Patient, Heal Thyself: How the New Medicine puts the Patient in Charge by Robert Veatch
Veatch on Medicine v Postmodern Medicine
Commentary and a Review of 'Patient, Heal Thyself: How the New Medicine puts the Patient in Charge' (2008).
This review features a quick overview, followed by a more in depth analysis. Readers should note that this book was published in 2008. As far as I’m concerned, its thesis is sufficiently contemporary to discuss in present tense terms.
A Quick Overview
In ‘Patient, Heal Thyself’ (2008), Robert Veatch addresses the question of patient autonomy and the balance of power in medical decision making. Following in the steps of early Enlightenment thinkers, like Kant, who implored people to escape from self-imposed passivity and dependency, Veatch implores patients to escape from under the paternalism of modern medicine. Though, despite echoing Enlightenment thinkers, Veatch takes a decidedly postmodern approach by recasting relationships between physicians and patients as power relationships.
Readers should note that ‘Patient, Heal Thyself’ is written for an American context. That said, Veatch targets the foundational values of modern western medicine wholesale because those values barely differ in a western context (even if they are achieved more-or-less successfully and a little bit differently).
Veatch suggests that current medical practises overemphasise paternalism and de-emphasise patient autonomy, and, therefore, are morally unjustifiable practises. Veatch argues that medicine has paternalistic and physician-centric roots. His central thesis is that ‘Modern Medicine’ must give way to a ‘Postmodern Medicine’, where instead of permitting physicians to make medical decisions in a patient’s best interest according to what the physician thinks appropriate, patients are free to make their own choices about medical care, beyond mere consent.
That central thesis is motivated by one core belief: the medical world is only now waking up to the value-laden nature of medicine. Veatch believes Medicine has only recently realised that a medical decision is not just a decision about the facts, but also a mediation of professional, legal, religious, cultural, social, and moral values. Postmodern Medicine is designed to empower patients to choose treatments that align with their beliefs and values. The core tenet of Veatch’s postmodern medicine is: ‘the patient has unique epistemic access to their own interests and is optimally positioned to make decisions about what may be in their interests.’ I would suggest that, essentially, Veatch believes a patient’s lived experience must have primacy.
Veatch divides his book into three major parts:
1. Why Doctor Doesn’t Know Best.
2. New Concepts for the New Medicine.
3. The New Medicine and the New Medical Science.
Many chapters present a case from which Veatch reasons his way to a rule. Every case presents Veatch with the chance to carefully tease apart numerous value-judgements, and he makes the most of every opportunity. Veatch’s structure lets him present the reader with hands-on problems, from which he extrapolates the central themes and underlying issues, and presents a solution. All of this work is done before summing up in Patient Manifesto.
For those interested in a precise outline of Veatch’s methodology: Veatch takes a top-down approach to bioethical reasoning by arguing for and reasoning about principles (autonomy, beneficence, and distributive justice). Veatch supplements his top-down approach with bottom-up case-based reasoning, the conclusions of which provide the evidence for his principle derived thesis.
Taken wholly, and in context of the current state of medicine, I would suggest that Veatch is crying wolf. That said, a fair appraisal shows that Patient, Heal Thyself contains some genuine insight and is a great example of the method of casuistry supporting theoretical work. Therefore, I would recommend this book to readers who are interested to see examples of case based reasoning and postmodern analysis in bioethics. I would not recommend this book to those who are seeking a compelling and watertight critique of modern medical practises.
Digging Deeper
Two chapters, ‘Are Fat People Overweight?’ and ‘Beyond Prettiness’, are excellent examples of Veatch’s potential for genuine insight, stemming from his real-world examples. In these chapters, Veatch introduces readers to the distinction between objective statements of fact and the expression of values and attitudes. Specifically, Veatch underlines how blurred those lines are in aspects of medical care, public health, and societal reasoning about well-being.
In ‘Are Fat People Overweight?’ Veatch cites the National Institutes of Health’s (NIH) introduction of the Body-Mass Index (BMI). He notes that one can say someone is fat without saying they are too heavy, because fat is a factual and absolute statement. Meanwhile, saying someone is overweight implies they are overweight relative to some judgement. I suspect that both fat and overweight are objective or subjective statements, depending on the context and intended meaning. But Veatch’s point that weight-descriptors can be used as statements of fact and statements of value (or expressions of attitudes and judgements) still holds.
