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Time demands and medical ethics in women's health care a
Candace C. Gauthier PhD & Eleanor Krassen‐Maxwell PhD a
b
Department of Philosophy , Religion University of North Carolina , Wilmington
b
Department of Sociology and Anthropology , University of North Carolina , Wilmington Published online: 14 Aug 2009.
To cite this article: Candace C. Gauthier PhD & Eleanor Krassen‐Maxwell PhD (1991) Time demands and medical ethics in women's health care, Health Care for Women International, 12:2, 153-165, DOI: 10.1080/07399339109515937 To link to this article: http://dx.doi.org/10.1080/07399339109515937
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TIME DEMANDS AND MEDICAL ETHICS IN WOMEN'S HEALTH CARE Candace C. Gauthier, PhD Department of Philosophy and Religion University of North Carolina at Wilmington
Eleanor Krassen-Maxwell, PhD
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Department of Sociology and Anthropology University of North Carolina at Wilmington
The perspectives of sociology and medical ethics are combined in this study of how the demands of women's social roles affect their efforts to obtain health care. The principles of justice, beneficence, and respect for autonomy are applied to die delivery of health care. A conflict between beneficence and respect for autonomy often leads to medical paternalism. Health care is not distributed justly in the United States, and three models of patient-practitioner interaction exist as a result of financial and time constraints on women. The first model is truly paternalistic. The second appears to be paternalistic. However, medical practitioners in this model are actually given a decision-making role by their female patients for specific issues for limited time periods. A third model exemplifies cooperation between medical professionals and patients, but this model is elusive to most women because of time constraints.
This article, written by a sociologist and an ethicist, is based on an analysis of clinical experience with health-care professionals in their milieu and naturalistic observations of both practitioners and patients. We discuss the ways women's time-consuming roles and ethical principles converge with regard to women's health care. Sociological theory and. empirical research pioneered by the work of Hollingshead and Redlich (1953) indicate that variations in medical diagnoses and access to treatment are in part a function of social class. In the work of Ruzek (1979), Danziger (1978), and McCrea (1983), we find the idea that disparities in social class and gender determine not only one's diagnosis and access to treatment, but also the quality of patient-practitioner interHealth Care for Women International, 12:153-165, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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action within the medical care system. An entire issue of the journal Women and Health (Perales & Young, 1987) was devoted to the special health problems of women who live in poverty. Our own research suggests that women in all social classes face competing demands on their time that interfere with the just delivery of health care. Traditionally, sociologists have measured class in terms of income, occupation, and education, although women had been assigned the social economic status of the significant men in their lives. When measurements of social class are made for women alone, they tend to be relatively low, especially for those whose labor is unpaid (Maxwell, 1988). In general, the time schedules of those with lower status tend to be controlled by those of higher status. We suggest that social class and gender are also related to time available to make decisions about health care. Physicians, most of whom are men, as a group enjoy the privileges of upper-middle-class society, including wealth, power, and prestige; professional autonomy; and the ability to influence how others spend their time. We describe these relationships in this three-part article. First, we discuss time demands and women's roles; second, we describe the ethical principles related to women's health care; and third, we present three models of patient-practitioner interaction that we suggest occur as a consequence of the way demands on women's time and ethical principles fit together. The models of patient-practitioner interaction emerged from a grounded theoretical analysis of our clinical and field experience. WOMEN'S ROLES AND TIME COMMITMENTS The categories of roles for women described herein are not mutually exclusive or collectively exhaustive of roles women play in society. Instead, they have been chosen as ideal types that characterize women as they encounter the medical establishment. The mythical homemaker is described as a middle-class woman in a home with modern conveniences whose responsibilities are few and easy to accomplish. Although she is expected to perform domestic chores, she is also assumed to have more time than anyone else in the family to care for the £ick, to pursue advice from physicians, and to consult with other homemakers about the latest health-care trends. In today's fastpaced Western culture, many people make demands on these women that are time-consuming. The time of women who spend their lives serving others in unpaid, low-status routines is considered less valuable and more flexible than the time of professionals. Rarely does a person of higher status consider that
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making demands on another's time may be unjust. Because the status of physicians is quite high, many believe that physicians should not have to wait for their patients. To avoid this situation, appointments may be scheduled in such a manner that patients are in the waiting room before the physician is expected on the premises and often must wait beyond their scheduled appointment times. In addition, physicians often require patients to pay for appointments as scheduled regardless of the circumstances leading to patient absence or lateness. Patients generally are not paid for their time in the- waiting room. In fact, apologies are occasionally offered by staff, but of course, if those managing medical services were actually sorry, changing the appointment system would be a more appropriate solution to the waiting problem than offering repeated apologies. The negative attitude of medical professionals toward women is exacerbated in instances in which health care is free or subsidized through programs like Woman, Infants, and Children (WIC), Medicaid, and Medicare. Attitudes toward the noninsured working poor may also be negative because these are the patients from whom practitioners are least likely to receive payment. One way in which medical practitioners may display lack of respect for these women is by making them wait for services. We wonder if practitioners realize that this lack of consideration for the patients' burdens may discourage poor and elderly patients from seeking care in the future. In field work on an Indian Reservation, one of us observed that women of this class often waited for hours in a clinic only to be told that they would have to return the next day because the clinic was closing (Maxwell & Maxwell, 1988). Because the work of low-income women is considered to be socially unimportant by those with higher prestige ratings, the poor wait in clinics for medical examinations, they wait in lines for Medicaid stickers and for transportation to medical facilities, and they may be shuffled around by the medical bureaucracy. Patients of higher status are considered to be busier and more deserving of quick attention from medical practitioners so that they can resume their important schedules. Perhaps a small proportion of poor women may have more time than those of higher status and can "afford" to wait. But there is a paradox concerning available time when it comes to making medical decisions. Low-status women tend to be less knowledgeable and sophisticated about health-care options because education is a dimension of social class, and thus they may not be able to use the time profitably. Medical practitioners may assume that it is too costly in terms of their own time to provide these women with the information needed to make decisions about health care. Low-status women may face practitioners who volunteer little medical information, make them wait for service, rush them
