Patient Education and Counseling 62 (2006) 271276 www.elsevier.

com/locate/pateducou

The moral nature of patient-centeredness: Is it just the right thing to do?

Patrick S. Duggan a, Gail Geller a,b,e, Lisa A. Cooper c,d,e, Mary Catherine Beach a,c,d,e,*
a Phoebe R. Berman Bioethics Institute, Johns Hopkins University, Baltimore, MD, USA Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA c Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins University, Baltimore, MD, USA d Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA e Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA b

Received 7 February 2005; received in revised form 29 July 2005; accepted 3 August 2005

Abstract Objective: Patient-centeredness is regarded as an important feature of high quality patient care, but little effort has been devoted to grounding patient-centeredness as an explicitly moral concept. We sought to describe the moral commitments that underlie patient-centered care. Methods: We analyzed the key ideas that are commonly described in the literature on patient-centeredness in the context of three major schools of ethical thought. Results: Consequentialist moral theories focus on the positive outcomes of providing patient-centered care. Deontological theories emphasize how patient-centered care reects the ethical norms inherent in medicine, such as respect for persons and shared decisionmaking. Virtue-based theories highlight the importance of developing patient-centered attitudes and traits, which in turn inuence physicians behaviors toward their patients. Conclusion: Different ethical theories concentrate on different features of patient-centered care, but all can agree that patient-centeredness is morally valuable. Practice implications: In order to sustain patient-centeredness as a moral concept, practitioners and students ought to examine these ideas to determine what their own personal reasons are for or against adopting a patient-centered approach. # 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Patient-centeredness; Ethics; Shared decision-making; Physicianpatient interaction

1. Introduction Patient-centeredness was originally coined by Balint to express the belief that each patient has to be understood as a unique human being [1]. Since its inception, the concept has evolved and expanded. Entire books and a number of articles have been written on the topic [27]. Although a broad denition of patient-centered care is care that is closely congruent with and responsive to patients wants, needs, and preferences [4], Mead and Bower suggest ve
* Corresponding author at: Welch Center for Prevention, Epidemiology and Clinical Research, John Hopkins University, Baltimore, MD, USA. Tel.: +1 410 614 1134; fax: +1 410 614 0588. E-mail address: mcbeach@jhmi.edu (M.C. Beach).

distinct dimensions that describe patient-centered care. They are: (1) adopting the biopsychosocial perspective (as opposed to a perspective that is narrowly biomedical); (2) understanding the patient as a person in his or her own right, not merely as a body with an illness; (3) sharing power and responsibility between the doctor and the patient; (4) building a therapeutic alliancea relationship that is both instrumentally and intrinsically valuable; (5) understanding the doctor as a person, not merely as a skilled technician [8]. Mead and Bower themselves suggest that there is uncertainty in how best to operationalize and balance these dimensions. Nevertheless, we begin with their denition as representative of the literature on patient-centeredness. To better understand what patient-centeredness is, it is instructive to consider what it is not. Because of the number

0738-3991/$ see front matter # 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2005.08.001

272

P.S. Duggan et al. / Patient Education and Counseling 62 (2006) 271276

of ways patient-centeredness has been construed, there is more than one model of care that can be regarded as antithetical to patient-centeredness. Some have argued that patient-centeredness is at one end of a continuum, with doctor-centeredness at the opposite end [9]. Others have contrasted patient-centered care with care that is directed primarily at combating disease, or illness-oriented medicine [1]. Still others have identied medical paternalism as the opposite of patient-centeredness, because it fails to acknowledge the preferences, needs, and values of individual patients [4]. On other accounts, patient-centeredness is seen in contrast to a purely technical or biomedical model of care, where the physician is seen merely as the technician who delivers interventions and performs procedures [10]. In short, it is fair to say that any of these alternative conceptions of patientphysician interactive styles are not patientcentered. Patient-centeredness could be envisioned as a strategy to correct for all of these tendencies in medicine simultaneously.

to frame patient-centeredness as a distinctly moral concept. Since people disagree about matters of moral theory, we aim only to outline the various arguments that people could use to ground a belief that patient-centeredness is morally right.

