What treatment was recommended by the physician, 4. The physician's stated reason for recommending it, 5. The potential side effects of the treatment, 6. The objectives of the treatment and expected outcome, 7. How long the treatment was expected to last, 8. The specific treatment protocol, and 9. Possible alternative treatments. The patients were asked whether they had received an explanation for each of these questions, and whether or not they felt that it was important for them to receive information in detail. The scores could vary between 0 and 9: the higher the score, the wider the desired scope of the explanations and the greater the importance attributed by the patient to receiving comprehensive explanations.

THE PHYSICIAN'S SAMPLE

The Evaluated Variables

1. Demographic

2. Physician-Patient Relationship

3. Consideration of Patient Autonomy in the Physician's Decision Making

These three major categories included the following items:

Demographic

Age, subject's country of birth, father's country of birth, sex, country of medical studies (Israel or abroad), seniority as physician, type of physician (specialist/resident) and extent of religiousness.

Physician-Patient Relationship

  1. Models of physician-patient relationship
The questions and categories of answers were the same as for the patient sample.

2. Explanations to the patient: content and extent

The physician was asked a series of questions in the same nine areas that the patients were asked, in terms of providing information and explanations on the patients' illnesses and recommended treatment. Here, too, the scores ranged from 0 and 9: the higher the score, the wider the scope of explanations that the physician reported having given.

Consideration of Patient Autonomy in the Physician's Decision Making

These items were based on the ones in the questionnaires formulated by Christie et al(1987) as detailed above.

Results

In addition to assessing the association between the demographic and the four main issues of this study, we also performed cross-analyses between involvement variables and patient-physician relationship variables of both the patient and physician samples.

Demographic and Health Variables of the Patients' Sample

Demographic

Most of the study patients were women (about 62%) who did not live alone (85%) and whose average age was 51 years (SD = 18). About one-half of them were Israeli-born, one-quarter were born in Asia-Africa and the rest in Europe-America.

About 60% of the subjects declared themselves to be religious. Few of the subjects had less than 9 years of schooling, and about one-half had 13 or more years of schooling. About one-half of them were employed.

Health variables

About 75% of the subjects maintained that their medical problem required chronic treatment. However, according to the health index scores (Abramson et al., 1992), their state of health was considered to be good (12.65 on a scale of 5 to 15).

Demographic and Health Variables of the Physicians' Sample

Most of the subjects in the physician's sample were men whose average age was 42 years (SD = 19). About 60% of them were Israeli-born and only about 5% were born in Asia-Africa. About 70% were secular, 62% were specialists, and approximately three-quarters of them had graduated from medical school in Israel. The average length of time post-residency was 15 years (SD = 9).

Behavioral Involvement and Pursuit of Information from the Patient's Point of View

An examination of the association between the number of approaches and the number of information sources, and between the two Krantz scores was conducted by calculating Pearson correlations (Table 3).

Since the number of approaches and the number of information sources were correlated with Krantz's information score and in the expected direction (Table 3), we will relate only to the results of the Krantz test. For the purpose of analyzing the results, Krantz et al. (1980) suggested the following division:

Behavioral involvement: Low score Chi - 2

Medium score 3-4

High score 5-9

Search for information: Low score Chi - 2

Medium score 3-5

High score 6-7

The results of our patients' sample showed they were more interested in information (an average score of 4 out of 7) than in being involved in decision making (an average score of 3 out of 9).

Physician-Patient Relationship from the Patients' Point of View

The study results indicated that, in the majority of the cases (69%), physicians did tend to meet patients' expectations regarding the models of relationships between the parties. Of those 56 patients, about 27% expected and received a paternalistic attitude from their physician, while the remaining 63% preferred equality or had a preference for patient control. Even though the desirable to actual direction ratio was not absolute, there did seem to be a slight preference for less paternalism in physician behavior (Table 4).

Patients who perceived the physician's attitude as being more paternalistic reported that he/she gave fewer explanations (a possible reason for such a perception). These findings correlated with those reported by Beisecker (1990).

In general, the study patients reported that physicians did supply explanations regarding most of the items about which they were asked, with the exception of "alternative treatment" and, to a certain extent, about the "duration of treatment". As for the importance of providing explanations in the various spheres, the vast majority of the patients (95%) indicated that it was important for them that such explanations be supplied.

Associations between continuous variables of patient involvement (number of approaches, number of information sources, information and involvement according to Krantz et al., 1980) and between the continuous variables of the relationship between the extent of explanation and its importance were examined using Pearson correlation (Table 5). No significant associations were found. A possible explanation for this is that while the patients were interested in receiving information, how much they were given was dictated by the physician. Analysis of the findings showed that the patients were quite satisfied with the information that had been imparted to them.

Unlike our own questionnaire on patient satisfaction, the Krantz questionnaire (Krantz et al., 1980) examines the active desire of the patients for and their pursuit of information, thus the relatively high score derived from the former list compared to the latter.

A modest number of correlations were found from the associations between patients' demographic and health variables, and between involvement and physician-patient relationship:

1. Country of Birth. Israeli-born patients were more involved (2 Krantz scores) and less accepting of paternalistic attitudes.

2. Education. The higher the education, the greater was patient involvement (as expressed by the number of information sources) and the less acceptance of paternalistic attitudes.

3. Occupation. The employed patients were more involved (as measured by the number of approaches and the number of information sources) and less accepting of paternalistic attitudes.

4. Health. The healthier the patients were, the more they expressed a need to be involved and a desire for "equality" in the physician-patient relationship. The extent of the explanations provided was considered by the healthier patients to be lower than desirable, whereas the importance of the explanations was rated higher than that by less-healthy patients.