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through examinations, and discourage questions about treatment options. Lenore Weitzman (1985) reported that the social class of divorced, middle-aged women, who may have limited education and work experience and who have child custody and home mortgage responsibilities, often drops dramatically after marital separation. Often among those things that women lose upon divorce are medical insurance benefits previously provided by the husband's employer. Many work in parttime, low-paying positions not qualifying for employer-assisted medical benefits; The women must handle domestic responsibilities alone. For such women, the general standard of living and the time available to accomplish one's role expectations are reduced after divorce. Although these women are expected to keep themselves and their children healthy, it is difficult for them to find the time and money to do so. Juggling responsibilities of career, marriage, and motherhood, without readily available day care, professional women are also burdened with time-consuming logistical arrangements (Ross & Mirowsky, 1988). Even in cooperative households where homemaking and child-care responsibilities are shared with men, both spouses have little time to seek medical treatment alternatives. Elaine Brody (1981) has used the expression "women in the middle" to describe another kind of role strain experienced by women in the United States. This concept has two dimensions: (a) Women in the middle are simultaneously caring for dependent children and dependent elderly, and (b) women are caught in the middle juggling the expectations of employers and family members. Caregivers of both children and dependent elderly have traditionally been women. Today, many such caregivers are also employed outside of the home. Caretaker roles may require so much time that one's own health is neglected (Sommers & Shields, 1987). All of the roles just described are distinctly American with regard to the way in which Americans conceptualize time. In contrast to Eastern societies that view time as infinite, Americans see time as limited. In American society, most perceive themselves as having more work to do in a given day than time available to accomplish that work. In any case, most are not thinking about whether the pace in any of these roles should or could be any different. Time is one element of society that Americans tend to respond to rather than one they attempt to manipulate, yet it seems as if it is one that can contribute negatively to the state of their health. Research in medical sociology indicates that physicians control how time is spent with regard to health care, although patients attempt to negotiate treatment timetables that are less time-consuming than those
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dictated by physicians (Davis, 1963; Roth, 1963). A crisis is said to occur when people believe a problem exists that requires immediate action. Women often believe they are in crisis due to role strain and role overload. With regard to health care, crises occur when situations are defined as medical emergencies. The declaration of an emergency occurs in two conditions. First, there are real emergencies, requiring the intervention of medical practitioners in order to save a life. Second, there are those situations that are presented to women as emergencies to encourage deference to the physician's view of necessary treatment. In each instance, decisions are difficult to make because there is insufficient time to investigate one's options. ETHICAL PRINCIPLES An ethical principle is a general moral standard that can be used in determining what is morally right and wrong regarding human behavior. The three ethical principles that are most applicable to the provision of medical care are the principle of justice, the principle of respect for autonomy, and the principle of beneficence. The principle of justice states that both the benefits and burdens of society must be distributed in a just, fair, or equitable manner. Social benefits may be distributed in many ways—according to need, merit, contribution to society, or ability to pay, for example. They may also be distributed equally among members of society. Distribution of health care on the basis of medical need is an ideal norm, in that it is professed by many Americans but it may not be followed in practice. In fact, health care in the United States is actually distributed more often on the basis of ability to pay. Individuals who can pay more receive the best medical treatment, and many of those who cannot pay do not receive any appropriate medical care. At the community level, residents in cities tend to have greater access to a large arena of medical services than do those in rural areas, where residents are disproportionately poor, lack transportation, and have few local services (Richardson, 1987). Distribution of medical services on the basis of ability to pay is a real norm to which members of the society do not admit but which is actually followed. Reporting on access to medical care in the United States, McBarnette (1987) revealed that as of 1980, "Medicaid covered only 39.1 percent of the population below the poverty level" and "in 1982, 42 percent of all live births involved women ages 18-24, but more than one in four of those women had neither public nor private health insurance" (p. 57). Policymakers and medical practitioners do not admit to another real norm regarding the distribution of health care that results in the alloca-
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tion of treatment on the basis of assumed social value. In a study of medical care given to dying patients, Glaser and Strauss (1965) found that the quality of patient-practitioner interaction was in part a function of practitioners' perceptions of the "social worth" of dying patients. Because the social worth of a patient is also correlated with that patient's ability to pay, those in the lowest class may receive poor medical care. We claim that neither ability to pay nor social worth, indicated by education and social class, are methods of distributing health care that satisfy the principle of justice. The distribution of health care that results is unfair and inequitable. This is particularly disturbing because as long as society maintains the ideal norm of distribution on the basis of medical need, this inequity goes unrecognized. Taking a different perspective on the justice of health-care delivery, we note, as well, that the burdens or costs of obtaining medical care are also not distributed equitably in the United States. Medical care is obtained at a cost in time and effort as well as at a financial cost. Our ideal norm characterizes these costs as being distributed equitably in society. The real norm is such that it costs some people more, in terms of time and effort, to obtain medical services. In particular, it is those with less education and those in lower social classes who must invest more time and more effort in obtaining the medical care they need. In the United States, the medical establishment professes to meet the requirements of the principle of justice by distributing health services on the basis of medical need. It professes to compensate for inability to pay for these services by providing free or low-cost medical care through clinics, Medicaid and Medicare, and public health departments. Yet, in practice, society exacts a greater burden in time and effort from those who cannot afford to pay for health services themselves, and many go untreated. The principle of beneficence states that the medical practitioner must do no harm and promote good, specifically by providing the best medical care possible, thereby healing, curing, and saving lives. Medical professionals act on this principle when they provide quality health care efficiently. One important dimension of efficiency is time economy. Although patients demand and expect optimum medical care, most do not want and cannot afford to invest large amounts of time in obtaining that care. This is particularly true of women in modern society whose various role demands limit the amount of time they can spend on health care. One of the specific ways in which health-care providers may act on the principle of beneficence and thus provide quality medical care efficiently is by taking the more active role in making health-care decisions for their patients. In this way, physicians save patients' time, which then can be used in meeting the demands of their social roles.