3. The consequences of patient-centeredness Consequentialist moral theories maintain that actions (and by some accounts, attitudes) are morally right to the extent that they lead to desirable consequences, and morally wrong to the extent that they lead to negative consequences. Those who reason from a consequentialist perspective aim to promote actions that bring about the greatest good for as many people as possible. On this account, patientcenteredness is a good thing only if it has good consequences, such as improved patient outcomes or decreased cost. With no such consequences, it would be morally neutral. And, if it were shown to have negative consequences, it would be morally wrong. When there are both good and bad consequences (as is often the case), one would need to assess the balance of good to bad consequences. The parallels with evidence-based medicine should be clear, as consequentialist reasoning is very much congruent with typical clinical reasoning. To assess patient-centered care from a consequentialist perspective, we might ask: does patient-centeredness lead to better outcomes? This question is an empirical one, and is relatively easy to answer. A signicant body of research has explored the effects of patient-centered behaviors and attitudes on patient outcomes. Such research has shown, for example, that patients who perceive their visits to be patientcentered (i.e., the physician fully explored their illness, and patients were able to reach an agreement with the physician about the nature of their illness and what to do about it) require fewer diagnostic tests and have fewer referrals to other physicians [12]. Good communication techniques on the providers part, such as eliciting the patients input and taking a less dominant role in the conversation, are associated with increased adherence to therapy [13]. Other research has shown how elements of patient-centered care positively affect patient satisfaction [1416], trust [16], and psychosocial outcomes [12,17], as well as health [14,18] and functional status [12,18]. On the basis of such evidence, it is fair to conclude that patient-centeredness leads to better outcomes for patients. To the extent that this is true, it follows that patient-centeredness is morally justied (perhaps even required) on consequentialist grounds. That is, unless one found an approach that led to even better outcomes, one would have no compelling reason not to be patient-centered. The fact that such research is done at all raises an important question, namely why researchers and practitioners are interested in the impact of patient-centeredness on outcomes in the rst place. That is, what purpose does such evidence serve? There are two likely answers. Either:

2. Is patient-centeredness a moral concept? Patient-centeredness is not merely a descriptive account of patientphysician encounters as they actually occur; it is also prescriptive or normative. That is, its advocates believe that it should be sought after as an ideal, and that there is something amiss when it is lacking. Patient-centeredness has been promoted extensively in the literature, and is now considered by many to be the standard for quality interpersonal care [11]. Nevertheless, very little has been done to ground these claims, ethically speaking. Indeed, the burden of proof seems to fall squarely on the shoulders of those who would advocate anything other than a patientcentered approach to medicine. Most people can probably agree that patient-centeredness is good in theory. That is, we have no prima facie reason to oppose or dismiss it. It is less clear that the concrete practice of patient-centered medicine is morally required, or at least morally preferred to other models of care. We believe that patient-centeredness is an inherently moral concept, but that its moral nature has not been adequately acknowledged or discussed. The idea of patientcenteredness was originally developed in the psychosocial literature as a method of clinical care, and less as a moral concept. When prompted to defend it, one might assert that it is just the right thing to do. Yet, this intuition cannot stand on its own. It needs to be developed and defended. We suspect that while mostly everyone agrees that patientcenteredness is important, people may disagree about why it is important. There are several different ways of justifying patient-centered practice and, in this paper, we will discuss the application of three general approaches: consequentialist, deontological, and virtue-based moral theories. Our goal is not to argue for one particular approach, but rather to outline a range of arguments that practitioners might employ

P.S. Duggan et al. / Patient Education and Counseling 62 (2006) 271276

273

(1) we are genuinely uncertain or ambivalent about the value of patient-centeredness, and we want to know whether or not it is actually beneting patients, or (2) we have other reasons for believing it is valuable, and we think that assembling independent evidence for our beliefs may help to convince others of its value. In other words, is patientcenteredness just like any other clinical intervention, to be promoted if it is found to be effective and discarded if ineffective, or is it something different altogether? This question is worth asking. We suspect that while some people are genuinely concerned about the outcomes of patientcentered care, others may have different reasons for advocating patient-centeredness. In other words, the empirical evidence, while potentially convincing, does not offer a full account of why patient-centeredness is morally desirable.

