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Comment & Response
June 2016

Against “Healthy Paternalism” at the End of Life—Reply

Author Affiliations
  • 1Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts
  • 2Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
  • 3Department of Public Health and Community Medicine, Tufts University, Medford, Massachusetts
JAMA Oncol. 2016;2(6):833. doi:10.1001/jamaoncol.2016.1490

In Reply We described healthy paternalism as a model of guided decision making in which information and counsel is provided to patients and families in a truthful and compassionate framework by a medical team with the requisite expertise and insight. This model seeks to remedy the deliberate withholding of prognostic information and recommendations by physicians when discussing cardiopulmonary resuscitation in advanced refractory cancer at the end of life, in deference to a surprisingly common and flawed notion of patient autonomy,1 the adverse consequences of which are yet to be fully understood. The seeds of this phenomenon in US medicine emerged from a necessary backlash against a form of paternalism that subjugated the patient’s voice, values, and preferences to those of the physician. Now, in response to a swing too far toward a flawed notion of autonomy, we proposed this model in which the voice of the clinical expert is not subjugated, but is rather fully required—without constraint on the patient’s voice, values, and preferences among the legitimate choices. We specifically endorse the SPIKES model2 as a compassionate and practical strategy toward exploring patients’ understanding of their illness and discerning goals, values, and preferences while offering empathy, information, and necessary guidance toward end-of-life decision making.

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