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Medical practitioners are the experts on health care. This is why people consult them concerning health needs and also why they have a special obligation to act according to the principle of beneficence. Decisions about medical diagnosis, prognosis, and treatment are routine for physicians. For patients, however, these decisions are difficult and not at all routine. Although most patients have the ability to understand their condition once it has been explained to them, most cannot spend the time required to investigate alternative diagnoses, prognoses, or treatments. They are thus forced to ask health-care providers to make medical decisions for them. The principle of respect for autonomy has traditionally been understood as requiring respect for others' self-determination. One would adhere to this principle by allowing fully competent adults to make and act on their own decisions. As applied to the provision of medical care, the principle of respect for autonomy would require medical practitioners to respect their patients' self-determination, allowing the patients to make their own health-care decisions. Those decisions would be based, at least, on information provided by the provider and his or her recommendations regarding treatment but may also be based on information the patients obtain on their own. Some health-care professionals are willing to provide complete information regarding diagnosis and prognosis. They want to suggest treatment options, recommending the one they judge to be the most effective, while encouraging the patient to accept or refuse the preferred treatment and to choose among the suggested treatment options. In these cases, the patient's self-determination is being respected. However, many medical practitioners take the dominant role in health-care decision making, virtually denying the patient's selfdetermination. This is medical paternalism. For example, the provider may give only partial information or present the information in such a way that the favored treatment is represented as the only option, when in fact there are alternatives. Medical paternalism has been defended traditionally in the following way. Patients are unable to make health-care decisions for themselves because they lack the knowledge, experience, and skill of the trained professional. Moreover, patients would not understand the information necessary to make self-determined choices, even if such information were offered. Finally, patients seek medical care when they are ill, and the physical and emotional effects of illness diminish their capacity to make decisions about the treatment of that illness. Thus, health-care providers are obligated, because of their greater knowledge, experience, and skill, to make these decisions for their patients. Medical paternalism is represented, then, as an expression of the principle of beneficence.
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The definitive court ruling on the physician's responsibility to disclose information to a patient regarding medical treatment is found in the case of Canterbury v. Spence, decided by the U.S. Court of Appeals in 1972. According to the ruling, the two exceptions to the rule of disclosure recognized by the courts are (a) when the patient is unconscious and emergency treatment is necessary and (b) when disclosure poses a threat of harm to the patient. The ruling states that the physician's privilege not to disclose information "does not accept the paternalistic notion that the physician may remain silent simply because divulgence might prompt the patient to forgo therapy the physician feels the patient really needs." Unfortunately, members of the medical profession have often generalized from conditions that may warrant paternalistic treatment to all of health care. Consequently, many women have had the experience of being treated paternalistically by physicians throughout their lives, most often in situations in which this attitude was not warranted. For example, pregnancy can hardly be said to diminish decision-making capacity, and yet paternalism is often present in obstetric care. When this happens repeatedly and the attempt to make decisions regarding one's health care is blocked continually, some women begin to confuse the goal of selfdetermination in medical decision making with total independence from the health-care establishment. Some of the "women's consciousness raising" writings encouraged women to be responsible for their own health care, including performing their own gynecological examinations (Boston Women's Health Collective, 1971). The obvious problem with this goal is that, while realizable, it may have dangerous consequences. Also, it would require obtaining all of the knowledge, skill, and experience of the health-care provider. Furthermore, it would mean practicing medicine on oneself, and this is something that even medical professionals can rarely do. Most individuals do not want or expect to be independent with regard to health care. Support by others and the division of labor to save time and maximize efficiency are part of people's expectations for a stable society (Mill, 1899; Smith, 1910). On the other hand, self-determination in seeking and accepting medical care is certainly a realistic goal and one that can be and is realized in the relationship between some physicians and their female patients. However, even if the medical professional is willing to respect the autonomy of the female patient, it will be costly for her to fully exercise medical self-determination. She must invest time and effort as well as money to learn about her condition and possible treatment options and to explore alternatives regarding providers and hospitals. It might be helpful to view this situation in terms of two levels of self-
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determination. The first level, deliberative self-determination, involves making specific health-care decisions for oneself, after considering one's options on the basis of the information provided by a health-care provider and perhaps supplemental information obtained elsewhere. The second level, deferred-judgment self-determination, involves choosing not to make health-care decisions for oneself, choosing instead to accept the recommendation of the medical practitioner without question or further investigation. Thus, a patient may choose not to deliberate about health-care options and thus relinquish his or her self-determination at the first level to save time and still retain it on the second level. The patient exercises deferred-judgment self-determination both in the choice of a health-care provider and in the choice to rely on that provider's best judgment in regard to specific medical decisions. Some women are forced to relinquish deliberative self-determination in their medical care because they truly cannot afford to exercise it. Because of other demands on their time, energy, and financial resources, women cannot invest the time, effort, and money required to obtain the information needed to be fully self-determining when a medical decision is necessary. Although this group of women may want to be selfdetermining in terms of specific medical decisions, this is impossible because of the excessive demands made on them by their various social roles. MODELS OF PATIENT-PRACTITIONER INTERACTION We have identified three models of patient-practitioner interaction that illustrate the ways in which medical decisions can be made. The first and most familiar model is characterized by real paternalism. Real paternalism occurs when medical practitioners take the decision-making role away from patients who want to make their own decisions and deny patients' self-determination with regard to treatment and the use of time. Health-care professionals who interact with their patients in this way believe they are acting with beneficence, but they are clearly not acting according to the principle of respect for autonomy. The assumed prevalence of this model is very high. For example, Scully (1987) reported that surgieal residents often persuade women to have hysterectomies that are unnecessary in order to gain surgical experience and the approval of their superiors. The prevalence of this model is probably highest for practitioners whose patients are women in the lowest social class and less than what is assumed for physicians whose patients are women in the middle and upper classes. This would be
