Co-production as a resolution to authoritarian attitudes in healthcare

Introduction

Paternalism in healthcare appears when healthcare professionals intend to benefit patients or prevent them from avoidable harm without their consent. ¹ The motivation behind paternalistic attitudes can be interpreted as twofold. First, as a patient, seeking service at a healthcare facility explicitly, or at least implicitly, means that the patient looks for healthcare professionals’ expertise to alleviate her/his medical problem. Second, healthcare professionals’ medical knowledge and experience allow them to foresee which kind of medical intervention would benefit the patient the most. The first point gives healthcare professionals the authority and the second one denotes their expertise to restore the patient’s health. Therefore, using the medical knowledge and skills to benefit patients, even without their explicit consent, may be considered a professional, legal, and ethical duty and requirement. However, certain counterarguments could be stated to refute this conclusion. First of all, going to or being taken to a healthcare institution only indicates the patient’s general aim to receive medical support, not her/his specific consent to a particular intervention. For example, walking into a restaurant may imply that the person wants to eat something but does not prove that she/he desires any course on the menu. Maybe, some may dispute such an analogy between a customer in a restaurant and a patient in a hospital, but ultimately, both businesses produce and sell certain services for/to their clients. Secondly, healthcare professionals are familiar with medical knowledge, not the patient’s wishes, perception, and expectations. The chef can be the best person to know how to cook the meals the restaurant serves, but she/he may have no idea about the customer’s taste for a meal.

Even though paternalistic attitudes chiefly result from physicians’ good intentions and their interpretation of beneficence and non-maleficence, paternalism is deemed the nullification of the patient’s “dignity and humanity” (p. 6). ² The assumption and perception that physicians are best qualified to help patients with their medical conditions can end up ignoring the patient’s voice and acknowledging the physician as the only authority in the relationship of the two parties. Furthermore, this unequal encounter can prompt a sense of psychological superiority in favor of physicians, which may manifest itself in the clinicians’ authoritarian attitudes. However, the contemporary healthcare service requirements and ethical standards encourage the relevant parties to establish a mutual collaboration between healthcare professionals and patients. Shared decision-making is such an idea, which aims to ensure the cooperation of clinicians and patients in decision-making processes. ³ However, authoritarian attitudes in healthcare are not merely related to decision-making processes or procedures, but the status between patients and healthcare professionals. This paper asserts that for a sustainable, applicable, and ethically justifiable resolution, the relationship between healthcare professionals and patients should be regarded as an “equal partnership” (p. 12). ⁴ In this context, this paper aims to shed light on authoritarian attitudes in healthcare and propose the concept of co-production as a resolution to this undesired feature of healthcare.

Authoritarian Manner of Healthcare

Don Stewart and Thomas Hoult define an authoritarian person as “one who is rigidly ethnocentric, anti-democratic, compulsively conventional, punitive and condescending toward those regarded as inferiors, and submissive to authority” (p. 274). ⁵ Authoritarianism may be derived from various factors, but it appears as “ethnocentric, rigid, [and] antidemocratic” behaviors and attitudes (p. 71). ⁶ Contemporary ethical standards do not allow healthcare professionals to reflect any of these traits in their professional practice. ⁷ They are expected to be authoritative professionals demonstrating their expertise in medical knowledge and skills as well as carrying interpersonal qualifications without transforming their professional savvy into an authoritarian style. ⁸ However, many studies and practices in healthcare reveal that the authoritarian character of healthcare is a widespread phenomenon. Harry A. Sultz and Kristina M. Young evaluate this fact in the United States as “the long tradition of physicians and other health care providers behaving in an authoritarian manner toward patients” (p. 5). ⁹ Olaf Gjerlow Aasland and his colleagues draw attention to the prevalence of coercion in Norwegian healthcare toward psychiatric and drug addiction patients. ¹⁰ Graeme Currie and Olga Suhomlinova accentuate British physicians’ authoritarian mindset resulting from their professional privileges and power. ¹¹ Furthermore, anti-democratic and condescending attitudes in healthcare do not merely surface in the physician-patient relationship but also among healthcare professionals. For instance, the study conducted by Andersen et al. ¹² explores the pervasiveness of harassment among physicians in Norway, Sweden, Iceland, and Italy.

