“Patient-centeredness” accommodates itself to a wide range of often contradictory perspectives about the nature of the good in health care. Earlier reconstructions of health law, in the 1970s and 1980s, for example, could qualify as patient centered as each of these shifted the focus of law away from the dominant paradigm of professionalism and toward the well-being of patients. They did so in radically different ways, however.
The health-law reform movement of the 1970s asserted the primacy of the individual patient’s moral agency, autonomy, and choice. This priority is apparent in legal norms of informed consent; choice at the end of life, including living wills; participation of lay members on medical licensure boards; as well as other developments. This reform movement was patient centered in that it elevated the power and status of the individual patient in the physician-patient relationship and revealed that the relevant norms in decision making about medical treatment were not owned by medicine alone, but rather were social and individual moral questions.
The subsequent reforms of the 1980s incorporated the notion of the autonomous patient but reconceived as a consumer. Much of the effort of that decade, however, was focused on limiting consumer choice at the point of service, relying on arguments that patients were ill-positioned to decide whether medical interventions recommended by their physicians were necessary or beneficial. These reforms of the 1980s, like those of the 1970s, also could be viewed as patient centered. Their goal was to improve the wellbeing of patients by enhancing quality, expanding access to necessary medical services by decreasing cost, and avoiding harm suffered at the hands of unnecessary medical care stimulated by perverse financial incentives.
Thus, the legal reforms of both the 1970s and the 1980s could fairly be considered patient centered—one on an individual basis and the other on a population basis—even though they adopted contrary notions of the capacity of patients and potentially contrary measures of success. This illustrates the threshold challenge that must be confronted by designers of a more patient-centered health law.
This Essay makes three points. First, it illustrates that notions of the good in health law are often competing and that a goal of patient-centeredness, standing alone, will not resolve those conflicts. Second, it briefly discusses the sometimes perverse interaction between law and medicine and argues that a focus on the outcomes of law should be an essential component of a more patient-centered health law. Finally, it addresses claims that the current health-law framework relies on false notions of the patient and of medical professionalism and thus is not patient centered. The current framework, according to this claim, misses the mark by failing to recognize how illness limits the capacity of patients and by excessively discounting the skill base, expertise, and moral authority provided by medical professionalism. This Essay argues that recovering older notions of the roles of patient and doctor does not adequately capture the physician-patient relationship and that, instead, a strong model of mutuality better explains physician behaviors that law seeks to influence.
