Posts Tagged ‘B. S. Cheng’

Is Paternalistic Model of Healthcare effective in Modern India?

July 20, 2009

I had mentioned in one of my previous blog about me writing on some of my thoughts from a Consumer perspective on the Healthcare scenario prevalent in India. This blog is a continuation along that line.

In this blog, I wanted to talk about the typical doctor-patient relationship model which I have seen being prevalent in India. Let me say on the onset that the purpose of the blog is no to opine on any one particular approach – but to lay forward the pros and cons and the factors governing them.

Almost everyone whom I have talked to (again from a Consumer perspective) are in common agreement that their typical experience of visiting a doctor in India is along the lines of following vignette

“Mr. Patel is suffering from a disease which is critical but not life-threatening. This particular disease has several treatment options which Mr. Patel is not aware of. Mr. Patel visits a specialist Dr. Shah who is known to specialize in the area of this particular disease and is aware of all the treatment options available. Dr. Shah believes one particular treatment option to be in the best interest of Mr. Patel and prescribes the same to Mr. Patel with little or no discussion about the other options.”

Note that in the above scenario – I am not implying that Dr. Shah had any ill-intentions or Mr. Patel suffered because of the prescribed treatment. However, just wanted to mention that this particular approach where the patient typically plays a passive role is termed as Paternalistic Model of doctor-patient relationship. The foundation of this model relies on the values such as personal loyalty and unquestioning obedience from the patient’s side and un-ending benevolence i.e. disposition to do good from doctor’s side.

Plenty of studies have shown that the Paternalistic Model of Management or Interaction is highly prevalent in almost all kinds of disciplines in India – be it in a Corporate settings or an Academic settings or as in this case even the Healthcare settings. Similar studies have also shown that such paternalistic model has traditionally worked favorably in Indian/Asian context with all the parties involved showing preferences for it. Also, as a Society, I have always believed that Indians – who have always traditionally been part of the collectivistic culture – have found the safety in relying on the paternalistic leaders for care, support, and protection. This has led to high paternalistic values in Indians. As a society, India’s culture values respect for hierarchical relations, strong family, and personal relationships assuming that there would be an affective reciprocity amongst all. This also fueled into India’s inclination towards paternalism into work places and institutions.

I strongly believe that at the core, the success of Paternalistic Model requires an effective leadership. From that point of view, I like the triad model which B. S. Cheng and D. Y. Jiang (you will have to do a Google search on this) presented about Paternalistic Leadership after their study in China. Essentially, they conceptualized Paternalistic Leadership as a three-dimensional construct involving –

  1. Benevolence – Holistic concern for dependent’s well-being.
  2. Morality – Demonstrating superior personal values
  3. Authoritarianism – Authority and control over the subject matter or the dependents.

This now brings me to the main part of this blog – is an Paternalistic Model of Healthcare effective in Modern India? My answer to this is ‘yes‘ and ‘no‘ both. I think as a society, India will soon have to find a middle ground on this. Here are my reasonings for it –

  • Rampant Illiteracy or Reducing Illiteracy – One of the common reasoning given in India for paternalistic approaches in Healthcare is rampant illiteracy. There is a strong belief amongst Healthcare providers (and many a times rightly so too) that such patients are unable to understand the nuances of medical treatment, procedures, and drugs and hence are unable to make the right choices for themselves. Hence the paternalistic view is taken. The corollary of this then is that such view then should not be taken with sufficiently literate patients or such view should be on its way out as the illiteracy levels in India reduces over a period of time (which is true!)
  • Human Body is one complicated piece of Machinery – I am sure, like me, many of you would have gone through the enormous amount of brain scratching (and stress) with or without your mechanic to figure out what is the matter with your car for not giving the mileage you desire. And we are talking about a machinery as simple as a car here (pun intended!). Complexity of Human Body machinery increases to the n’th level as compared to the cars. Except the run-of-the-mill problems, majority of problems in human body are complicated and requires a joint partnership between a doctor (or several doctors together) and the patient. In my opinion, one individual (be it the doctor or even the patient) providing the authoritative leadership over the subject matter of human body is just not humanly possible. There are limits of healthcare alternatives. It is not an exact science. Neither patients should believe that nor should doctors make their patients believe that. Hence paternalistic model of healthcare has its inherent limitations, IMHO.
  • Benevolence from Doctors – In my experience, Indian Doctors are typically extremely stressed with the work overload. Keeping an expectations from them to continiously have an holistic view of the patient’s health (it does take substantial time to do a good checkup of a patient, BTW) is being extremely unfair to them. I am saying this with the deepest amount of respect to the doctors. This is where, IMO, patients have to play an equal role in their personal healthcare. Rather than simply playing a passive role, they need to be the facilitators to the doctors so that the doctors can suggest proper decisions. Doctors on the other hand also need to be open and honest about this kind of expectations with their patients.
  • Morality – Paternalism rides upon enormous amount of faith and trust in the leadership. In this model of relationship, the expectations of patients are similar to the ones as to what a son would have from his father. In the same way as parents make decision for their children, doctors are supposed to make the decisions for their patients. Unfortunately, in the recent times, this aspect of relationship and/or trust seems to have taken a major beating for the worse in India. Hence the role of complete paternalistic model might be under question in healthcare in India.
  • Finally, it is “my body” – Majority of the doctors will continue suggesting what is the best for your body in the same manner as banks/financial institutions would continue taking care of your earnings. But this should not imply that you or me – as the individual owner of our body or our financial investments – do not have any responsibility. In my personal opinion, patients too have to rise up to take up the responsibility of owning what in reality only belongs to them.

Several literature in the West have gone to the extent of terming Paternalistic Approaches in Healthcare as an endemic. I would not go so far in terming it in that way considering that there are enough valid reasons for its existance today. However, as the Society in India evolves, an hybrid approach has to make its way.  Even the Prime Minister of India has acknowledged about this need in his address to AIIMS few years back.

I would love to hear your thoughts, comments, and fires on this topic. Depending on which shoes you wear, I have seen that this topic does induce a lot of passion.

[Update] – To read a Doctor’s perspective on this topic – please refer to my new blog post – “Doctor’s View – Paternalistic Model of Healthcare in India!