2.3.1 Patients and therapeutic responsibility
Activity 6: Therapeutic responsibility
Based on your own experience, and using the evidence you have read about and heard, answer the following questions.
Do you believe there has been a significant shift towards shared decision making during therapeutic encounters with CAM practitioners?
What impact do you think more equal relationships might have on shared therapeutic responsibility?
Whereas, in the past, responsibility for successful outcomes was exclusively the practitioner's, people are now encouraged to accept a far greater level of self-responsibility in the therapeutic relationship. How far this extends to taking some responsibility for therapeutic outcomes should also be considered.
In CAM, outcomes and expectations may not be just about a narrow definition of health. Patients may seek happiness or wellbeing, a new understanding of their health or their lives, education about a particular topic, a feeling of pleasure and relaxation, or even the fulfilment of a sense of curiosity (Budd and Sharma, 1994, p. 2). The aims of CAM therapy are not, therefore, limited to a cure or the management of symptoms. Given this diversity, the question is whether the models of therapeutic responsibility used in other settings, such as orthodox health care, are useful or appropriate for discussing CAM. Stone and Matthews (1996) argue that, even though CAM relationships stress the centrality of patient self-responsibility, courts and professional bodies still place the entirety of the burden of therapeutic responsibility on the practitioner:
[T]he law is not prepared to impose duties of self-responsibility on patients. Patients are not held personally responsible in a legal system which is shaped more by the Hippocratic medical tradition than one which sees the legitimacy of health professionals as deriving solely from the patient's rights and the patient's consent to be treated. … there is little room for contributory negligence in a medical negligence action. Is there anything wrong with the status quo? The answer in relation to cases concerning allopathic medical practitioners is probably not. The technical expertise base of most of modern medicine is such that it probably is justifiable to regard the practitioner as the expert, and the patient as the grateful, and often passive, recipient of health care who expects not to be harmed by unreasonable errors, and expects to find legal redress should such errors occur.
(Stone and Matthews, 1996, p. 213)
In orthodox medicine, where doctors assume a high degree of professional expertise and successful therapeutic outcomes are attributed to a range of interventions, doctors should arguably be held accountable when things go wrong, because the person on the receiving end of that professional expertise cannot contribute much to professional wisdom, and so depends entirely on responsible professional judgement being used. The more power that a single party holds, the fairer it seems to place all the liability on that one party because, in essence, the disempowered party cannot significantly influence the outcome of the therapeutic exchange. Stone and Matthews (1996) argue that, as health care becomes more patient-centred, this way of thinking about therapeutic responsibility will become increasingly outmoded. This model is not appropriate for a therapeutic relationship which depends for its success on the client's active participation. They cite psychotherapy as an example of how existing legal and professional models of accountability may be ill-suited to analyse patient-centred encounters. In psychotherapy, they argue, the therapist gives the client space to realise their potential. If the client fails to do so, no one would expect this to be expressed through the law: for example, ‘I'm suing you because you promised to make me happy.’ Where the efficacy of a therapy depends on both the patient and the practitioner exercising self-responsibility, the practitioner should not be held accountable if the patient fails to fulfil their part of the deal.
Stone and Matthews go on to argue that, unless and until the law shifts towards a contractual model founded on mutual responsibility, the notion of patient self-responsibility will amount to little more than lip service. Patient-centred rhetoric is one matter, but backing up patient-centredness with the force of law denotes a significant shift in how practitioner-patient relationships are conceptualised:
Suggesting this model has profound political implications. If we are to expect patients in this context to make responsible choices and to take steps to promote their own health, then this relies on the patient having access to a far greater amount of information than the law currently requires.
(Stone and Matthews, 1996, pp. 292–3)