4. Inherently valuable features of patientcenteredness Deontological moral theories hold that actions and attitudes are morally good not on account of their consequences, but rather because they possess some intrinsic property of rightness that ought to be pursued as a matter of duty. According to this account, something that is considered good in and of itself, e.g., being truthful with patients, would not be regarded as any less good if it were shown that telling the truth had negative consequences. Deontology is exemplied in codes of medical ethics and professionalism [1921], which outline duties, ideals, and standards of conduct that are to be upheld because they are regarded as inherently right. Many of these ideals can be linked with positive outcomes, but from a deontological perspective, this would be regarded as a happy coincidence, rather than a necessary feature. To explore the morality of patient-centeredness from a deontological perspective, we need to ask: are there features of patient-centeredness that are inherently right? By exploring the ethical commitments that are involved in the ve aspects of patient-centeredness identied by Mead and Bower, we hope to uncover the latent moral commitments that underlie many practitioners attachment to patient-centeredness. The rst two dimensions the biopsychosocial perspective and the patient-as-person are closely related, and so we treat them together. We believe that recognizing the patient as a person is the natural result of applying the biopsychosocial perspective (as a general theory) to individual patients. A physician who is patient-centered recognizes a need to attend to all of the different facets of the person simultaneously. The physicians task is viewed not simply as guring out what is wrong with a patient and striving to x it. All patients are unique in some respects. It is not enough to know that a patient A is sick with condition X, and therefore is in need of treatment Y. A physician who is truly patient-centered understands that the story leading

up to patient As having condition X may be entirely different from the story leading up to patient Bs having the very same condition. Patient A may be most distressed by one symptom, whereas patient B is unfazed by that symptom, but nds some other aspect of his illness to be unbearable. Treating patients in this way is not merely good clinical practice: it is a good moral practice as well. There has been a growing emphasis among some ethicists on the use of narratives to fully inform moral decision-making, on the presumption that having all information about a given situation is important for determining the right way to act [22,23]. Proponents of narrative ethics, as it is often called, maintain that expanding the use of narrative into clinical situations is a matter of moral necessity. The more a physician knows about what has happened and is happening with a given patient, the more he or she will be able to chart a prudent course of action that honors the unique experiences, needs, and goals of that particular patient [24,25]. A second reason that these dimensions of patientcenteredness are morally signicant is that they are related to the ethical principle of respect for persons. The notion of the patient as person seems at the same time both trite and profound. On rst approach, it is obvious, for what could patients be, if not persons? Yet, it calls to mind a rich and sophisticated moral tradition of respect for persons [26]. Respect for persons is essentially the recognition of persons as ends in themselves irrespective of their individual capacities and accomplishments, and might involve (as patient-centeredness seems to promote) acknowledgement of their inherent dignity, their wholeness, their experiences, their capacities to feel and to think. The categorical imperative that philosopher Kant described as the recognition that each individual has unconditional and incomparable moral worth and dignity [27] is remarkably consonant with Balints denition of patient-centeredness as understanding each person as a unique human being [1]. Patient-centered care also involves a movement toward sharing power and responsibility, which occurs when a physician encourages the patient to become an active participant in his or her own care. Rather than envisioning the patient as a passive recipient of care, a physician should empower patients to ask questions, receive and understand information, and participate in his or her own health care decisions. This can be quite clearly grounded in the ethical principle of respect for autonomy, because it acknowledges the beliefs, values, preferences, and choices of individual patients [4,28]. The patient-centered vision of sharing power and responsibility goes beyond a limited conception of respect for autonomy as simple noninterference with a patients expressed preferences. Genuine sharing of power, and genuine respect for autonomy, encourages patients to deliberate and form preferences, even patients who might normally be passive in clinical situations. At the same time, a truly patientcentered approachwhich takes patients goals and needs

