Beach MC, Sugarman J, Johnson RL, Arbelaez JJ, Duggan PS, Cooper LA. Ann Fam Med. 2005 Jul-Aug;3(4):331-8.
Introduction
I confess that, upon reading the title, Do Patients Treated With Dignity Report Higher Satisfaction, Adherence, and Receipt of Preventive Care?, my cynicism automatically went on full alert as I sardonically calculated the likelihood that a negative finding to that kind of set-up question would be published or even submitted for publication.1
While I hereby declare myself unreservedly in favor of treating patients with dignity, I also suspect that in a tiny, dark, staunchly adolescent corner of my soul, I would not have been displeased if the research had demonstrated that treating patients with dignity had a negative correlation with reported satisfaction, adherence, and receipt of preventive care, thereby forcing doctors everywhere to disrespect and humiliate their patients in order to provide optimal care.2
Well, I shan’t keep you in suspense; the official conclusions follow:
Being treated with dignity and being involved in decisions are independently associated with positive outcomes. Although involving patients in decisions is an important part of respecting patient autonomy, it is also important to respect patients more broadly by treating them with dignity.
The Study
The path by which the researchers got to their desired destination starts with a 2001 survey (a questionnaire of multiple choice items) of 5,514 adults living in the United States designed to examine the independent correlations of (1) patients being treated with dignity and (2) patients being involved in decisions to the three titular outcomes (satisfaction, adherence, and receipt of preventive health care). The study also analyzed the results for differences across racial and ethnic groups.
Consideration Of Dignity
The authors point out, at length, that dignity is not synonymous with patient autonomy:
… the broader ethical principle of respect for persons, from which the principle of respect for autonomy is conceptually derived. Respect for persons has been broadly defined as the recognition that all persons have dignity or inherent worth. Thus, involving patients in decisions (respect for autonomy) is one important, but not exhaustive, expression of respect for persons.
This explanation is followed by a somewhat redundant Venn diagram of the relationship between Respect For Persons and Respect For Autonomy.
In gathering the data, the researchers cut through the Gordian knot of defining the complex ethical concept of dignity by the simple expedient of placing that onus on the respondent:
The primary independent variables were 2 items inquiring about different expressions of respect during the patient’s last encounter with a doctor: “Did the doctor involve you in decisions about your care (as much as you wanted, almost as much, less than you wanted, a lot less than you wanted)?” and “Did the doctor treat you with (a great deal of) respect and dignity (a fair amount, not too much, none at all)?”
Later, as part of the Discussion section, the authors offer their suggestion “that treating someone with dignity primarily involves recognizing inherent value in that person.” To their credit, the authors straightforwardly, if belatedly, affirm that the questionnaire and the data collected from it do not associate specific behaviors with being treated with dignity, explicate how the respondents arrived at their evaluation of dignity, or distinguish being treated with dignity from being treated kindly. As they note,
… such concepts as respect for persons and respect for autonomy are not perfectly measured by survey items, particularly from single items.
The Results
The authors summarize their results in this excerpt from the paper:
Overall, 76% of respondents reported being treated with a great deal of respect and dignity, and 77% reported being involved in decisions to the extent that they wished. There were no differences in the percentage of respondents reporting either type of respect by sex or education, yet there were differences in reports of involvement in decisions and treatment with dignity across age, race/ethnicity, and income.3 … Most respondents (62%) reported both being treated with dignity and being involved in decisions, although there were 12% who reported being treated with dignity only (without being involved in decisions), 12% who reported being involved in decisions only (without being treated with dignity), and 14% who reported neither.
The Conclusions
The authors hold that these results
have several important implications for practicing clinicians, medical educators, researchers, and medical ethicists. Practicing clinicians ought to consider how to foster their own attitudes of respectfulness toward patients by engaging in self-reflection or participating in educational or training programs in communication skills and professionalism. Medical educators ought to teach students about the principle of respect for autonomy, as well as foster environments in which patients are regarded as valuable and treated with dignity. After all, the most egregious cases of student-reported physician misconduct no longer seem to be in the realm of paternalism, but in the systematic devaluing of patients. Researchers ought to investigate which behaviors are interpreted by patients as an indication of treatment with dignity and, if our findings are replicated in other studies, to design and evaluate the impact of programs aimed at increasing levels of respect within health care systems.
They to on to report that
For ethicists, these data lend support to conceptual arguments for honoring the broader principle of respect for persons that incorporates treating patients with dignity in addition to the narrower responsibility of respecting autonomy. Although respect for persons is conceptualized as the broader principle, our data suggest that patients do not always experience being involved in decisions as an indication of respect more broadly. This finding may be because involving patients in decisions is only one part of respecting autonomy, but it may also be because respect for autonomy is not the full expression of respect, insofar as there are aspects of persons in addition to their autonomy (such as their dignity) that require attention morally.
Commentary
Perhaps I’m missing something because it seems to me that a data set generated by asking patients if they were treated with dignity, an ambiguous and intricately complex quality that was not defined for those surveyed and which the authors themselves note can’t be measured by the instruments used in this paper, is inherently suspect and perhaps fatally flawed. By reducing the multidimensional concept of “respect,” with all its implications and social, historical, and emotional baggage, to two questions, one of which seems to have a political agenda (see below), the study creates a self-selected group of satisfied patients that has been too easily and too confidently labeled “treated with respect” (i.e., patients who report being treated with respect may well be responding to a generally positive treatment experience). Nifty statistical manipulations of invalidly interpreted data does not yield compelling results that convince me to reassess or change anything about the way I operate clinically.
Further, one could, it seems to me, make a case that the other of the two major expressions of respect designated by the authors, involving the patient in the decision-making process, may be an important issue but does not necessarily correlate with respect. In any case, the point smacks of false egalitarianism enlisted to support a specific sociological perspective. This bias is revealed in the manner in which the question is asked:
Did the doctor involve you in decisions about your care (as much as you wanted, almost as much, less than you wanted, a lot less than you wanted)?
One of the first differences I noticed between the textbook descriptions of patients and real patients was that not every patient wanted the be empowered as a co-member of their treatment team. Some patients, in fact, all but panicked at the prospect of assuming that role. Setting aside for now the questionable proposition that patient empowerment is a universal benefit, one notes that the question put to the patients in this study does not include all the pertinent options. To present the issue to the subjects in a neutral manner, the question have been (additional options printed in bold),
Did the doctor involve you in decisions about your care (as much as you wanted, almost as much, less than you wanted, a lot less than you wanted, more than you wanted, much more than you wanted)?
I would argue, that coercing a patient to be more involved than he or she wishes is an ethically untenable position for the doctor.
On the other hand, I do agree with the authors that
Further research is needed to understand what clinician behaviors are interpreted by patients as an indication of treatment with dignity.
Only after that is accomplished, should a study be done to determine if being treated with dignity has an impact on adherence to treatment.
__________- The answer, by the way, falls into the proverbial range of slim to none↩
- Because of this cynical slant on my part, I have excerpted somewhat larger chunks of the article than I might have otherwise to lessen the possibility of taking the authors’ words out of context↩
- Shown in a table but not relevant to this discussion↩