Paternalism is out. Shared decision-making is in. But some communication and ethics experts say medicine is veering far too much toward full patient autonomy. 

A new review in the journal Health Communication found that clear delivery, active listening, and empathy were associated with patient trust. Obvious? Probably. But here’s the twist: The authors also found that paternalistic styles didn’t always harm trust — and even aided shared decision-making in some situations, particularly in contexts such as emergency care, serious illness, and end-of-life decisions. 

The findings reflect what many describe as a call for physicians to embrace beneficence: the moral duty to act in the patient’s best interest. Doctors may need to reclaim a middle ground on the continuum from paternalism to autonomy. 

“We’ve swung all the way to the other end, which is actually an inaccurate understanding of what shared decision-making is,” said Andrea Justine Landi, MD, MPH, a clinical medical ethicist and associate professor at the University of Louisville in Kentucky. True shared decision-making combines patient values with clinical expertise. “We’re missing the mark when it comes to autonomy…we worry that providing a recommendation is actually paternalism.” 

How We Got Here 

Beneficence was the moral justification used during medicine’s bygone paternalism era, with roots deep in ancient civilizations. Amid a broad cultural shift toward individual autonomy, medicine changed too — driven in part by the Tuskegee Syphilis Study (which stretched to 1972) and the second wave of the feminist movement (marked by the 1973 Roe v. Wade ruling). 

In an effort to rebuild trust, medicine leaned into patient autonomy, elevating such aspects as informed consent, transparency, and empathy. Now, some medical ethicists suggest that beneficence has become a scapegoat for the loss of trust in medicine. It got lumped together with paternalism, and the medical field overcorrected. 

Eric Prystowsky, MD, a cardiologist specializing in electrophysiology in Indianapolis, Indiana, recalled the starkness of the paternalistic attitudes that were prevalent when he graduated from medical school in the 1970s. His physician mentors advised: “There are some things you don’t have to tell patients. You’re just going to make them nervous.” 

In those days, it was commonplace not to tell patients they were prediabetic because “they’re just going to worry about it for years,” he said. 

Today, a similarly stark style is emerging at the other extreme. 

Some physicians think their responsibility is to help patients understand all the options, putting patients through “mini-medical school,” said Amy Trowbridge, MD, an associate professor at the University of Washington School of Medicine in Seattle. Their philosophy: “It’s not my job as a physician to make hard decisions for you. This is your child or your life, and you need to make this decision.” 

That may mean laying out complex choices — such as weighing fourth-line chemotherapy against hospice — or running through a laundry list of medication options for patients who are drug-averse. 

Some say the reason is to keep physician values out of the equation, said Trowbridge, a pediatric palliative care specialist. But for patients, it may feel like abandonment. 

“For families to have to make such a heart-wrenching decision by themselves is really hard,” Trowbridge said. “I have seen families be harmed by feeling like they are the ones who have chosen to stop life support on their babies, and carrying guilt around that because they are the ones who had to make that decision.” 

Going Back to Center 

Prystowsky recalled being drawn to mentors who used a different style from the prevailing paternalism. He bristles a bit at the term “shared decision-making,” saying it codifies patient care. 

“Like everything, there’s an art to shared decision-making,” he said. “If I walk into the room and say, ‘We’ve got all the studies, now we’re going to talk about it. Sorry to tell you, your heart function is really low, and you could die suddenly.’ How do you think that’s going to go? I can promise you that the patient has shut down, and they’re not even listening to you at that point.” 

He’s learned that the key to shared decision-making is letting patients tell their story. When a patient arrives after a frightening event, like passing out, his go-to instruction is “I need details.” 

“At the end of the interview with the patient, if they’ve not told you their story, they’re going to go away upset, and they’ll say, ‘My doctor didn’t care,’” Prystowsky said. “And when your patient thinks their doctor doesn’t care, they’re not going to listen to you, and then the whole trust breaks down.” 