274

P.S. Duggan et al. / Patient Education and Counseling 62 (2006) 271276

seriouslydoes not force patients to assume power and responsibility that they would prefer to leave with their physicians. For willing patients, shared decision-making can help to restore a sense of control and self-efcacy, which is an essential part of preserving patients dignity and autonomy [29]. Patient-centeredness stresses the importance of building a therapeutic alliance between the physician and the patient. Mead and Bower emphasize the therapeutic aspectthe capacity of the patientphysician relationship in and of itself to effect positive outcomes [8]. Since we have already addressed the association between patient-centeredness and outcomes above, here we will discuss the moral nature of the patientphysician relationship (the alliance) itself. The ethical issue here is not one of justifying the relationship (which is essentially a given); it is instead a matter of valuing the relationship in a special way. This valuing is also embodied in the practice of relationship-centered care, which has been suggested as a more comprehensive reframing of patient-centeredness [30]. Reecting on the nature of the patientphysician relationship helps to generate or clarify the responsibilities of a physician toward his or her patient [31]. In medicine, as well as in other spheres, the failure to live up to ones responsibilities often stems from an indifference to relationships, the refusal to acknowledge the duties generated by ones relationships with others. Many feminist scholars in ethics have shed light on this moral dimension of relationships [3234]. Patientcenteredness (and, to a greater extent, relationship-centeredness) is an important corrective force, because it suggests that the relationship should be valued and enhanced. Some patients, by virtue of being young, old, sick, weak, underserved, or otherwise vulnerable, require more attention or attention of a different sort. From a patient-centered perspective, it is because of the a priori value ascribed to relationshipsthe alliances forged between patient and physicianthat such requirements come to be seen clearly as moral duties, not simply professional ones. The nal, perhaps least well-dened, dimension of patient-centeredness is the recognition of the doctor-asperson, analogous to the patient-as-person dimension described above. Physicians bring not only their objective clinical expertise, but their own personal experience to bear on the clinical encounter. Like any other person, a physician is a responsible moral agent, and hence, exists in a person-toperson relationship with his or her patients. Physician and patient may not be equals in this encounter, but they still relate to each other as persons. Consequently, subjectivity is pervasive in the clinical encounter. Subjective inuences may be either positive (e.g., when a physician expresses empathy) or negative (e.g., when a physician has an unfounded bias against certain patients), but are pervasive in either case. The important point is that these subjective factors need to be openly acknowledged, and, when they are harmful, corrected. This requires a moral capacity for selfawareness and self-criticism on the physicians parta

desire to better understand and choose the attitudes and dispositions that inuence ones own behavior. Selfawareness has been identied as one of the core features of relationship-centered care [30], and it is also a cornerstone of a virtue-based, or agent-centered approach to ethics [34], which has its origins in the philosophy of Aristotle [35].

5. Is patient-centeredness a virtue? When discussing virtue theory, it is important to distinguish patient-centered behaviors or actions from patient-centered attitudes. This is not because we believe they ought to be (or for that matter, can be) separated in practice, but because virtue theory differs from both consequentialist and deontological theories in the importance it ascribes to behaviors versus attitudes. Patientcentered behaviors are those characteristics of an encounter that can be objectively observed, including both verbal behaviors (e.g., asking questions in a way that shows interest in what the patient says) and non-verbal behaviors (e.g., sitting down when possible in order to assume a less dominating position). Patient-centered attitudes are characteristics of a physician that may best be assessed by selfreport (e.g., the belief that asking about psychosocial issues is a necessary part of assessing a patients condition, or that a physician ought to share information, power, and control with patients) [16,36]. It should be obvious that both behaviors and attitudes are important, and though they can be separated in practice, both are necessary components of authentically patient-centered care. Virtue theory occupies a middle ground between consequentialist and deontological theories. While it does not regard the observable consequences of actions to be the most important feature for distinguishing right from wrong, neither does it insist on adherence to pre-existing rules from a sense of duty. Virtue theory, rather, focuses on fostering the right kind of attitudes and character traits, and then, acting in the way those attitudes and traits naturally dispose one to act. Attitudes and actions exist in a kind of equilibrium. A person learns to act in the right way by following the example of a teacher or mentor. In doing so, one gradually begins to adopt the dispositions of the other person as ones own. Being a virtuous person is not solely a matter of reason, on this account, but requires intense practice. One cannot be truly patient-centered if one lacks the attitudes and beliefs that underlie patient-centeredness, namely that all patients are unique individuals (as emphasized by Balint) [1], that they have inherent worth and dignity, that a physicians responsibility is to secure the patients holistic well-being as much as possible, that patients values and preferences ought to be acknowledged and respected, and that they should be involved in making decisions as much as possible. Absent these attitudes, one can act in a patient-centered way but will not really be patient-centered. Of course, acting as if