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consistent with the literature indicating that medical diagnosis and treatment are a function of social class and gender. When medical practitioners establish relationships of real paternalism with patients, we observed two outcomes. Patients may find another physician who is willing to respect their autonomy to the extent they desire. This outcome is not always possible. The alternative is to remain under the paternalistic provider's care and yet be dissatisfied with the relationship. Patients may be resentful of the denial of their selfdetermination but be forced to accept it because they lack the time, opportunity, or resources to seek alternative medical care. This will often be true for poor women and the elderly, women in rural communities, those on Medicaid and Medicare, and those who must obtain medical care in clinics and public health departments. These women recognize that they will not receive medical care unless they accept this type of interaction. In terms of time expenditure, this model is the most economical for physicians. The second model is referred to as apparent paternalism because it is so often mistaken for real paternalism. Apparent paternalism occurs when health-care providers are given the decision-making role by their patients for a specific issue for a limited period of time. These practitioners are acting on the principle of beneficence while also respecting the patient's autonomy with regard to medical decisions. This model characterizes the relationship between women and medical professionals who feel socially pressed for time. Health-care providers are almost always in this position, with more patients needing attention than the provider's time allows. Women may defer to professional expertise in medical decision making in order to use their own time efficiently. These women relinquish, for specific issues, for the specific time periods, deliberative self-determination in their medical care, judging deliberation to be too costly in terms of their available time. In this case, health-care providers are perceived as beneficent agents in a burdensome social system, the demands of which exceed a woman's available resources. Of course, it is more efficient in terms of time for the providers as well, if patients defer to their best medical judgment. It is important to recognize that it is not the individual medical professional's fault if women feel forced to give up deliberative selfdetermination. Rather, it is a product of the financial and time pressures on women in U.S. society. Given role expectations for women, this model is perhaps the most prevalent. This model of patient-practitioner interaction does not always go smoothly. As women defer to their practitioners in specific situations for limited time periods, it is likely that both practitioner and patient will be
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uncertain as to the extent of these deferred judgments. A woman may wish to be more deliberative when her schedule permits her to do so and more deferential when time is unavailable for deliberation. If this model is to be maintained, and the provider is to continue to respect the autonomy of the patient, there needs to be a great deal of communication and flexibility on the part of both the provider and the patient. If the medical professional is not flexible enough, the relationship may become one of real paternalism. With sufficient communication, the relationship may become a cooperative one. In the cooperative model of patient-practitioner interaction, the practitioner provides information on patient diagnosis, prognosis, and treatment possibilities. Patients add what they may know about medicine and their personal situations and together the patient and practitioner discuss options for health-care regimens. However, the patient makes the final decision regarding possible treatment plans. Medical professionals operating within the cooperative model act on both the principle of beneficence and the principle of respect for autonomy by encouraging women to exercise deliberative self-determination with regard to medical decisions. Feminists advocate cooperation because it allows self-determination for women and control of their own bodies (which are obviously the minimal demands of autonomous existence). Even though many desire a patient-practitioner relationship they can view as a cooperative partnership, such a relationship is available to few. It is time-consuming for both practitioners and patients. For practitioners, cooperation may mean that fewer patients can be served in the time available. For patients, this model may require that demands of family and career go unanswered as medical needs are met. In addition, a cooperative relationship requires more in terms of financial resources and education on the part of the patient than either of the other types of patient-practitioner relationship. There is one other possible problem with this model. Rarely a physician may desire a cooperative relationship with a patient who cannot handle such a situation. This may be because the patient is not accustomed to this attitude because of past experience with real paternalism and does not expect a cooperative relationship with the physician. The patient may be distrustful of the provider and may not realize that some medical professionals actually do want to have a fully cooperative relationship with their patients. Szasz and Hollender (1956) presented a similar three-model analysis of patient-practitioner interaction from the perspective of the practitioner. They claimed that most physicians feel more comfortable operating in one model and that they are not as adaptable as their patients.
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CONCLUSION In this article we have pointed out the constraints placed on women in modern U.S. society in their efforts to obtain adequate health care. In particular, we have emphasized the constraints posed by the lack of time to satisfy social role expectations and to meet health-care needs. Three principles of medical ethics were also examined, specifically as they apply to the provision of health services to women in U.S. society. The principle of justice in the distribution of medical care is not presently being satisfied in the United States. Also, the conflict that can arise between the principle of beneficence and the principle of respect for autonomy often results in medical paternalism. Finally, we have suggested three models of patient-practitioner interaction that we believe operate within the framework of expectations for women in U.S. society. The first is truly paternalistic. The second, although appearing to be paternalistic, actually allows women to exercise deferred-judgment self-determination. A third model of patientpractitioner interaction requires cooperation between patients and those who serve them. The cooperative model offers women medical advantages but is elusive to all but a few in this society. Until a restructuring of role expectations occurs in society as a whole, this model will remain out of reach to most people. REFERENCES Boston Women's Health Collective. (1971). Our bodies, ourselves. New York: Simon & Schuster. Brody, E. M. (1981). Women in the middle and family help to older people. The Gerontologist, 21(15), 471-480. Canterbury v. Spence, 464 F. 2d 772 (D.C. Cir. 1972). Danziger, S. K. (1978). The uses of expertise in doctor-patient encounters during pregnancy. Social Science and Medicine, 12, 310-321. Davis, F. (1963). Passage through crisis: Polio victims and their families. Indianapolis, IN: Bobbs-Merrill. Glaser, B., & Strauss, A. (1965). Awareness of dying. Chicago: Aldine. Hollingshead, A. B., & Redlich, F. C. (1953). Social stratification and psychiatric disorders. American Sociological Review, 18, 163-170. Maxwell, E. K. (1988). Status differences in cohorts of aging women. Health Care for Women International, 9, 83-91. Maxwell, E. K., & Maxwell, R. J. (1988). Perceived health care needs of elderly Northern Cheyenne and Blackfeet (Final report, postdoctoral fellowship program in applied gerontology). Washington, DC: Gerontological Society of America. McBamette, L. (1987). Women and poverty: The effects on reproductive status. Women and Health, 12, 55-81.
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McCrea, F. B. (1983). The politics of menopause: The discovery of a deficiency disease. Social Problems, 31(1), 111-118. Mill, J. S. (1899). Principles of political economy (Vol. 1). New York: Colonial Press. Perales, C. A., & Young. L. S. (Eds.). (1987). Women and Health, 12, Special Issue on Women, Health and Poverty. Richardson, H. (1987). The health plight of rural women. Women and Health, 12, 41-54. Ross, C. E., & Mirowsky, J. (1988). Child-care and emotional adjustment to wives' employment. Journal of Health and Social Behavior, 29, 127-138. Roth, J. R. (1963). Timetables; Structuring the passage of time in hospital treatment and other careers. Indianapolis, IN: Bobbs-Merrill. Ruzek, S. B. (1979). The women's health movement. New York: Praeger. Scully, D. (1987). Negotiating to do surgery. In H. Swartz (Ed.), Dominant issues in medical sociology (2nd ed., pp. 252-258). New York: Random House. Smith, A. (1910). The wealth of nations. New York: Dent. Sommers, T., & Shields, L. (1987). Women take care: The consequences of caregiving in today's society. Gainesville, FL: Triad. Szasz, T. S., & Hollender, M. H. (1956). The basic models of doctor-patient relationships. Archives of Internal Medicine, 97, 585-592. Weitzman, L. J. (1985). The divorce revolution. New York: Free Press.
