THE ROLE OF PATIENT VALUE AND PATIENT-CENTRED
CARE IN HEALTH SYSTEMSChapter 1: Introduction: Refocusing medicine
Echoes of a long-established hierarchy
The most striking feature for today ’s reader of the Hippocratic Oath—the ancient Greek launchpad
of Western medical ethics—is almost certainly the patient’s relative absence. The new doctor swears
loyalty to gods and fellow professionals, then to help the ill according to “my ability and judgement”,
but makes no promise to ask patients anything, let alone what they might hope for from treatment.^1
Patients are to be objects of genuinely solicitous care, but apparently not independent agents and
certainly not partners.
Although the oath some time ago became a historical artefact, the paternalism it embodies has
remained ingrained in healthcare far longer. Worth recalling is how just relatively recently the
importance of any patient viewpoint has been acknowledged. Even in the US, where patient rights
efforts often spearhead global developments, the concept of “informed consent” appeared only in 1957
with a court ruling.^2 The more extensive idea of patient autonomy gained widespread recognition as
late as 1979 with the publication of Thomas Beauchamp and James Childress’s seminal The Principles
of Biomedical Ethics, and it was not until 1987 that the Picker Institute developed the principles of
patient-centred care,^3 which have since become an influential framework. Finally, it was only in the
past 15 years or so that medical associations have given up resistance to patients bringing information
found on the internet to discussions with clinicians.
Meanwhile, genuinely shocking examples of medical paternalism in developed countries from this
century remain easy to find. In Japan, as late as 2005 many doctors did not disclose cancer diagnoses
to patients, despite a majority of the latter wanting to know,^4 while the common use of electroshock
therapy, sometimes against patients’ wishes and without legal review, gave rise to concerns in
Australia’s state of Victoria in 2011.^5 A similar lack of even basic communication occurs in developing
states too: a 2008 survey found that under half of relevant specialists in Brazil informed patients of
Alzheimer’s diagnoses,^6 and a small 2018 study in China revealed that more than half of patients did not
know they had cancer until they started chemotherapy.^7
These examples are extreme in degree, but not necessarily unique in nature. Although most clinicians
would now find them troubling, even today, ancient attitudes are still present, notes Roy Beveridge,
the chief medical officer at Humana who has also practiced oncology for more than 20 years. “I find
there is still a viewpoint in medicine which equates to ‘I went to medical school, so I know what is best
for you.’ Even physician language uses terms like ‘the patient was not compliant with medical orders.’”
The patient might not follow orders, however, not through uninformed rebelliousness but because of a
substantially different viewpoint. A 2013 review of 46 studies looking at doctor and patient preferences
- Hippocrates, The Oath, Loeb Classic
Library. - Dennis J Mazur, “Influence of the law on
risk and informed consent,” BMJ, 2003. - https://www.picker.org/about-us/picker-
principles-of-person-centred-care/ - H Miyata et al. “Disclosure preferences
regarding cancer diagnosis and prognosis:
to tell or not to tell?” Journal of Medical
Ethics, 2005. - “Mental health care inquiry,” The Age,
September 6th 2011. - Irina Raicher et al, “Alzheimer’s disease
diagnosis disclosure in Brazil: a survey of
specialized physicians’current practice and
attitudes,” International Psychogeriatrics,
2008. - Yuxiu Liu et al, “Disclosure of cancer
diagnosis in China,” Cancer Management
and Research, 2018.