P.S. Duggan et al. / Patient Education and Counseling 62 (2006) 271276

275

patient-centered is still preferable to some of the alternatives, and paradoxically, it may be that one can ultimately come to be patient-centered by rst acting in that way.

We believe that patient-centeredness will be easier to facilitate if students are encouraged to reect on the many reasons why patient-centered care is the right thing to do.

6. Discussion and conclusion 6.1. Discussion In reviewing the arguments in favor of patient-centeredness, we conclude that patient-centered care can be promoted primarily on moral grounds. However, we wish to question the uncritical assumption that it is just the right thing to dothat there are no deeper reasons to ground this moral belief. In this paper, we have described the important features of patient-centeredness and outlined a range of different reasons that people might use to explain or ground the belief that patient-centeredness is morally desirable. As with any moral question, people can and do disagree about the features or goals that are most salient in deciding how best to act, and so we have explored how three different ethical schools of thought might assess patient-centeredness in moral terms. 6.2. Conclusion Perhaps what is most remarkable is that these quite different approaches lead to essentially the same answer, namely that patient-centeredness is a morally desirable feature of physicianpatient interaction. Using consequentialist reasoning, patient-centered care is morally required, on account of the empirical evidence that it leads to improved outcomes for patients. Using deontological reasoning, patient-centeredness may be justied because many of the features of patient-centered care align with important ethical norms and principles, for example, respect for persons, shared decision-making, and the responsibility to care for particularly vulnerable patients. Finally, patientcenteredness also encompasses an element of virtue-based ethics in its insistence that physicians possess a moral capacity for self-reection and a desire to better understand and adopt those attitudes and dispositions that positively inuence their own behaviors. 6.3. Practice implications While we do not endorse any particular moral approach here, we believe that practitioners and students alike ought to explore the arguments for themselves, to think carefully about the moral nature of patient-centeredness, and to determine what their own reasons are for or against its adoption. When the reasons for patient-centeredness are explicitly stated, students and practitioners of medicine will be able to evaluate them and act in concert with their own moral compasses. It is only through understanding why we ought to behave in a certain way that we can fully embrace it.

Acknowledgement Dr. Beach is a recipient of a K-08 from the Agency for Healthcare Research and Quality and a Robert Wood Johnson Generalist Physician Scholar.