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Time demands and medical ethics in women's health care a
Candace C. Gauthier PhD & Eleanor Krassen‐Maxwell PhD a
b
Department of Philosophy , Religion University of North Carolina , Wilmington
b
Department of Sociology and Anthropology , University of North Carolina , Wilmington Published online: 14 Aug 2009.
To cite this article: Candace C. Gauthier PhD & Eleanor Krassen‐Maxwell PhD (1991) Time demands and medical ethics in women's health care, Health Care for Women International, 12:2, 153-165, DOI: 10.1080/07399339109515937 To link to this article: http://dx.doi.org/10.1080/07399339109515937
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TIME DEMANDS AND MEDICAL ETHICS IN WOMEN'S HEALTH CARE Candace C. Gauthier, PhD Department of Philosophy and Religion University of North Carolina at Wilmington
Eleanor Krassen-Maxwell, PhD
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Department of Sociology and Anthropology University of North Carolina at Wilmington
The perspectives of sociology and medical ethics are combined in this study of how the demands of women's social roles affect their efforts to obtain health care. The principles of justice, beneficence, and respect for autonomy are applied to die delivery of health care. A conflict between beneficence and respect for autonomy often leads to medical paternalism. Health care is not distributed justly in the United States, and three models of patient-practitioner interaction exist as a result of financial and time constraints on women. The first model is truly paternalistic. The second appears to be paternalistic. However, medical practitioners in this model are actually given a decision-making role by their female patients for specific issues for limited time periods. A third model exemplifies cooperation between medical professionals and patients, but this model is elusive to most women because of time constraints.
This article, written by a sociologist and an ethicist, is based on an analysis of clinical experience with health-care professionals in their milieu and naturalistic observations of both practitioners and patients. We discuss the ways women's time-consuming roles and ethical principles converge with regard to women's health care. Sociological theory and. empirical research pioneered by the work of Hollingshead and Redlich (1953) indicate that variations in medical diagnoses and access to treatment are in part a function of social class. In the work of Ruzek (1979), Danziger (1978), and McCrea (1983), we find the idea that disparities in social class and gender determine not only one's diagnosis and access to treatment, but also the quality of patient-practitioner interHealth Care for Women International, 12:153-165, 1991 Copyright © 1991 by Hemisphere Publishing Corporation
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action within the medical care system. An entire issue of the journal Women and Health (Perales & Young, 1987) was devoted to the special health problems of women who live in poverty. Our own research suggests that women in all social classes face competing demands on their time that interfere with the just delivery of health care. Traditionally, sociologists have measured class in terms of income, occupation, and education, although women had been assigned the social economic status of the significant men in their lives. When measurements of social class are made for women alone, they tend to be relatively low, especially for those whose labor is unpaid (Maxwell, 1988). In general, the time schedules of those with lower status tend to be controlled by those of higher status. We suggest that social class and gender are also related to time available to make decisions about health care. Physicians, most of whom are men, as a group enjoy the privileges of upper-middle-class society, including wealth, power, and prestige; professional autonomy; and the ability to influence how others spend their time. We describe these relationships in this three-part article. First, we discuss time demands and women's roles; second, we describe the ethical principles related to women's health care; and third, we present three models of patient-practitioner interaction that we suggest occur as a consequence of the way demands on women's time and ethical principles fit together. The models of patient-practitioner interaction emerged from a grounded theoretical analysis of our clinical and field experience. WOMEN'S ROLES AND TIME COMMITMENTS The categories of roles for women described herein are not mutually exclusive or collectively exhaustive of roles women play in society. Instead, they have been chosen as ideal types that characterize women as they encounter the medical establishment. The mythical homemaker is described as a middle-class woman in a home with modern conveniences whose responsibilities are few and easy to accomplish. Although she is expected to perform domestic chores, she is also assumed to have more time than anyone else in the family to care for the £ick, to pursue advice from physicians, and to consult with other homemakers about the latest health-care trends. In today's fastpaced Western culture, many people make demands on these women that are time-consuming. The time of women who spend their lives serving others in unpaid, low-status routines is considered less valuable and more flexible than the time of professionals. Rarely does a person of higher status consider that
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making demands on another's time may be unjust. Because the status of physicians is quite high, many believe that physicians should not have to wait for their patients. To avoid this situation, appointments may be scheduled in such a manner that patients are in the waiting room before the physician is expected on the premises and often must wait beyond their scheduled appointment times. In addition, physicians often require patients to pay for appointments as scheduled regardless of the circumstances leading to patient absence or lateness. Patients generally are not paid for their time in the- waiting room. In fact, apologies are occasionally offered by staff, but of course, if those managing medical services were actually sorry, changing the appointment system would be a more appropriate solution to the waiting problem than offering repeated apologies. The negative attitude of medical professionals toward women is exacerbated in instances in which health care is free or subsidized through programs like Woman, Infants, and Children (WIC), Medicaid, and Medicare. Attitudes toward the noninsured working poor may also be negative because these are the patients from whom practitioners are least likely to receive payment. One way in which medical practitioners may display lack of respect for these women is by making them wait for services. We wonder if practitioners realize that this lack of consideration for the patients' burdens may discourage poor and elderly patients from seeking care in the future. In field work on an Indian Reservation, one of us observed that women of this class often waited for hours in a clinic only to be told that they would have to return the next day because the clinic was closing (Maxwell & Maxwell, 1988). Because the work of low-income women is considered to be socially unimportant by those with higher prestige ratings, the poor wait in clinics for medical examinations, they wait in lines for Medicaid stickers and for transportation to medical facilities, and they may be shuffled around by the medical bureaucracy. Patients of higher status are considered to be busier and more deserving of quick attention from medical practitioners so that they can resume their important schedules. Perhaps a small proportion of poor women may have more time than those of higher status and can "afford" to wait. But there is a paradox concerning available time when it comes to making medical decisions. Low-status women tend to be less knowledgeable and sophisticated about health-care options because education is a dimension of social class, and thus they may not be able to use the time profitably. Medical practitioners may assume that it is too costly in terms of their own time to provide these women with the information needed to make decisions about health care. Low-status women may face practitioners who volunteer little medical information, make them wait for service, rush them
