The Silent World of Doctor and Patient

First published two decades ago, Jay Katz's The Silent World of Doctor and Patient proffered a new model of physician-patient communication, one that would make true informed consent possible, and help bridge the communication gap, as old as the profession of medicine itself, between doctors and their patients.  Katz's radical premise was that doctors and patients should talk to each other, ending millennia of silence that secured the paternalistic authority of physicians and left their patients with few options beyond silently acquiescing or silently rebelling. Katz eloquently argued that the silence between doctors and patients has far-reaching psychic and ethical consequences, among the most damaging of them the mutual distrust that exists between patients and doctors. Patients can't trust their physicians to act in their interests, while physicians, trained to believe in what amounts to a self-fulfilling prophecy -- that patients are incapable of making informed, intelligent, rational decisions about health care -- can't trust patients to act in their own interests. The result is that patients are essentially disenfranchised. Stripped of power and control in medical decision-making, their interests and values are ignored when they matter most: in matters of life, death and well-being.

Twenty years later, Katz's analysis of the problems remains relevant because the problems themselves continue to press, with implications both for the quality and the ethics of health care. The new edition of The Silent World of Doctor and Patient is a much-needed addition to the bioethical canon. Katz begins his discussion with an informative examination of the historical roots of medical paternalism and nondisclosure in Western medicine, starting with the philosophical precedent set by the ancient Greeks and the Hippocratic Oath, and ending with the twentieth century's nascent legal doctrine of informed consent. Perhaps Katz's greatest insight is that nondisclosure in medicine has historically been viewed as necessary, justified by medical uncertainty and the impotence of doctors with little to offer their patients beyond kind words and psychological comfort. As the modern science of medicine has made great strides in the diagnosis and treatment of human illnesses, however, it has also made nondisclosure a relic of the past, Katz argues. While uncertainty is still a fact of modern medicine, it should now be acknowledged by physicians on the way towards empowering patients as medical decision-makers. The silence of doctors, particularly when they have reached the limits of medical knowledge and capability, that is, when they are confronted with medical uncertainty, is nothing less than the abandonment of patients, Katz argues.

Katz wears his psychoanalytic influences on his sleeve throughout The Silent World of Doctor and Patient. While the focus of much of the bioethical literature on informed consent has been on the denial of liberty, rights and autonomy, Katz turns his attention to the damaging psychological affects of the manipulation and coercion doctors engage in to secure patient consent, as well as the loss of autonomy and independence. Much of his discussion hinges on Freudian concepts, such as transference and countertransference between doctors and patients, the "infantile regression" experienced by patients in the throes of illness, the narcissism of doctors elevated to the status of caring, all-knowing parents, and their subsequent fear of being revealed as less than omnipotent. These unconscious influences explain the silence that stalks doctor-patient relations, Katz claims, and undermines the real communication that would make mutual trust and meaningful patient autonomy possible.

Katz's reliance on psychoanalytic concepts is not as helpful or necessary as his prolonged discussion of it would suggest, but his thesis is intriguing nonetheless. Ancient medicine, he suggests, may have succeeded largely because of the placebo effect. In the face of scientific ignorance and medical uncertainty, it was the compassionate authority of doctors, as much as any potion, that cured and comforted the ailing. The neediness and helplessness of patients only served to reinforce the power and confidence of the physician, and both justified and necessitated keeping patients in the dark. Paternalism, and the confidence it fostered, was, in times of limited medical knowledge, the best medicine. If physicians demand today that patients surrender autonomy and independence, they are merely acting on an outdated but thoroughly inculcated and self-flattering belief system that justifies paternalism on the grounds that it is in the best interests of patients who need to have confidence in the authority of doctors. But patients, Katz notes, are not as helpless and ignorant as doctors would like to believe, and so, what once fostered trust in physicians now engenders mistrust and resentment. Katz's emphasis on the psychological roots of the communication gap and patient-physician mistrust is well-considered, thoroughly and eloquently argued, and unique. It also provides a ready remedy, even if one rejects the notion that the sources of the mistrust are largely unconscious factors. Doctors, Katz argues, have engendered patient mistrust, and they can foster trust as well, simply by listening to patients and respecting their decisions. Conversation, Katz writes, "will protect the integrity of the physician-patient relationship only if doctors are willing to confront and change their views of themselves as sole authority and of their patients as incompetent participants in decision making. Otherwise, manipulation and coercion will continue to rule their interactions."

