A role for the sick role [response]
Online posting: Oct. 24, 1997
Published in print: November 15, 1997 (CMAJ 1997;157:1350)
Re: "A role for the sick role: patient preferences
regarding information and participation in clinical decision-making", by Anne M. Stiggelbout and Gwendoline M. Kiebert, CMAJ 1997;157(4):383-9 [full text / résumé]
In response to: R. Salole
Our paper did not state or suggest that people consciously choose
to play the sick role once they become patients. We hypothesized
that being a patient makes people behave in a less active way
than they might have foreseen for themselves when still healthy.
Neither did we speculate on the mechanism of such a change. It
may be the result of a process of emotional regression or
demoralization, as suggested by Dr. Salole. It could also relate
to a fear of responsibility for a decision and its outcomes.
Perhaps the misunderstanding is caused by the expression "playing
the sick role," which was employed by Dr. Laine in her editorial.
The term "playing a role" implies a conscious and voluntary act.
We think that the role known in medical sociology as the "sick
role" is adopted subconsciously.
In our paper we deliberately did not embark on an ethical
discussion of the ideal of shared decision-making. However, in
light of the emphasis given this topic by both the editorial and
Salole's letter, we feel we should respond, to prevent readers
from ascribing to us a moral viewpoint that is not ours. It is
not clear whether Laine promotes shared decision-making because
of patient preferences or because of empirical evidence for
better health outcomes. An important difference exists between
arguing for shared decision-making out of respect for patients'
preferred role in decision-making (respect for autonomy) and
doing so because of better health outcomes (for reasons of
beneficence or from utilitarian motives). We indicated that, as
long as evidence is lacking about patients' motivations regarding
decision-making preferences, we should hold on to patient-centred
medicine and respect patients' perspectives on their role in
decision-making. We do not feel that evidence showing improved
health outcomes is strong enough to "force" shared decision-
making upon patients.
Finally, we subscribe wholeheartedly to Salole's point about the
importance of the physician's role in this complicated process of
people becoming patients. Not only must physicians be capable of
gauging a patient's mental state and his or her reserves for
coping with disease and treatment, but they must also be flexible
and creative in adopting an idiosyncratic role that best responds
to the patient's needs. Part of their role is to stimulate
patients' participation in, compliance with and acceptance of
personal responsibility in the treatment plan -- certainly not an
easy task.
Anne M. Stiggelbout, PhD
Stiggelbout@rullf2.medfac.leidenuniv.nl
Gwendoline M. Kiebert, PhD
Leiden University Medical Center
Leiden
The Netherlands
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