Patient empowerment or the emperor's new clothes

Patient empowerment pervades clinical practice, teaching and research: patients are expected to take control over their illnesses or treatments where possible, and doctors are expected to encourage or 'empower' them to do so. The concept is in tune with a wider political and cultural emphasis on individual choice, and gains scientific justification from psychological research and theory that attests to the superiority of ways of coping with challenges—including illness or treatment—that exert control over the challenge.1 The validity of the view that patients should be empowered to take control and make choices is therefore widely assumed to be unassailable. Nevertheless, patient empowerment sits uncomfortably with other current medical ideologies, in particular evidence-based medicine.2 Moreover it is, in reality, constrained by organizational, clinical or economic factors. The scientific basis for the importance of choice and control is also weaker than it first appears. Although controlled studies of empowerment—for example, arranging for patients to choose the nature or timing of treatment, or teaching them 'coping skills'—do often favour intervention groups,1 effects are variable; sometimes they are transient or favour lack of choice. Moreover, whereas it is normally assumed that such interventions enhance feelings of choice or control, researchers have rarely demonstrated that they do. In a study of treatment choice in breast cancer, even though patients of surgeons who offered choice were happier, choice was not the critical factor.3 Because of these contradictions and ambiguities, the concept of empowerment needs to be more closely examined than it has been. The term empowerment purports to describe the positivity of patients' experience of involvement in managing illness. Therefore the validity of the concept should be tested by studying the experience of patients who have been empowered.