Behavioral Involvement and Patient's Pursuit of Information from the Physician's Point of View

The physicians were asked about the extent of the explanations they provided: they stated that they generally explained all nine of the items in the questionnaire. While these responses represented their subjective evaluation, it would be reasonable to conclude that they were aware of the importance of providing adequate explanations to their patients.

Consideration of Patient's Autonomy in Physician's Decision Making

Using simulated cases for which the physician had to choose within a range from "physician control" through "patient control" in the treatment encounter and between "patient autonomy" versus "patient welfare" in medical decision making processes was a heretofore unapplied approach to investigate their attitudes towards the larger question of "patient autonomy". We compared the distribution of their choices with those found in studies conducted in the United Kingdom (Christie et al, 1989) and in the United States (Hoffmaster et al., 1991) (Table 6).

On the scale "physician control - patient control":

a. In all three samples, and for each case, the percentage of physicians who "hesitated" between the two extreme ends of the scale (score around 3) was comparatively low, indicating that physicians generally did have a definite attitude whatever the direction.

b. The stand taken by the physician was dependent on the specific case, as indicated by the difference in distribution for different cases.

c. The difference in the course of action taken in the above-mentioned cases was not a function of the ethical dilemma presented (control of information [A and C] and interference in lifestyle [B and D]), since the distribution differed in both types of dilemmas.

Testing whether the preferred ethical consideration depended upon the case in hand was carried out by means of a two-way analysis of variances (ANOVA) with repeated measurements, in which the independent variables were the specific cases (multiple sclerosis, smoking, bleeding and sexual disease). The considerations (PA and PW), and the dependent variable were the graded scores (between 0 to 3).

The analysis revealed that (Graph 1):

a. There was no major effect of the specific case (F(3,57) = 2.01; p = N.S.).

b. There was a major effect of the kind of consideration (F(1,91) = 10.37; p = .005), with PA having been rated higher than PW regardless of the type of case, with the exception of smoking.

c. There was significant interaction between the type of consideration and the specific case (F(3,57) = 16.51; p = .001).

Graph 1: Rating of importance of consideration in light of the interaction between the specific case and the type of consideration.

Discussion

This study represents the first investigation of the attitudes and practices of both patients and physicians regarding the issue of "Patient Autonomy" in Israel. Its timing bears special significance, having been conducted just prior (1995) to the passing of the Israeli Patient's Rights Law.

The Patient's Rights Law in Israel intended to represent a desired change in the nature of physician-patient relationship, moving away from the traditional paternalistic approach on the part of the physicians to a "consumer" approach on the part of the patients, where emphasis is placed on individual rights and sovereignty. However, the results of our study revealed that the law does not necessarily express the current will of the patients and physicians. The patient sample was neither particularly interested in being a party to the medical decision making process (average score: 3 out of 9 on the Krantz Behavioral Involvement Sub-scale [Krantz et al., 1980]), nor in the pursuit of information (average score: 4 out of 7 on the Krantz Search for Information Sub-scale [Krantz et al., 1980]).

The physicians, on the other hand, did claim to prefer that the patients be interested in receiving information and in taking an active role in the medical decisions regarding their treatments. However, when presented with the cases dealing with ethical dilemmas regarding the issue of patient autonomy, they revealed no consistent ethical basis for their decisions.

We had expected the physicians to more clearly prefer either patient-controlled or physician-controlled courses of action for the various cases. We also expected physician-controlled courses of actions to be associated with patient welfare and patient-controlled courses of action to be associated with patient autonomy. This "dilemma" questionnaire was based on research conducted by Christie et al. (1987, 1989) in the UK, USA and Canada. These studies, too, failed to show a consistent ethical basis for the physicians' decisions. The difficulty in interpreting the physicians' decisions by means of concrete ethical considerations may stem from the fundamental difficulty in defining a concept as imprecise as "individual autonomy" and then in applying it to such complex and often highly precise situations as those involving medical decision making. There is also the possibility that the therapeutic goals will be more prominent in motivating a physician to act in a specific manner, with ethics playing a more subtle part.

In her article which explored most of the more important works in this field, Beisecker (1990) noted that despite the use of varying definitions for the term "patient participation", there was a certain unity in the findings in most of the published studies. The following findings were supported in our study as well: (1) patients are not interested in being the main decision makers on issues of their health; (2) in many cases, the more serious the illness, the less the patients' desire to participate; (3) socioeconomic characteristics have no bearing on a patient's preference; (4) despite the lack of desire to make decisions, there is a strong desire for receiving information. Another interesting finding that emerged from Beisecker's article (1990) was that patients' earlier stated attitudes did not predict their behavior in the real-life setting, as evidenced in studies which taped or filmed physician-patient sessions. The patients' behavior appeared to evolve from the specific reasons and context of each session, rather than result from declared ethical stance.

Concluding Remarks

The current study has illustrated that autonomy in the physician-patient relationship cannot easily be put into practice. Therefore, we believe that it is impossible to affect or enforce a change of attitudes and practices merely by passing a law. Implementation of such important legislation must, therefore, be accompanied by comprehensive research that will shed more light on the practices and attitudes of physicians and patients concerning the issue of patient autonomy, and which will elucidate the behavioral changes necessary for the effective enforcement of the law. The public will then need to be educated in order to appreciate the value and importance of the autonomy granted to them, and to be guided in exercising that autonomy to its best advantage. The medical professionals will also need to accept the patient in a new light ¾ as a respected partner in achieving their mutual goal of optimal medical care.

Acknowledgment

The Research was partially financed by the Israeli Ministry of Science and the Arts and the Israeli Ministry of Health.

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