References
[1] Balint E. The possibilities of patient-centred medicine. J R Coll Gen Pract 1969;17:26976. [2] Brody H. The biopsychosocial model, patient-centered care, and culturally sensitive practice. J Fam Pract 1999;48:5857. [3] Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through the patients eyes: understanding and promoting patient-centered care. San Francisco: Jossey-Bass Publishers; 1993. [4] Laine C, Davidoff F. Patient-centered medicine. A professional evolution. JAMA 1996;275:1526. [5] Mead N, Bower P. Patient-centred consultations and outcomes in primary care: a review of the literature. Patient Educ Couns 2002;48:5161. [6] Smith RC, Marshall-Dorsey AA, Osborn GG, Shebroe V, Lyles JS, Stoffelmayr BE, Van Egeren LF, Mettler J, Maduschke K, Stanley JM, Gardiner JC. Evidence-based guidelines for teaching patient-centered interviewing. Patient Educ Couns 2000;39:2736. [7] Stewart M, Brown J, Weston W, McWhinney I, McWilliam C, Freeman T. Patient-centered medicine: transforming the clinical method.. London: Sage; 1995. [8] Mead N, Bower P. Patient-centredness: a conceptual framework and review of the empirical literature. Soc Sci Med 2000;51:1087110. [9] Byrne PS, Long BEL. Doctors talking to patients: a study of the verbal behaviour of general practitioners consulting in their surgeries. London: H.M. Stationery Ofce; 1976. [10] Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatr 1980;137:53544. [11] Committee on Quality Health Care in America. Crossing the quality chasm: a new health system for the 21st century. Washington, DC: National Academy Press; 2001. [12] Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The impact of patient-centered care on outcomes. J Fam Pract 2000;49:796804. [13] Hall JA, Roter DL, Katz NR. Meta-analysis of correlates of provider behavior in medical encounters. Med Care 1988;26:65775. [14] Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:21320. [15] Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract 1991;32:17581. [16] Krupat E, Bell RA, Kravitz RL, Thom D, Azari R. When physicians and patients think alike: patient-centered beliefs and their impact on satisfaction and trust. J Fam Pract 2001;50:105762. [17] Little P, Everitt H, Williamson I, Warner G, Moore M, Gould C, Ferrier K, Payne S. Observational study of effect of patient centredness and positive approach on outcomes of general practice consultations. Brit Med J 2001;323:90811. [18] Kaplan SH, Greeneld S, Ware Jr JE. Assessing the effects of physicianpatient interactions on the outcomes of chronic disease. Med Care 1989;27:S11027.

276

P.S. Duggan et al. / Patient Education and Counseling 62 (2006) 271276 [28] Beauchamp TL, Childress JF. Principles of biomedical ethics, 5th ed., New York: Oxford University Press; 2001. [29] Katz J. The silent world of doctor and patient. New York: Free Press; 1984. [30] Pew-Fetzer Task Force on Advancing Psychosocial Health Education. Health professions education and relationship-centered care. San Francisco: Pew Health Professions Commission; 1994. [31] Emanuel EJ, Emanuel LL. Four models of the physicianpatient relationship. JAMA 1992;267:22216. [32] Friedman M. What are friends for? Feminist perspectives on personal relationships and moral theory. Ithaca, NY: Cornell University Press; 1993. [33] Noddings N. Caring: a feminine approach to ethics and moral education. Berkeley: University of California Press; 1984. [34] Cates DF. Choosing to feel: virtue, friendship, and compassion for friends. Notre Dame, IN: University of Notre Dame Press; 1997. [35] Aristotle. Nicomachean ethics. London: Clarendon Press; 1952. [36] Haidet P, Dains JE, Paterniti DA, Chang T, Tseng E, Rogers JC. Medical students attitudes toward patient-centered care and standardized patients perceptions of humanism: a link between attitudes and outcomes. Acad Med 2001;76:424.

[19] Medical professionalism in the new millennium: a physician charter. Ann Intern Med 2002;136:2436. [20] American Medical Association. Declaration of professional responsibility: medicines social contract with humanity.; 2001, http:// www.ama-assn.org/ama/upload/mm/369/decofprofessional.pdf [cited August 24, 2005]. [21] Accreditation Council on Graduate Medical Education. ACGME Outcome Project.; 2001, http://www.acgme.org/outcome/comp/compFull.asp [cited August 24, 2005]. [22] Jones AH. Narrative based medicine: narrative in medical ethics. Brit Med J 1999;318:2536. [23] Widdershoven G, Smits M. Ethics and narratives. In: Josselson R, editor. Ethics and process in the narrative study of lives. London: Sage; 1996. p. 27587. [24] Charon R. The patientphysician relationship. Narrative medicine: a model for empathy, reection, profession, and trust. JAMA 2001;286:1897902. [25] Charon R. Narrative medicine: form, function, and ethics. Ann Intern Med 2001;134:837. [26] Ramsey P. The patient as person: explorations in medical ethics. New Haven: Yale University Press; 1970. [27] Kant I. Ethical philosophy: the complete texts of grounding for the metaphysics of morals, and metaphysical principles of virtue. Indianapolis: Hackett Publishing Company; 1983.