In contemporary Western medical practice, collaborative decision making is the gold standard (1). Patient input into treatment plans (whenever possible) is considered critical, and patient autonomy is heralded as a key bioethical principle. In practice, however, the interplay between autonomy, alliance and collaboration can be complex and variable.

Phenomenologically speaking, the definition of personal autonomy is somewhat elusive. Immanuel Kant deemed a person autonomous “only if his choices and actions are unaffected by factors that are external, or inessential, to himself" (2,3). In contrast, John Stuart Mill required only that an autonomous person “direct his actions in accordance with his own values, desires, and inclinations” (2). Considered more “realistic” for its tolerance of external influence, environmental interaction and contextual force, Mill’s conception of autonomy better suits the medical-clinical domain (2). Related to what Martin Heidegger called “being-in-the-world”—and more modern scholarship terms “relational autonomy”—Mill’s approach to autonomy highlights the truth that no decision is made in a social or structural vacuum (3-5). Autonomy is lived and practiced in social connection, not alone. This relational perspective, however, complicates the aforementioned principles of patient autonomy and patient-centered collaboration—principles prone to oversimplification in both medical and public spheres. Indeed, it is crucial to consider how autonomy, collaboration and their synergy might look different across different physician-patient/family dyads. Such consideration is especially important given the diversity of patients’ relational worlds and physicians’ interactions with, and interpretations of, those worlds (5-7).

The structure of the “ideal” patient-physician relationship is similarly subject to debate, and has evolved strikingly over the past several decades (8,9). Today, trainees are taught to practice “patient-centered” care—to engage in parallel partnership rather than vertical paternalism, educational exchange rather than unilateral instruction. (Importantly, “patient-centered” care is not synonymous with a “technical” model of practice, in which providers offer “technical medical expertise” to patients, including information about diagnoses, tests and therapeutic options, but relinquish all ultimate decision making to patients in the name of “pure” autonomy (7-9)). While the modern model of mutual responsibility has precipitated critical “improvements in patient satisfaction and outcomes,” it places significant responsibility in the hands of patients; patient “preparedness,” from knowledge of personal medical history to declaration of clear health/life priorities, drives care as much as provider knowledge and experience (8). But for a variety of reasons—inability to access medical records or resources online, anxiety around decision making, lack of education, state of severe illness, etc.—not all patients can participate productively in such a balanced collaborative approach (7). Some patients may seek more explicit direction within the confines of expressed values. Still others may be unsure of their preferred values in the first place. To what adaptations of, or variations on, “patient-centeredness” should physicians then turn?*

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*In nearly every doctor-patient relationship, there exists some imbalance in power. Power is said to derive from “three key sources: force, material resources and knowledge" (10). Historically, although less dramatically today given widespread access to health information, physicians serve as guardians of medical knowledge; they are also gatekeepers to medical resources (e.g., medications, diagnostic tests, inpatient admissions, etc.). In these senses, physicians carry outsized power in relationships with patients. While power itself is “neither inherently good nor evil,” it can certainly be leveraged for positive or negative impact, either consciously or subconsciously (10). The details of doctor-patient power differentials—especially as impacted by diversity in background/ethnicity, gender identity, sexual orientation, religion, and culture more broadly speaking—deserve pointed attention. While we do not focus on these details here, we acknowledge their criticality, weight and contribution to the discussion above. 

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Illustrative Scenarios:

• After sharing a universally fatal diagnosis with a pediatric patient's family, a physician begins to discuss next steps. The family asks that "everything be done." The physician wonders which experimental, therapeutic and/or palliative options to present as "choices” along the path to tragic certainty.

• A patient cannot decide between conservative versus aggressive surgical approach. She asks her physician for guidance: "What would you do if you were me? Tell me what to do."

• An elderly patient reveals to her physician that her family wants her to take an aggressive approach to treatment. The patient says she is content to follow their wishes, given that “they will keep on living after I am gone.” She admits, however, that if left to her own devices, she would prefer a palliative option.

• A patient with metastatic cancer asks his surgeon to perform a palliative operation (to potentially enhance the quality of time remaining). The surgeon considers the procedure too risky, and considers refusing to operate (11).

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