Veatch then tackles the social value of being ‘pretty’ in relation to being under/overweight and argues against the supposed authority on which scientists might say 25 BMI is acceptable, but anything beyond that is bad. In ‘Beyond Prettiness’ Veatch questions the decision to draw the line there and even whether to draw a line at all. Veatch aggressively doubts the NIH’s reasoning and examines study after study, highlighting many questions that need answering. By the end of the two chapters, Veatch has carefully teased apart the standard separations of welfare and preference interests as two different kinds, where they are often erroneously presented as the same thing.
The NIH, and physicians, spoke of losing weight as something which is in a patient’s interests. However, they fail to acknowledge that losing weight maximises one’s health but may not necessarily maximise one’s well-being. That is, losing weight is in a patient’s welfare interests but may be competing with their preferences. When Veatch separated health maximising treatment from well-being maximising treatment, he preempted the Fat Acceptance and Body Positivity movements as we know them today (although, both movements typically fail to articulate the implied premises of their beliefs). Veatch also demonstrated that supposedly irrational behaviours which don’t maximise health can be understood as rational behaviours if a patient’s values are fully accounted for.
Veatch’s vision makes patient autonomy sovereign and dominant. He believes that modern medical practise smuggles values into diagnoses and treatment plans which it purports to be purely objective assessments and that, by doing so, modern medicine is unjustifiably coercive and paternalistic. Veatch is circling a truth. Science (and its associated applied realms like medicine and engineering) can sometimes tell you how the world is (or will be, given a set of conditions), but it cannot tell you how the world ought to be. It is not revolutionary to suggest that ‘ought’ cannot be derived from ‘is’ in the moral sense; descriptions, in and of themselves, do not validate or justify prescriptions. So, when Veatch accuses physicians of coercion and paternalism, he is accusing physicians of making a value judgement on behalf of the patient while presenting the options as if they are absent of value judgements. We might say this is a kind of false equivalence, presenting values as if they were facts or vice versa.
In Veatch’s postmodern medicine world, everything a physician does must be re-conceptualised. He goes to painstaking length to follow a strict adherence to supreme patient autonomy to the bitter end, reimagining the entire healthcare system as he goes. In the epilogue, Patient Manifesto, he lists reforms. Among them are:
1. Abandoning the language of modern medicine.
2. Promoting ‘choice’ over ‘consent’.
3. Favouring well-being maximisation over health maximisation.
4. Providing age-adjusted health insurance, unbounded by a list of accepted treatments.
5. Placing hospice care in the domain of Social Security, because it isn’t healthcare.
6. Preventing experts being the gatekeepers of medical care, because they only know their own values.
Veatch’s reforms are the kind one would make if one took the lowest denomination of medical practice to be standard practice. Veatch fears what he perceives to be an authoritarian medical culture in which physicians prescribe on a whim and treat arbitrarily. While it is true that if one is to be subjected to a fickle choice, then it is marginally more palatable if it is one’s own, it is certainly untrue that modern healthcare is always and necessarily fickle. Current law and professional practice standards are imperfect, but they do well to safeguard patients from an unrestrained and autocratic use of medical authority.
I believe Veatch reaches for a conclusion more powerful than the sum of its parts can justify. Chapter by chapter, part by part, Veatch gains traction but ultimately goes nowhere. I can buy his social constructionist and postmodern account of covert value-judgements in healthcare. I can buy all sorts of reasons healthcare systems need to improve and I can buy into Veatch’s belief that much of medicine, including its language, is in a transitionary period from prioritising ostensible beneficence to prioritising legal and moral rights to self-determination and autonomy. In fact, as far as we have come, I believe we will go further still to emphasise and facilitate patient choices in even the most dire and pressing circumstances. But I cannot buy into implementing all of Veatch’s suggested changes and I cannot be convinced of his general thesis.
A patient may have unique epistemic access to a subset of their own interests, but it does not mean that they know what is best for them. Each of us has desires and dispositions which run contrary to our long-term welfare and even to our long-term preferences. In fact, when inspired by the wrong passions, many of us have desires which run contrary to all but our shortest-term interests. Such problems are only exacerbated when we are in unfamiliar contexts, like life-changing illness, confronted with unknown unknowns.