The study conducted by Dominick L. Frosch et al. ¹³ in California in 2009 reveals that even though patients are willing to participate in decision-making processes, physicians’ authoritarian attitudes deter them from expressing their preferences, concerns, and expectations regarding available treatment alternatives to their medical conditions. Furthermore, the study demonstrates that even well-educated and wealthy patients are negatively affected by authoritarian behaviors in shared decision-making. This situation indicates that neither the physician nor the patient considers the therapeutic relationship the collaboration of two equal parties. This imbalance between the actors not only stems from the physician’s authority on medical knowledge and experience, but also results from the patient’s physical and mental state being distracted by the disease. Edmund D. Pellegrino describes the patient as a “human in distress … who enters in a relationship of inequality [and] loses some of the most precious of human freedoms” (p. 225). ¹⁴ Although Pellegrino ¹⁴ acknowledges the inequality of the parties, he suggests protecting the patient’s vulnerability by establishing a joint relationship with the physician through consent. At first glance, these two statements seem to conflict with each other. However, the confusion may be removed by distinguishing the patient’s disease-based vulnerability and the physician’s expertise-based dominance from the equality of the two stakeholders. In other words, the patient and physician are in an unequal relationship in terms of their medical knowledge as well as their physical, mental, and emotional conditions. However, they are in an equal relationship regarding their role as two major stakeholders of care.

Co-production

Co-production is a concept that emerged in the 1970s in the private sector and was used in the public sector as well in the 1980s as a partnership between service providers and service users. ¹⁵ In particular, in the public sector, co-production may be interpreted as citizens’ participation in the democratization of services as well as their contribution to the production of public services. ¹⁶ Even though co-production refers to the involvement of users in the production of services, the intention behind this term shapes its goal. In this view, “democratization of services” addresses a political purpose, while “contribution to services” denotes an outcome-based aim. However, regardless of its purpose, co-production allows for users, as consumers and/or citizens, to play a role in the production and delivery of certain services.

Healthcare is one of the primary areas to which co-production is applied, particularly in countries where healthcare services are provided by the government. ¹⁷ Femke D. Vennik et al. ¹⁸ define co-production in healthcare as patients’ contribution “to the provision of health services as partners of professional providers” (p. 151). The partnership has a significant function in the therapeutic relationship between the clinician and patient to produce quality healthcare services through the combination of the clinician’s medical knowledge and experience and the patient’s values and preferences. ¹⁹ However, many concepts, such as “informed consent process,” “shared decision-making,” “patient-centeredness,” and “personalized healthcare” that indicate certain interactions and collaboration between healthcare professionals and patients are already in clinical settings, which prompts the question of whether co-production offers more than these concepts. Co-production has a close relationship with all the mentioned concepts due to addressing the participation of patients in treatment processes and procedures. However, the unique aspect of co-production is the requirement for the patient’s input in the production phase of healthcare services. ²⁰ In other words, co-production demands the patient’s active involvement as much as possible in relevant treatment processes, rather than a passive position of accepting or rejecting a recommended treatment. ²¹ At that point, even though, in practice, co-production may reveal the same function of shared-decision making, in terms of the working togetherness of healthcare professionals and patients (making decisions together), co-production contextually transcends the shared-decision making process by addressing all the production cycles of healthcare services (producing together). ²²

According to Avedis Donabedian, the quality of care in practice depends on two factors “[o]ne is the science and technology of health care, and the second is the application of that science and technology in actual practice” (p. 4). ²³ From this perspective, “science and technology of health care” is related to the clinician’s medical knowledge and skills, and “application of that science and technology” is directly associated with the art of care, which is the essence of nursing, and the partnership with the patient. ²⁴ Donabedian refers to those two different parts as “a technical task and an interpersonal exchange” (p. 247). ²⁵ At that point, healthcare services may be considered a co-product of delivering medical knowledge and experience. Therefore, co-production necessitates a new mindset and structure to acknowledge the patient as a major player in the whole system, not only in the decision-making process. ⁴ In this view, as Donabedian ²⁵ elaborates, it is reasonable to define patients as co-producers of care, vehicles of control, reformers of healthcare, informants, and definers and evaluators of quality due to their remarkable role in the relevant area.