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through examinations, and discourage questions about treatment options. Lenore Weitzman (1985) reported that the social class of divorced, middle-aged women, who may have limited education and work experience and who have child custody and home mortgage responsibilities, often drops dramatically after marital separation. Often among those things that women lose upon divorce are medical insurance benefits previously provided by the husband's employer. Many work in parttime, low-paying positions not qualifying for employer-assisted medical benefits; The women must handle domestic responsibilities alone. For such women, the general standard of living and the time available to accomplish one's role expectations are reduced after divorce. Although these women are expected to keep themselves and their children healthy, it is difficult for them to find the time and money to do so. Juggling responsibilities of career, marriage, and motherhood, without readily available day care, professional women are also burdened with time-consuming logistical arrangements (Ross & Mirowsky, 1988). Even in cooperative households where homemaking and child-care responsibilities are shared with men, both spouses have little time to seek medical treatment alternatives. Elaine Brody (1981) has used the expression "women in the middle" to describe another kind of role strain experienced by women in the United States. This concept has two dimensions: (a) Women in the middle are simultaneously caring for dependent children and dependent elderly, and (b) women are caught in the middle juggling the expectations of employers and family members. Caregivers of both children and dependent elderly have traditionally been women. Today, many such caregivers are also employed outside of the home. Caretaker roles may require so much time that one's own health is neglected (Sommers & Shields, 1987). All of the roles just described are distinctly American with regard to the way in which Americans conceptualize time. In contrast to Eastern societies that view time as infinite, Americans see time as limited. In American society, most perceive themselves as having more work to do in a given day than time available to accomplish that work. In any case, most are not thinking about whether the pace in any of these roles should or could be any different. Time is one element of society that Americans tend to respond to rather than one they attempt to manipulate, yet it seems as if it is one that can contribute negatively to the state of their health. Research in medical sociology indicates that physicians control how time is spent with regard to health care, although patients attempt to negotiate treatment timetables that are less time-consuming than those
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dictated by physicians (Davis, 1963; Roth, 1963). A crisis is said to occur when people believe a problem exists that requires immediate action. Women often believe they are in crisis due to role strain and role overload. With regard to health care, crises occur when situations are defined as medical emergencies. The declaration of an emergency occurs in two conditions. First, there are real emergencies, requiring the intervention of medical practitioners in order to save a life. Second, there are those situations that are presented to women as emergencies to encourage deference to the physician's view of necessary treatment. In each instance, decisions are difficult to make because there is insufficient time to investigate one's options. ETHICAL PRINCIPLES An ethical principle is a general moral standard that can be used in determining what is morally right and wrong regarding human behavior. The three ethical principles that are most applicable to the provision of medical care are the principle of justice, the principle of respect for autonomy, and the principle of beneficence. The principle of justice states that both the benefits and burdens of society must be distributed in a just, fair, or equitable manner. Social benefits may be distributed in many ways—according to need, merit, contribution to society, or ability to pay, for example. They may also be distributed equally among members of society. Distribution of health care on the basis of medical need is an ideal norm, in that it is professed by many Americans but it may not be followed in practice. In fact, health care in the United States is actually distributed more often on the basis of ability to pay. Individuals who can pay more receive the best medical treatment, and many of those who cannot pay do not receive any appropriate medical care. At the community level, residents in cities tend to have greater access to a large arena of medical services than do those in rural areas, where residents are disproportionately poor, lack transportation, and have few local services (Richardson, 1987). Distribution of medical services on the basis of ability to pay is a real norm to which members of the society do not admit but which is actually followed. Reporting on access to medical care in the United States, McBarnette (1987) revealed that as of 1980, "Medicaid covered only 39.1 percent of the population below the poverty level" and "in 1982, 42 percent of all live births involved women ages 18-24, but more than one in four of those women had neither public nor private health insurance" (p. 57). Policymakers and medical practitioners do not admit to another real norm regarding the distribution of health care that results in the alloca-
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tion of treatment on the basis of assumed social value. In a study of medical care given to dying patients, Glaser and Strauss (1965) found that the quality of patient-practitioner interaction was in part a function of practitioners' perceptions of the "social worth" of dying patients. Because the social worth of a patient is also correlated with that patient's ability to pay, those in the lowest class may receive poor medical care. We claim that neither ability to pay nor social worth, indicated by education and social class, are methods of distributing health care that satisfy the principle of justice. The distribution of health care that results is unfair and inequitable. This is particularly disturbing because as long as society maintains the ideal norm of distribution on the basis of medical need, this inequity goes unrecognized. Taking a different perspective on the justice of health-care delivery, we note, as well, that the burdens or costs of obtaining medical care are also not distributed equitably in the United States. Medical care is obtained at a cost in time and effort as well as at a financial cost. Our ideal norm characterizes these costs as being distributed equitably in society. The real norm is such that it costs some people more, in terms of time and effort, to obtain medical services. In particular, it is those with less education and those in lower social classes who must invest more time and more effort in obtaining the medical care they need. In the United States, the medical establishment professes to meet the requirements of the principle of justice by distributing health services on the basis of medical need. It professes to compensate for inability to pay for these services by providing free or low-cost medical care through clinics, Medicaid and Medicare, and public health departments. Yet, in practice, society exacts a greater burden in time and effort from those who cannot afford to pay for health services themselves, and many go untreated. The principle of beneficence states that the medical practitioner must do no harm and promote good, specifically by providing the best medical care possible, thereby healing, curing, and saving lives. Medical professionals act on this principle when they provide quality health care efficiently. One important dimension of efficiency is time economy. Although patients demand and expect optimum medical care, most do not want and cannot afford to invest large amounts of time in obtaining that care. This is particularly true of women in modern society whose various role demands limit the amount of time they can spend on health care. One of the specific ways in which health-care providers may act on the principle of beneficence and thus provide quality medical care efficiently is by taking the more active role in making health-care decisions for their patients. In this way, physicians save patients' time, which then can be used in meeting the demands of their social roles.
