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The Doctor Can’t Know What Is Best

There is an even more subtle problem. Relying on a professional medical expert to prescribe what he or she thinks is best runs afoul of a mistake in the model for medical decision-making in the modern era. The model of modern medical decisionmaking is that there is a class of well-trained experts who can diagnose, review treatment alternatives, and choose what is best for the patient. This has, in fact, been the dominant ethic of physician ethics since the Hippocratic era (Veatch 1978), but in the twentieth century, an adjustment was made. The clinician was still deemed authoritative in matters of diagnosis, prognosis, and the expected effects of treatment alternatives but was expected to test his or her judgments about these matters of medical fact with standard conventions of modern science: peer review, randomized clinical trials, and other devices to test the individual clinician’s understanding of the facts against the consensus of experts and the best scientific knowledge (Veatch 2012). What remained was the assumption that “doctor knows best,” that is, that once the diagnosis and prognosis were established (now based on the best standards of medical science), this could lead to a professional judgment about what was best for the patient. Hence, medicine held out the view that there were objective standards of “medically indicated treatments” and among alternative treatments the science could determine a “treatment of choice.” Medical textbooks could specify what the appropriate treatment was for any given patient’s condition once that patient’s condition was specified sufficiently.

This assumption that physicians (aided by standards of peer consensus) could know what was best for the patient was what was behind the model of modern medicine, which included the requirement that treatments be “prescribed” by physicians and that patients—presumably having less knowledge of these medical facts—were not capable of deciding what was appropriate except in the most trivial cases of easily diagnosed problems for which safe, simple, and reasonably effective treatments were available for purchase over the counter.

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