First published two decades ago, Jay Katz’s The Silent World of
Doctor and Patient proffered a new model of physician-patient
communication, one that would make true informed consent possible, and help
bridge the communication gap, as old as the profession of medicine itself,
between doctors and their patients.  Katz’s radical premise was that doctors
and patients should talk to each other, ending millennia of silence that
secured the paternalistic authority of physicians and left their patients with
few options beyond silently acquiescing or silently rebelling. Katz eloquently
argued that the silence between doctors and patients has far-reaching psychic
and ethical consequences, among the most damaging of them the mutual distrust
that exists between patients and doctors. Patients can’t trust their physicians
to act in their interests, while physicians, trained to believe in what amounts
to a self-fulfilling prophecy — that patients are incapable of making
informed, intelligent, rational decisions about health care — can’t trust
patients to act in their own interests. The result is that patients are
essentially disenfranchised. Stripped of power and control in medical
decision-making, their interests and values are ignored when they matter most:
in matters of life, death and well-being.

Twenty years later, Katz’s analysis of the problems remains
relevant because the problems themselves continue to press, with implications
both for the quality and the ethics of health care. The new edition of The
Silent World of Doctor and Patient is a much-needed addition to the
bioethical canon. Katz begins his discussion with an informative examination of
the historical roots of medical paternalism and nondisclosure in Western
medicine, starting with the philosophical precedent set by the ancient Greeks
and the Hippocratic Oath, and ending with the twentieth century’s nascent legal
doctrine of informed consent. Perhaps Katz’s greatest insight is that
nondisclosure in medicine has historically been viewed as necessary, justified
by medical uncertainty and the impotence of doctors with little to offer their
patients beyond kind words and psychological comfort. As the modern science of
medicine has made great strides in the diagnosis and treatment of human
illnesses, however, it has also made nondisclosure a relic of the past, Katz
argues. While uncertainty is still a fact of modern medicine, it should now be
acknowledged by physicians on the way towards empowering patients as medical
decision-makers. The silence of doctors, particularly when they have reached
the limits of medical knowledge and capability, that is, when they are
confronted with medical uncertainty, is nothing less than the abandonment of patients,
Katz argues.

Katz wears his psychoanalytic influences on his sleeve throughout The
Silent World of Doctor and Patient. While the focus of much of the
bioethical literature on informed consent has been on the denial of liberty,
rights and autonomy, Katz turns his attention to the damaging psychological
affects of the manipulation and coercion doctors engage in to secure patient
consent, as well as the loss of autonomy and independence. Much of his
discussion hinges on Freudian concepts, such as transference and countertransference
between doctors and patients, the "infantile regression" experienced
by patients in the throes of illness, the narcissism of doctors elevated to the
status of caring, all-knowing parents, and their subsequent fear of being
revealed as less than omnipotent. These unconscious influences explain the
silence that stalks doctor-patient relations, Katz claims, and undermines the
real communication that would make mutual trust and meaningful patient autonomy
possible.

Katz’s reliance on psychoanalytic concepts is not as helpful or
necessary as his prolonged discussion of it would suggest, but his thesis is
intriguing nonetheless. Ancient medicine, he suggests, may have succeeded
largely because of the placebo effect. In the face of scientific ignorance and
medical uncertainty, it was the compassionate authority of doctors, as much as
any potion, that cured and comforted the ailing. The neediness and helplessness
of patients only served to reinforce the power and confidence of the physician,
and both justified and necessitated keeping patients in the dark. Paternalism,
and the confidence it fostered, was, in times of limited medical knowledge, the
best medicine. If physicians demand today that patients surrender autonomy and
independence, they are merely acting on an outdated but thoroughly inculcated
and self-flattering belief system that justifies paternalism on the grounds
that it is in the best interests of patients who need to have confidence in the
authority of doctors. But patients, Katz notes, are not as helpless and
ignorant as doctors would like to believe, and so, what once fostered trust in
physicians now engenders mistrust and resentment. Katz’s emphasis on the
psychological roots of the communication gap and patient-physician mistrust is
well-considered, thoroughly and eloquently argued, and unique. It also provides
a ready remedy, even if one rejects the notion that the sources of the mistrust
are largely unconscious factors. Doctors, Katz argues, have engendered patient
mistrust, and they can foster trust as well, simply by listening to patients
and respecting their decisions. Conversation, Katz writes, "will protect
the integrity of the physician-patient relationship only if doctors are willing
to confront and change their views of themselves as sole authority and of their
patients as incompetent participants in decision making. Otherwise,
manipulation and coercion will continue to rule their interactions."