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Medical practitioners are the experts on health care. This is why people consult them concerning health needs and also why they have a special obligation to act according to the principle of beneficence. Decisions about medical diagnosis, prognosis, and treatment are routine for physicians. For patients, however, these decisions are difficult and not at all routine. Although most patients have the ability to understand their condition once it has been explained to them, most cannot spend the time required to investigate alternative diagnoses, prognoses, or treatments. They are thus forced to ask health-care providers to make medical decisions for them. The principle of respect for autonomy has traditionally been understood as requiring respect for others' self-determination. One would adhere to this principle by allowing fully competent adults to make and act on their own decisions. As applied to the provision of medical care, the principle of respect for autonomy would require medical practitioners to respect their patients' self-determination, allowing the patients to make their own health-care decisions. Those decisions would be based, at least, on information provided by the provider and his or her recommendations regarding treatment but may also be based on information the patients obtain on their own. Some health-care professionals are willing to provide complete information regarding diagnosis and prognosis. They want to suggest treatment options, recommending the one they judge to be the most effective, while encouraging the patient to accept or refuse the preferred treatment and to choose among the suggested treatment options. In these cases, the patient's self-determination is being respected. However, many medical practitioners take the dominant role in health-care decision making, virtually denying the patient's selfdetermination. This is medical paternalism. For example, the provider may give only partial information or present the information in such a way that the favored treatment is represented as the only option, when in fact there are alternatives. Medical paternalism has been defended traditionally in the following way. Patients are unable to make health-care decisions for themselves because they lack the knowledge, experience, and skill of the trained professional. Moreover, patients would not understand the information necessary to make self-determined choices, even if such information were offered. Finally, patients seek medical care when they are ill, and the physical and emotional effects of illness diminish their capacity to make decisions about the treatment of that illness. Thus, health-care providers are obligated, because of their greater knowledge, experience, and skill, to make these decisions for their patients. Medical paternalism is represented, then, as an expression of the principle of beneficence.
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The definitive court ruling on the physician's responsibility to disclose information to a patient regarding medical treatment is found in the case of Canterbury v. Spence, decided by the U.S. Court of Appeals in 1972. According to the ruling, the two exceptions to the rule of disclosure recognized by the courts are (a) when the patient is unconscious and emergency treatment is necessary and (b) when disclosure poses a threat of harm to the patient. The ruling states that the physician's privilege not to disclose information "does not accept the paternalistic notion that the physician may remain silent simply because divulgence might prompt the patient to forgo therapy the physician feels the patient really needs." Unfortunately, members of the medical profession have often generalized from conditions that may warrant paternalistic treatment to all of health care. Consequently, many women have had the experience of being treated paternalistically by physicians throughout their lives, most often in situations in which this attitude was not warranted. For example, pregnancy can hardly be said to diminish decision-making capacity, and yet paternalism is often present in obstetric care. When this happens repeatedly and the attempt to make decisions regarding one's health care is blocked continually, some women begin to confuse the goal of selfdetermination in medical decision making with total independence from the health-care establishment. Some of the "women's consciousness raising" writings encouraged women to be responsible for their own health care, including performing their own gynecological examinations (Boston Women's Health Collective, 1971). The obvious problem with this goal is that, while realizable, it may have dangerous consequences. Also, it would require obtaining all of the knowledge, skill, and experience of the health-care provider. Furthermore, it would mean practicing medicine on oneself, and this is something that even medical professionals can rarely do. Most individuals do not want or expect to be independent with regard to health care. Support by others and the division of labor to save time and maximize efficiency are part of people's expectations for a stable society (Mill, 1899; Smith, 1910). On the other hand, self-determination in seeking and accepting medical care is certainly a realistic goal and one that can be and is realized in the relationship between some physicians and their female patients. However, even if the medical professional is willing to respect the autonomy of the female patient, it will be costly for her to fully exercise medical self-determination. She must invest time and effort as well as money to learn about her condition and possible treatment options and to explore alternatives regarding providers and hospitals. It might be helpful to view this situation in terms of two levels of self-
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determination. The first level, deliberative self-determination, involves making specific health-care decisions for oneself, after considering one's options on the basis of the information provided by a health-care provider and perhaps supplemental information obtained elsewhere. The second level, deferred-judgment self-determination, involves choosing not to make health-care decisions for oneself, choosing instead to accept the recommendation of the medical practitioner without question or further investigation. Thus, a patient may choose not to deliberate about health-care options and thus relinquish his or her self-determination at the first level to save time and still retain it on the second level. The patient exercises deferred-judgment self-determination both in the choice of a health-care provider and in the choice to rely on that provider's best judgment in regard to specific medical decisions. Some women are forced to relinquish deliberative self-determination in their medical care because they truly cannot afford to exercise it. Because of other demands on their time, energy, and financial resources, women cannot invest the time, effort, and money required to obtain the information needed to be fully self-determining when a medical decision is necessary. Although this group of women may want to be selfdetermining in terms of specific medical decisions, this is impossible because of the excessive demands made on them by their various social roles. MODELS OF PATIENT-PRACTITIONER INTERACTION We have identified three models of patient-practitioner interaction that illustrate the ways in which medical decisions can be made. The first and most familiar model is characterized by real paternalism. Real paternalism occurs when medical practitioners take the decision-making role away from patients who want to make their own decisions and deny patients' self-determination with regard to treatment and the use of time. Health-care professionals who interact with their patients in this way believe they are acting with beneficence, but they are clearly not acting according to the principle of respect for autonomy. The assumed prevalence of this model is very high. For example, Scully (1987) reported that surgieal residents often persuade women to have hysterectomies that are unnecessary in order to gain surgical experience and the approval of their superiors. The prevalence of this model is probably highest for practitioners whose patients are women in the lowest social class and less than what is assumed for physicians whose patients are women in the middle and upper classes. This would be