Recently, Landi had a patient with terminal colon cancer whose daughter had also been her longtime patient. Through discussion, it was clear that the patient and her family wanted hospice and comfort care. Landi skipped the mini-medical school lecture, instead saying, “I hear you. Knowing now that time is short, you want to take mom home to be around family and to be at home and die at home. So I’m going to provide you the recommendation of hospice.” 

Things got messy for a minute. 

“Because I did not do a mini-med school about stenting the [gastrointestinal] tract, geriatric doses of chemotherapy, and hospice, I was asked [by a colleague], don’t you feel like you’re being a little paternalistic, by not telling them the other options?” Landi recalled. “Her values were defined, fixed, and known. If I had a feeling of an obligation to tell them every piece of information known to man in the books, and in articles, and in publications, and on PubMed, then the way that the patient’s autonomy is exercised is by [saying], ‘Tell us what you want.’” 

Some younger doctors are swinging back toward paternalism out of anxiety that their patients will make the wrong (not evidence-based) choice, according to a recent qualitative study from Netherlands. “They were worried about causing harm — that if they tell a family everything about two options and not give an opinion, that’s no good because what if they pick the wrong option?” Trowbridge said, describing the concern as well-intentioned. “I actually think there’s something to that.” 

What to Do 

One way forward is to increase beneficence. 

Shared decision-making “not only respects autonomy of patients but also recognizes the importance of beneficence — that doctors want to do good for patients,” said Peter Angelos, MD, PhD, a professor of surgery and director of the MacLean Center for Clinical Ethics at the University of Chicago. “With this principle, we feel a responsibility to find the right diagnosis and make the right recommendation.” 

The experts offered this advice for fine-tuning your approach: 

1. Diagnose your patient’s communication style. Most clinicians today operate on the informative model of communication, which focuses on providing all relevant information. Landi suggests first asking patients what communication style they prefer. 

Why this works: Your communication style reflects how you see your job, but instead of defaulting to “information provider,” an effective physician will first figure out what role the patient needs from them in that moment, Landi said. 

How to do it: Don’t just go off feel; explicitly ask. Landi suggests this prompt: “How do you like to receive information? How do you like to go about medical decisions?” 

2. Find a process that builds trust. Your role evolves as decision-making progresses. You might be guardian in the first minute (explaining why it matters), teacher at the 5-minute mark (presenting options), and advisor by the end (making a recommendation), Landi said. 

Why this works: Adapting your role helps you gather intel on your patient so you can share information in a way that addresses their values and preferences. A hidden process is at work through the give-and-take. “Many of the decisions that are happening in the shared decision-making space are less about the transfer of information and more about does the patient trust the physician,” Angelos said. 

How to do it: Let’s say you’ve learned that your patient wants to be as independent as possible and live at home, but is skeptical of medication. You say, “Knowing that you don’t want to take a pill every day but you want to prevent osteoporosis and a hip fracture that could move you out of independent living, my recommendation is an intravenous treatment every 3 years.” Landi had this encounter recently, and her longtime patient agreed, “but she could have easily said, ‘No, you’re way off.’ And then I’d say, ‘OK, let’s start over. I missed something.’” 

3. Treat it like an art. Prystowsky suggests a philosophy of “either you learn or you just keep making mistakes.” 

Why this works: Everything physicians learn is taught in steps and mentored over time. You can treat communication the same. “There’s this belief that you either have good bedside manner or you don’t, and that’s absurd,” Trowbridge said. 

How to do it: Active listening is a simple place to start. Look at the patient, not the computer, both Prystowsky and Angelos suggested. You may observe patterns of where decision-making gets tough. Prystowsky noticed patients hesitating to accept medication, so he developed videos of blood clots causing strokes and now shows them to patients on his phone. For those who like a structured approach, Trowbridge suggests Vital Talk or its pediatric counterpart PedsTalk (which her lab developed), programs designed to teach communication skills to clinicians. 

The experts cited in this article reported no relevant disclosures.