BEYOND OBJECTIVITY, PATERNALISM, AND AUTONOMY

The “objectification myth,” which requires psychological distance in professional relationships, is detrimental to the patient and impairs clinical empathy.

Smith and Newton, 1984, p. 57

The birth of modern science began with the scientific and philosophical revolution of the 17th century, catalyzed by the work of philosopher Renee Decartes. Bordo (1987) observed that Decartes' “seventeenthcentury rationalist project” has brought forward the “objectivist, mechanist presuppositions of modern science” (p. 1). Objectivity holds that each person exists independently of each other, and that people are able to view things and interact with others independent of—detached from—their emotions, thoughts, and biases. Bordo notes that since the 17th century, “The Cartesian epistemological ideals of clarity, detachment, and objectivity” have remained “largely unquestioned” (p. 4). As such, the presuppositions of clarity, detachment, and objectivity have become the underlying assumptions that have shaped the modern era. These ideals have also informed theoretical conceptualizations of the patient–clinician relationship, and influenced formulation of models of care. These models of care have been predominately based on what Bordo labels “absolute epistemic objectivity” (p. 2).

History demonstrates how over time, along with objectivity, the moral principles of paternalism and autonomy have also informed conceptual frameworks for models of care and paradigms for the patient–clinician relationship (Roter, 2000; Schermer, 2003; Smith & Newton, 1984). At the beginning of the 20th century, the patient–clinician model included a “paternalistic” ethic and physician privilege, which were based on the Hippocratic Oath. According to the paternalistic ethic, in this paradigm the
professional care provider was held as an objective “authority” that delivered information, and power relations (Emanuel & Emanuel, 1992; Roter, 2000) inherent in the clinical relationship were not acknowledged.

Developed in parallel with, and in response to, paternalism, models for the patient–clinician relationship evolved that emphasized the role of patient autonomy. The principle of autonomy underscores the patient's right to make her or his own decisions about care (Schermer, 2003; Smith & Newton, 1984).

Models of care based on patient autonomy also emphasize the clinician's nondirectiveness and value-neutrality (Wachbroit & Wasserman, 1995). The clinician's value-neutrality is based on the underlying assumption that the clinician can be “objective” and, in so doing, the clinician's objectivity facilitates upholding a clinical distance to ensure that the clinician does not interfere with the patient's autonomy.

These three paradigms have thus at times intertwined and reinforced each other. In the objectivist, paternalist, and autonomous models, the clinician's and the patient's lived experiences are partitioned off from each other. The “autonomous patient” remains independent of the “objective clinician,” and thus, the illusion of separateness is perpetuated. However, Smith (an internist) and Newton (a philosopher) recognized that “the old 'objective' medical tradition, which aims to separate me from my patient, is invoked as a mechanism—a very ineffective mechanism—to prevent such entanglement of our lives” (1984, p. 53). Smith and Newton concluded: “The myth of clinical distance between the patient and the physician is, after all, only a myth” (p. 53).

In contrast to objectivity, subjectivity describes the presence of one's personal thoughts and emotions, and one's unique personal reality. Smith and Newton (1984) captured the subtle, yet important, aspect of subjectivity in the clinical relationship: “To understand the patient, the physician must see the patient, which requires personal contact with the sphere of the subjective, a difficult skill to learn or teach” (p. 57).

Intersubjectivity extends subjectivity by recognizing the interactive features of human relatedness. Intersubjectivity, as Stolorow, Atwood, and Brandchaft stated, underscores the importance of the “reciprocal mutual influence” (1994/2004, p. 37) between the patient and the clinician. The paradigm of intersubjectivity acknowledges that relational interactions between people take place within an intersubjective sphere that is comprised of each person's subjectivity.

A new model for the patient–clinician relationship, the IRMOC aims to account for the importance of intersubjectivity. The IRMOC conceptualization stresses the importance of understanding the unique intersubjective experiences of the patient and the clinician and the mutual influence they have on each other. This paradigm also values and calls attention to the meaning of relationship. In this way, instead of emphasizing paternalism,
objectivity, autonomy, and clinical distance, this new model recognizes the mutually reciprocal intersubjective spheres of engagement—the worlds of connection—between the patient and the clinician, and in so doing encourages mutual trust, suffering, and compassion.

 
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