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consistent with the literature indicating that medical diagnosis and treatment are a function of social class and gender. When medical practitioners establish relationships of real paternalism with patients, we observed two outcomes. Patients may find another physician who is willing to respect their autonomy to the extent they desire. This outcome is not always possible. The alternative is to remain under the paternalistic provider's care and yet be dissatisfied with the relationship. Patients may be resentful of the denial of their selfdetermination but be forced to accept it because they lack the time, opportunity, or resources to seek alternative medical care. This will often be true for poor women and the elderly, women in rural communities, those on Medicaid and Medicare, and those who must obtain medical care in clinics and public health departments. These women recognize that they will not receive medical care unless they accept this type of interaction. In terms of time expenditure, this model is the most economical for physicians. The second model is referred to as apparent paternalism because it is so often mistaken for real paternalism. Apparent paternalism occurs when health-care providers are given the decision-making role by their patients for a specific issue for a limited period of time. These practitioners are acting on the principle of beneficence while also respecting the patient's autonomy with regard to medical decisions. This model characterizes the relationship between women and medical professionals who feel socially pressed for time. Health-care providers are almost always in this position, with more patients needing attention than the provider's time allows. Women may defer to professional expertise in medical decision making in order to use their own time efficiently. These women relinquish, for specific issues, for the specific time periods, deliberative self-determination in their medical care, judging deliberation to be too costly in terms of their available time. In this case, health-care providers are perceived as beneficent agents in a burdensome social system, the demands of which exceed a woman's available resources. Of course, it is more efficient in terms of time for the providers as well, if patients defer to their best medical judgment. It is important to recognize that it is not the individual medical professional's fault if women feel forced to give up deliberative selfdetermination. Rather, it is a product of the financial and time pressures on women in U.S. society. Given role expectations for women, this model is perhaps the most prevalent. This model of patient-practitioner interaction does not always go smoothly. As women defer to their practitioners in specific situations for limited time periods, it is likely that both practitioner and patient will be
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uncertain as to the extent of these deferred judgments. A woman may wish to be more deliberative when her schedule permits her to do so and more deferential when time is unavailable for deliberation. If this model is to be maintained, and the provider is to continue to respect the autonomy of the patient, there needs to be a great deal of communication and flexibility on the part of both the provider and the patient. If the medical professional is not flexible enough, the relationship may become one of real paternalism. With sufficient communication, the relationship may become a cooperative one. In the cooperative model of patient-practitioner interaction, the practitioner provides information on patient diagnosis, prognosis, and treatment possibilities. Patients add what they may know about medicine and their personal situations and together the patient and practitioner discuss options for health-care regimens. However, the patient makes the final decision regarding possible treatment plans. Medical professionals operating within the cooperative model act on both the principle of beneficence and the principle of respect for autonomy by encouraging women to exercise deliberative self-determination with regard to medical decisions. Feminists advocate cooperation because it allows self-determination for women and control of their own bodies (which are obviously the minimal demands of autonomous existence). Even though many desire a patient-practitioner relationship they can view as a cooperative partnership, such a relationship is available to few. It is time-consuming for both practitioners and patients. For practitioners, cooperation may mean that fewer patients can be served in the time available. For patients, this model may require that demands of family and career go unanswered as medical needs are met. In addition, a cooperative relationship requires more in terms of financial resources and education on the part of the patient than either of the other types of patient-practitioner relationship. There is one other possible problem with this model. Rarely a physician may desire a cooperative relationship with a patient who cannot handle such a situation. This may be because the patient is not accustomed to this attitude because of past experience with real paternalism and does not expect a cooperative relationship with the physician. The patient may be distrustful of the provider and may not realize that some medical professionals actually do want to have a fully cooperative relationship with their patients. Szasz and Hollender (1956) presented a similar three-model analysis of patient-practitioner interaction from the perspective of the practitioner. They claimed that most physicians feel more comfortable operating in one model and that they are not as adaptable as their patients.
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CONCLUSION In this article we have pointed out the constraints placed on women in modern U.S. society in their efforts to obtain adequate health care. In particular, we have emphasized the constraints posed by the lack of time to satisfy social role expectations and to meet health-care needs. Three principles of medical ethics were also examined, specifically as they apply to the provision of health services to women in U.S. society. The principle of justice in the distribution of medical care is not presently being satisfied in the United States. Also, the conflict that can arise between the principle of beneficence and the principle of respect for autonomy often results in medical paternalism. Finally, we have suggested three models of patient-practitioner interaction that we believe operate within the framework of expectations for women in U.S. society. The first is truly paternalistic. The second, although appearing to be paternalistic, actually allows women to exercise deferred-judgment self-determination. A third model of patientpractitioner interaction requires cooperation between patients and those who serve them. The cooperative model offers women medical advantages but is elusive to all but a few in this society. Until a restructuring of role expectations occurs in society as a whole, this model will remain out of reach to most people. REFERENCES Boston Women's Health Collective. (1971). Our bodies, ourselves. New York: Simon & Schuster. Brody, E. M. (1981). Women in the middle and family help to older people. The Gerontologist, 21(15), 471-480. Canterbury v. Spence, 464 F. 2d 772 (D.C. Cir. 1972). Danziger, S. K. (1978). The uses of expertise in doctor-patient encounters during pregnancy. Social Science and Medicine, 12, 310-321. Davis, F. (1963). Passage through crisis: Polio victims and their families. Indianapolis, IN: Bobbs-Merrill. Glaser, B., & Strauss, A. (1965). Awareness of dying. Chicago: Aldine. Hollingshead, A. B., & Redlich, F. C. (1953). Social stratification and psychiatric disorders. American Sociological Review, 18, 163-170. Maxwell, E. K. (1988). Status differences in cohorts of aging women. Health Care for Women International, 9, 83-91. Maxwell, E. K., & Maxwell, R. J. (1988). Perceived health care needs of elderly Northern Cheyenne and Blackfeet (Final report, postdoctoral fellowship program in applied gerontology). Washington, DC: Gerontological Society of America. McBamette, L. (1987). Women and poverty: The effects on reproductive status. Women and Health, 12, 55-81.
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McCrea, F. B. (1983). The politics of menopause: The discovery of a deficiency disease. Social Problems, 31(1), 111-118. Mill, J. S. (1899). Principles of political economy (Vol. 1). New York: Colonial Press. Perales, C. A., & Young. L. S. (Eds.). (1987). Women and Health, 12, Special Issue on Women, Health and Poverty. Richardson, H. (1987). The health plight of rural women. Women and Health, 12, 41-54. Ross, C. E., & Mirowsky, J. (1988). Child-care and emotional adjustment to wives' employment. Journal of Health and Social Behavior, 29, 127-138. Roth, J. R. (1963). Timetables; Structuring the passage of time in hospital treatment and other careers. Indianapolis, IN: Bobbs-Merrill. Ruzek, S. B. (1979). The women's health movement. New York: Praeger. Scully, D. (1987). Negotiating to do surgery. In H. Swartz (Ed.), Dominant issues in medical sociology (2nd ed., pp. 252-258). New York: Random House. Smith, A. (1910). The wealth of nations. New York: Dent. Sommers, T., & Shields, L. (1987). Women take care: The consequences of caregiving in today's society. Gainesville, FL: Triad. Szasz, T. S., & Hollender, M. H. (1956). The basic models of doctor-patient relationships. Archives of Internal Medicine, 97, 585-592. Weitzman, L. J. (1985). The divorce revolution. New York: Free Press.
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