Using Metaphors to Characterize Doctor--Patient Relationships: Paternalism Versus Consumerism

Two metaphors describing doctor-patient relationships, paternalism and consumerism, are compared. We discuss the implications of each metaphor with reference to features implied in the relationship, motivational expectations for doctor and patient, and acceptable relationship outcomes. Paternalism focuses on obligations; consumerism focuses on rights. Paternalism assumes the doctor is beneficent; consumerism assumes the doctor is self-centered. Paternalism implies the existence of trust; consumerism replaces trust with accountability. Paternalism assumes that principles of good medical care override individual treatment preferences; consumerism presumes that the patient's health care values dominate. Paternalism assumes that third-party intervention is inappropriate whereas consumerism may require third-party supervision. Conflict may develop when doctor and patient approach the relationship using differing metaphors. Even if doctor and patient agree on a paternalistic relationship, society may demand consumeristic accountability. The institutionalization of medical consumerism may create paternalism anew where patients' rights advocates and third-party payers assume the paternalistic role once held by the physician.