A shortcoming of the new edition of The Silent World of Doctor and Patient is that Katz misses an opportunity to address some recent developments that have complicated patient-physician relations. As Alexander Morgan Capron notes in his forward to the new paperback edition, the rise of managed care organizations -- reviled by patients and physicians alike as interfering third parties -- has added considerations of cost-cutting and profits to the doctor-patient relationship, placing further constraints on patient choice. If doctors previously limited patient access to information about the full range of therapeutic options available for reasons of authority and personal preference, the rationing of health care dollars under managed care plans has given them financial incentives -- or, more likely, disincentives -- to providing full disclosure of options. Furthermore, if doctors are driven by reduced payments to spend less time with patients, Katz's remedy for the loss of patient autonomy and the lack of informed consent  -- more conversation -- seems less likely to be adopted by physicians. Katz briefly addresses the problem, suggesting that conversation might actually result in controlling medical costs, chiefly by eliminating many procedures and treatments which are either unnecessary or provide, at best, only limited benefit. Talk, his proposal suggests, is quite literally cheap. "The time costs of conversation may turn out to be much less than the costs of intervention. Of all proposals to contain the explosion in medical costs one has not received the attention it deserves: having patients play a more vital role in deciding whether to undergo tests and treatments that need not necessarily be performed. 'Second medical opinions' may be one answer, but 'first patient opinions' may be a better answer." Katz has touched on an intriguing possibility, and one that warrants empirical study.

A further development that affects the patient-physician relationship is the explosion in medical information accessible to the general public. Some of that information is provided by parties with financial motives, such as pharmaceutical companies, now promoting their wares directly to consumers rather than intermediary doctors. The development is not necessarily a favorable one for the quality of patient care, or for informed consent. The most significant increase in access to information has been facilitated by the Internet, however, and the proliferation of websites offering both good and bad medical advice and information. To some extent, this has shifted the balance of power between physicians, formerly the gatekeepers of medical knowledge, and patients, who are no longer blinkered by the withholding of information. Katz, it seems, should welcome such a development because, by empowering patients with knowledge, it could have the effect of forcing doctors to be more open and forthcoming, even while there are other pressures on them to withhold information. At the same time, it makes trust between doctors and patients even more vital, for, confronted with a bewildering array of medical information, some of it quite questionable, patients need trusted practitioners to help them make truly informed decisions. Access to information is a precondition for informed consent, but it is only one of several preconditions.

In general Katz pays scant attention to these and other practical considerations that bear on the implementation of his conversation prescription, but in identifying the root causes of the alienation between doctors and patients, Katz instead endeavors to establish the preconditions for informed consent and mutual trust, and examine the ill consequences of neglecting them. It would be too easy to dismiss Katz's plan as impractical, for, while his solution appears deceptively simple, his aims are lofty -- he seeks nothing less than a new way of doing medicine, one that could enhance not just doctor-patient relations, but many other aspects of human existence. "Living the life of medicine in such new and unaccustomed ways could extend the dominion of reason and thus make doctors true healers to mankind," he writes. Katz acknowledges that the new relationship he imagines will not be easy to implement, and his neglect of some of the practical impediments and aids to trust and communication leaves much room for a discussion of how and why his plan can or cannot work. His prescription for some of the principal ills of modern medicine is simply more sunshine. It is left to doctors to figure out how to open the windows.

© 2004 L. Syd M Johnson

L. Syd M Johnson, M.A., is a bioethicist and Ph.D. candidate at SUNY Albany, currently working on a dissertation exploring the implications for reproductive choices of the Non-Identity Problem and new genetic technologies.