A shortcoming of the new edition of The Silent World of Doctor and
Patient is that Katz misses an opportunity to address some recent
developments that have complicated patient-physician relations. As Alexander
Morgan Capron notes in his forward to the new paperback edition, the rise of
managed care organizations — reviled by patients and physicians alike as
interfering third parties — has added considerations of cost-cutting and
profits to the doctor-patient relationship, placing further constraints on
patient choice. If doctors previously limited patient access to information
about the full range of therapeutic options available for reasons of authority
and personal preference, the rationing of health care dollars under managed
care plans has given them financial incentives — or, more likely,
disincentives — to providing full disclosure of options. Furthermore, if
doctors are driven by reduced payments to spend less time with patients, Katz’s
remedy for the loss of patient autonomy and the lack of informed consent  —
more conversation — seems less likely to be adopted by physicians. Katz
briefly addresses the problem, suggesting that conversation might actually
result in controlling medical costs, chiefly by eliminating many procedures and
treatments which are either unnecessary or provide, at best, only limited benefit.
Talk, his proposal suggests, is quite literally cheap. "The time costs of
conversation may turn out to be much less than the costs of intervention. Of
all proposals to contain the explosion in medical costs one has not received
the attention it deserves: having patients play a more vital role in deciding
whether to undergo tests and treatments that need not necessarily be performed.
‘Second medical opinions’ may be one answer, but ‘first patient opinions’ may
be a better answer." Katz has touched on an intriguing possibility, and
one that warrants empirical study.

A further development that affects the patient-physician
relationship is the explosion in medical information accessible to the general
public. Some of that information is provided by parties with financial motives,
such as pharmaceutical companies, now promoting their wares directly to
consumers rather than intermediary doctors. The development is not necessarily
a favorable one for the quality of patient care, or for informed consent. The most
significant increase in access to information has been facilitated by the
Internet, however, and the proliferation of websites offering both good and bad
medical advice and information. To some extent, this has shifted the balance of
power between physicians, formerly the gatekeepers of medical knowledge, and
patients, who are no longer blinkered by the withholding of information. Katz,
it seems, should welcome such a development because, by empowering patients
with knowledge, it could have the effect of forcing doctors to be more open and
forthcoming, even while there are other pressures on them to withhold
information. At the same time, it makes trust between doctors and patients even
more vital, for, confronted with a bewildering array of medical information,
some of it quite questionable, patients need trusted practitioners to help them
make truly informed decisions. Access to information is a precondition for
informed consent, but it is only one of several preconditions.

In general Katz pays scant attention to these and other practical
considerations that bear on the implementation of his conversation
prescription, but in identifying the root causes of the alienation between
doctors and patients, Katz instead endeavors to establish the preconditions for
informed consent and mutual trust, and examine the ill consequences of
neglecting them. It would be too easy to dismiss Katz’s plan as impractical,
for, while his solution appears deceptively simple, his aims are lofty — he
seeks nothing less than a new way of doing medicine, one that could enhance not
just doctor-patient relations, but many other aspects of human existence.
"Living the life of medicine in such new and unaccustomed ways could
extend the dominion of reason and thus make doctors true healers to
mankind," he writes. Katz acknowledges that the new relationship he
imagines will not be easy to implement, and his neglect of some of the
practical impediments and aids to trust and communication leaves much room for
a discussion of how and why his plan can or cannot work. His prescription for
some of the principal ills of modern medicine is simply more sunshine. It is
left to doctors to figure out how to open the windows.

© 2004 L. Syd M Johnson

L. Syd M Johnson, M.A., is a bioethicist and Ph.D. candidate at
SUNY Albany, currently working on a dissertation exploring the implications for
reproductive choices of the Non-Identity Problem and new genetic technologies.

Categories: Ethics, Philosophical