When we think of rights in healthcare, we think of protecting the patient. In reality, we are placing the patient at odds with their medical care.
Rights are something to protect, implying that they are something to protect against. It is a subtle cognitive shift, but it matters when dealing with subtle clinical decisions. Consider the following patient scenario.
A sixty-five-year-old Hispanic female with diabetes has a non-healing wound in her right heel. She has tried improving her diet and adjusting her medications, even adding insulin injections. Nothing has worked. She is now opting for surgery to debride her wound. This can proceed in one of two ways.
In one scenario, we think of the patient safeguarding against all liabilities. She reviews the consent; she monitors for all possible adverse outcomes or risks. She ensures she is protected, that she knows of her rights.
In the other scenario, she takes a far less adversarial approach. She focuses on preparing herself for surgery: maintaining the appropriate level of physical activity, eating better, monitoring her blood sugar closely, and avoiding things that would worsen the wound.
Both scenarios play out the same, a successful debridement, but the perspectives of the patient differ. And likely, so will the long term post-operative outcomes. Looking at medicine as a series of rights to protect or restrict is in vogue right now, particularly with a conspicuous, litigious veneer covering the most polarizing health issues today.
But there is a better way to look at healthcare. Instead of thinking about patient rights, think about patient duties. Rights are what we have, what is owed; duties are what we should do, what we owe. One is passive; the other is active.
Healthcare, at its root, is a series of active decisions. The hypothetical patient above does not randomly become diabetic. She makes decisions that culminate in her diagnosis.
And we can view her decisions from the perspective of either rights or duties. In the former, the patient expects certain services, and demands certain outcomes and results to be met. In the latter, the patient considers her role in preparing for the surgery and recovering from it. In the second scenario, the patient is actively engaged in the process. She is in control.
We talk a big game about bodily autonomy: “my body, my choice”. But we talk little about bodily agency, the consequences that come with the responsibility of autonomy. We conveniently miss this correlation when we consider only patient rights.
But when we think of duty, a patient’s responsibility in the process of healthcare, the autonomy comes with agency, hand in hand.
The shift in thinking may be subtle, but the patient outcomes are not. In fact, clinical outcomes improve when we think of duty instead of rights.
While we can wax poetic about the reasons for this, the issue boils down to one thing: when we think of medicine in terms of rights, we think individually. When we think of medicine in terms of duty, we think of our obligation to others.
This matters because medicine is inherently a service. Yet, we look at it like a product, focusing only on the outcome. Service is ongoing, an outcome has finality. This misunderstanding lies at the heart of why we cannot think of rights in medicine.
As long as we apply such thinking to medicine, we will always be at odds with each other. My rights conflict with your rights. A physician’s right to make medical decisions conflicts with a patient’s rights to do as he or she pleases.
But when we think of duty, we become reconciliatory. The physician is obligated to the patient as much as the patient is obligated to the physician.
This is not just an exercise in idealized rhetoric. We have ways of implementing this thinking in medicine: adjust the incentives to be reconciliatory.
As it currently stands, medicine focuses on individual protections and liabilities. Instead, if we reward communication, active engagement between patients and physicians, then what was once a liability becomes an opportunity to discuss treatment options.
Like the hypothetical patient with the diabetic wound. If she only focuses on her individual right and the liability of others, then she will be less engaged. But if she considers her role in the surgery, then she will see herself as part of a system in service of her health – with a responsibility to those who are caring for her.
She will see it as a matter of duty.
