Better Patient Care Calls for a 'Platinum Rule' to Replace the Golden One
MEDICINE
Better Patient Care Calls for a 'Platinum Rule' to Replace the Golden One
A new principle in medicine focuses on understanding patients' values, not assuming they share your own.
By Claudia Wallis
Originally published on Scientific American dot com
February 1, 2023
For much of human history and across multiple cultures, ethical behavior has been guided by the Golden Rule: do unto others as you would have them do unto you. We draw on this cherished principle when we act with empathy and compassion. But the rule could be better.
People vary greatly in their values, lived experiences, and sense of what is acceptable. What you want in each situation may not be what another person desires.
In medicine, the stakes for making or influencing choices for others can be incredibly high. Such decisions impact people's quality of life and even their chances of survival. As health care becomes less paternalistic and more individualized, the time seems right for a new ethical guideline. Enter the "platinum rule," proposed by Harvey Max Chochinov, a professor of psychiatry at the Canada's University of Manitoba: do unto others as they would want done unto themselves.
Chochinov, an expert on palliative care, eloquently describes this principle in his essay "Seeing Ellen and the Platinum Rule," published last year in JAMA Neurology. He begins with a story about a health crisis affecting his late sister Ellen, who was severely disabled by cerebral palsy. After seeing her twisted body and respiratory distress, the intensive care doctor managing her case was weighing whether to insert a breathing tube when he asked Chochinov a peculiar question: Did Ellen read magazines? "The subtext was chilling," Chochinov writes, because "this was not an attempt to get to know Ellen ... but rather a cryptic way of deciding if hers was a life worth saving."
Ellen, her brother, knew, read widely, and relished many simple pleasures of life, but the gulf between her life as a frail person who uses a wheelchair and the physician's sense of what he would want in her situation was too vast to be bridged by the Golden Rule.
"When the lived experience of another, the sensibility and perspective of another, varies widely from your own perspective, that's when using yourself as this infallible barometer of what another might need or want begins to break down," Chochinov explained. "We must acknowledge how our personal biases can shape how we perceive and respond to patients."
Those patients can differ from healthcare workers by more than their abilities or disabilities. Their values can also be shaped by race, culture, and experience. In a diverse society, doctors ought not to project their values and presumptions onto the patient "as if the patient were a blank screen or clone of the doctors themselves," observes Catherine Frazee, a disability advocate, author, and emerita professor of disability studies at Toronto Metropolitan University. Medical practitioners, she adds, "are well educated, well respected, and well paid. Those three things alter the way you see the world. So, there is a real bias."
The platinum rule has been introduced previously. But in medicine, it pulls together existing ideas about patient autonomy, equity, and diversity in a succinct formulation that "is quite brilliant" and well suited to being taught to health practitioners, says medical ethicist Joseph Fins of Weill Cornell Medicine. Indeed, within weeks of writing about the idea in JAMA Neurology and in the Journal of Palliative Medicine, Chochinov began to hear of its uptake at a medical ethics conference and, before long, in other journal articles.
Making an effort to understand a patient's personal needs and wishes does not mean catering to all of them. Medicine can't be "a take-out service," Chochinov says. "Not all patients can always receive all things. That's the reality of living with a healthcare system with limited resources."
One of those limited resources is time, and there's no denying that getting to know a patient as an individual—as opposed to the generic host of a disease—means investing additional minutes or hours. Still, Fins believes such investment is usually cost-effective: "If we know what patients want, we will spend less time giving them things they don't want."
There are benefits for the clinician as well. "When doctors emotionally connect to their patients, they do a better job," Chochinov says. "We have data to show heightened job satisfaction and less burnout."
In cases where patients cannot speak for themselves and where loved ones are uncertain of their wishes, clinicians may need help applying the platinum rule. But, as Frazee sees it, there is value in the effort: "At the very least, your attempt to work through it will ensure that you have sufficient humility about the wisdom of your choices."
Claudia Wallis is an award-winning science journalist whose work has appeared in the New York Times, Time, Fortune, and the New Republic. She was the science editor at the time and the managing editor of Scientific American Mind.
Additional editing provided by M. Zuleger-Thyss
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