Patients often stand on the wrong side of time to see the path before them with clear eyes. Physicians may not know quite what the journey of treatment will entail for a patient, but they know the lay of the land. So, while a physician must always consult a patient about their preferences, having taken those preferences into account, a physician is significantly better positioned to determine what makes good treatment. Furthermore, a patient’s preferences contain aspects of a patient’s values. Therefore, if a patient is properly consulted, then no is-ought gap remains.
Experienced physicians have seen the same scenarios a thousand times over. We can imagine that if a cancer patient values quality of life over quantity of life, then an experienced physician could consult their experience of every other patient who had the same desires in the same circumstances and consider how those patients fared. Perhaps most importantly, an experienced physician knows how wide the gap between expectations and reality may really be. Each of our lives are full of experiences we were certain would be satisfying but were in fact disappointing, or worse, the precisely the opposite. Patient autonomy is embedded in good medical practice and decision making is bolstered by access to a forthright, experienced advocate (which a good physician is).
I will go further, too. Patients do not always need to be consulted; some values may be assumed. In most circumstances, if you seek medical care in a given medical system, it is reasonable to assume you share at least some of the values of that system. You must at least agree that health is better than ill-health and that there is a way the world could be for you which is better than the way the world currently is. Unless the only options available are extreme, assuming patients share the same values as the system they seek help from is reasonable and pragmatic.
In addition to dubious claims about patient interests, Veatch makes little-to-no account of distributive justice in medical decision making. It seems utterly unfair – even cruel – to burden patients with the duty to determine so much of their medical care at a time when they are so vulnerable. Under Veatch’s postmodern medicine, if asked, a physician must present their patient with all of the facts and let the patient choose. No account is given as to how a healthcare system can justify expending so many resources. No account is given about how many patients come to physicians precisely because they want the burden of choice to be shouldered by someone else. No account is given as to why current frameworks (requiring physicians to provide explanations of the options available, including an assessment of the expected and relevant risks, side effects, benefits, and costs of each option) is significantly different to his radical choice model, except that current standards are conservative enough to be pragmatic.
Finally, Veatch makes no proper account of capacity tests for true patient choice. A patient, when presented with a limited range of options approximately amenable to their values, is typically very capable of deciding which treatment is best for them. But in a world where physicians cannot be prescriptive — in Veatch’s world of radical choice — a patient would need the capacity of a medical professional to choose between the full range of options which are truly available to them. And what is more, in a radical choice model, a patient really must choose between the full range of options available or they would merely be consenting to a limited range presented according to the physician's undisclosed values, which is precisely what Veatch advocates against. As such, a radical choice model is an unattainable ideal. Utopian, even. As with so much idealism, while radical choice may be a lofty and noble dream for medicine to strive towards, it is by no means a world to rush into as if it is actually achievable today.
I will make two broader points in conclusion.
While I am utterly unenthusiastic about Veatch’s analysis, I am sympathetic with his motivations. We are right to be skeptical of experts and expertise. No doubt, each of us has been burned by someone too cocksure of their abilities and so enamoured by their vision for us that they fail to comprehend our real needs, including our need to be active participants. In a multi-stakeholder situation, the right course of action can rarely, if ever, be determined solely by an expert’s understanding. The right of people to live sub-optimally but freely should not be undervalued. Yet we must not deny the vital role experts play as consultants, advocates, and efficient decision makers. Until we have advocate avatars to serve us, and perhaps even then, a perfect, bespoke, and leisurely consultation for all people in all matters is unscalable. Experts are in finite supply. Striving for perfection for a few rather than raising the floor for all, will result in worse outcomes for more people. Therefore, partnering with experts is pragmatic.
Veatch’s position implies that principle-agent hazards are insurmountable and that two experts of different domains cannot enter into a sufficiently equal, productive partnership. As with most postmodern analyses, Veatch only sees a binary option: someone must have power over somebody else. Therefore, Veatch obsesses over why the patient must have dominance and reaches for a sub-optimal position. If, as Veatch contends, the patient is an expert in their own preferences and a physician is an expert in patient welfare, then why is partnership and negotiation between these different-but-equal experts impossible?