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Medical Decision-Making: the Family-Doctor-Patient Triad

Posted by plosmedicine on 30 Mar 2009 at 23:40 GMT

Author: Naveed Zafar Janjua
Position: Medical Epidemiologist
Institution: Aga Khan University
Additional Authors: Fawad Aslam, Omar Aftab, Naveed Zafar Janjua
Submitted Date: March 16, 2005
Published Date: March 17, 2005
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

The importance of a person-centred approach and the intricacies of risk communication have recently been well described in the journal [1,2]. The applicability of the patient-centred approach to the eastern countries, however, has cultural, religious, and practical impediments that demand careful consideration. The bulk of the world population lives outside USA and Western Europe. Unlike in the west, where patient takes the centre stage both by tradition and law, the family-doctor-patient triad is the norm in eastern states in general and Pakistan in particular [3,4,5,6,7,8].

Pakistan is a predominantly Muslim country of 150 million people. About half the population is uneducated and more than a third lives below the poverty line. There is one doctor for every 1432 patients as compared to one doctor for every 390 patients in USA. The health insurance system is virtually non-existent and there is no concept of old homes with the care of the elderly largely taking place at homes by the families. Strongly held religious beliefs and cultural views govern everyday life and dictate the roles of every member of the society. Families consist of well-knit, supportive and collectively earning inter-dependent members who take mutual decisions on all matters pertaining to life and death [3,4]. The elder members of the family command the greatest respect and authority. The family unit is the functional unit of the society, the dynamics of which need attention and respect.

Strong family systems and the authoritative position of the doctor are the governing forces of medical decision-making in these countries. Illiteracy, poverty, poor patient rights awareness and lack of physician accountability are factors conducive to such a practice. With this background, the role of the patient is limited. Health expenditure is borne by the family giving it a central role in decision-making. The concept of the financial survival of the family is a harsh reality [3,4]. The healthcare costs of one seriously ill member may jeopardize the survival of others by draining the limited resources. Due to familial moral and monetary support, the patient absolves himself from the responsibility of decision-making and gives the primary role to the family or the doctor. Women, for example, may not give consent unless they get approval from their spouses [5]. In cases of women, who may have a lesser say in the patriarchal family system, the doctor should strive for active participation of such patients. The family aims to protect the patient from stress and in terminal conditions, the doctor and family act in concert to conceal complete information from the patient. They, for example, may not mention the word cancer to patients who have malignancies [9].

In contrast to western practice, the role of the doctor is authoritative. He is regarded as an instrument of God and given the final authority in decision making [3,4,10]. In such circumstances, the doctor is likely to take decisions unilaterally. When they do involve the patients in decision-making, physicians accept the centrality of families with some considering patients and families as one [5]. One worry, regarding harm communication, is of loosing patients to other physicians with a more reassuring nothing will go wrong attitude [5]. It is also said that more time and patience is required to explain things to the illiterate. It is perhaps impractical therefore, to expect overworked and underpaid physicians to practice risk communication as per the book.

Thus the concept of individual centrality that is so elementary in the west stands challenged in the east. Research is needed to formulate appropriate strategies of risk-communication. These areas needing research include the patientsb concept of autonomy; the role of the family as perceived by the patients and doctors; the existing practices of medical decision-making; and training of doctors in communicating risk.

An economically sound and literate population; properly trained doctors and institutional checks and balances are essential prerequisites for establishing decision-making with parity of partners. The need is to find a middle ground where not only the family unit is respected but the patient also plays a proactive role. A dynamic balance between the cultural values of caring and the possibility of a more individualistic role in healthcare is needed and indeed attainable. Doctors, being the most influential component of the family-doctor-patient triad, can play a significant role in bringing about this change.

1 Alaszewski A (2005) A Person-Centred Approach to Communicating Risk. PLoS Med 2: 93-95.
2 Herxheimer A (2005) Communicating with Patients about Harms and Risks. PLoS Med 2: 91-92.
3 Moazam F (2000) Families, patients, and physicians in medical decisionmaking: a Pakistani perspective. Hastings Cent Rep 30: 28-37.
4 Moazam F (2001) Reconciling patients' rights and God's wisdom: medical decision making in Pakistan. Responsive Community 11: 43-51.
5 Jafarey AM, Farooqui A (2005) Informed consent in the Pakistani milieu: the physician's perspective. J Med Ethics 31: 93-96.
6 Cong Y (2004) Doctor-family-patient relationship: the Chinese paradigm of informed consent. J Med Philos 29: 149-178.
7 Fetters MD (1998) The family in medical decision making: Japanese perspectives. J Clin Ethics 9: 132-146.
8 Younge D, Moreau P, Ezzat A, Gray A (1997) Communicating with cancer patients in Saudi Arabia. Ann N Y Acad Sci 809: 309-316.
9 Holland JC, Geary N, Marchini A, Tross S (1987) An international survey of physician attitudes and practice in regard to revealing the diagnosis of cancer. Cancer Invest 5: 151-154.
10 Kanabar P (2002) Doctor-patient partnership. J Indian Med Assoc 100: 718.

No competing interests declared.