Additionally, Stephen Buetow points out the recognition of patients “as principal primary health care workers” and “co-producers of formal health care” and highlights the requirement of “joint respect and integration of the major interests of patients and professionals” in healthcare (p. 243, 246). ²⁶ In the case of such a consideration, patients can no more be regarded as passive participants or stakeholders, but as prominent co-producers. Implementing this approach to healthcare would eliminate or at least mitigate healthcare professionals’ authoritarian and paternalistic attitudes and behaviors by replacing the assumption that clinicians are best equipped to do best for patients with the viewpoint that patients are active players shaping healthcare services through an equal partnership with healthcare professionals.

However, describing such a broad function for the patient could bring about several challenges in practice. Firstly, as Caitlin McMullin and Catherine Needham mention, expertise is one of the major matters when providing the patient with a more active role in medical procedures. ²¹ Secondly, healthcare professionals already experience high workloads, and working with patients throughout treatment processes would cause them to face greater time pressure-based negative outcomes. ²⁷ Thirdly, the limitations of informed consent, including the issue of incompetent patients, cultural differences, the level of the patient’s engagement, and the patient’s willingness to participate in the production of services are valid and pertinent problems in a co-production-oriented relationship. ²⁸

Ethical Aspect of Co-production

Collaboration in healthcare indicates promising outcomes for all stakeholders and requires an acceptable relationship among relevant parties. ³⁰ In particular, the relationship between healthcare professionals and patients is substantial in improving the quality of care, access to care, and patient satisfaction. ³¹ However, regarding healthcare professionals and patients, establishing an effective relationship necessitates both parties’ efforts. In terms of clinical and research ethics, informed consent is utilized as a legal and ethical requirement to demonstrate the patient’s engagement in decisions. However, as many studies prove, informed consent or its application carries various challenges, including the patient’s understanding and language barriers, the level and scope of the disclosed information, religious and cultural influences, and the situation of patients who lack decisional capacity, which turn the process into a formal ritual of having a signature on a document or form.^{28,29,32,33,34} Due to the prevalence of such problems, some scholars suggest alternatives to informed consent, such as “understood consent” and “informed request” to produce solutions for those issues.^28,33

Even though informed consent plays an important role in the communication and relationship between healthcare professionals and patients, it appears that merely looking for a resolution around the concept of informed consent and its practices may be problematic and insufficient. The birth of informed consent goes back to Walter Reed’s yellow fever research in Cuba, but it has flourished in the bioethics period, which started in the early 1970s, as a fundamental component of the right to self-governance and respect for autonomy. ³⁴ However, without acknowledging patients as the primary party of the equal partnership, the implementation of informed consent with the current challenges would continue to denote a mere ritual or a signed form stemming from the physician’s benevolence. In other words, informed consent should be considered an agreement and collaboration between two equal parties rather than a legal, ethical, or professional obligation of physicians or healthcare professionals, which needs a paradigm shift. Therefore, accepting patients as co-producers of healthcare services would help to fulfill that paradigm shift.

Application of Co-production

Even though informed consent, shared-decision making, and similar concepts require the patient’s involvement in decision-making processes, it may be difficult to establish a mutual and equal relationship between healthcare professionals and patients through these tools because such an approach implicitly considers healthcare professionals the only party producing healthcare services; patients are only co-decision makers, not co-producers, which gives healthcare professionals psychological superiority and authority. In some cases, patients even voluntarily surrender to healthcare professionals due to the power stemming from medical knowledge and practice. ³⁵ This situation proves that neither healthcare professionals nor patients deem patients as an equal party and necessitates “[s]hifting the balance of power from healthcare professionals to patients” (p. 695). ³⁶ At that point, co-production is an applicable way to change or redesign the basic mentality about the position of patients in the therapeutic relationship.

However, a few issues should be elaborated on to clarify why and how a new approach should be implemented. Firstly, some may ask, even though the informed consent process carries many limitations and challenges, how would it be possible to go a step further through co-production? ³⁷ Responding to this question requires looking at the patient’s status in the therapeutic relationship. As Martin Christensen and Jaqui Hewitt-Taylor accentuate, the traditional view defines patients as “unaccustomed, disinclined and unequal to questioning medical decision making” (p. 695). ³⁶ Implicitly or even explicitly placing patients into such a position cannot encourage patients to actively participate in healthcare decisions. In other words, not recognizing patients as equal partners of healthcare professionals not only induce caregivers’ authoritarian attitudes, but also causes patients to put themselves in a submissive and inferior position. Healthcare professionals and patients should sit around a table to discuss treatment processes and procedures as two equal partners.

Another question that may be raised about the application of co-production is how patients can actively get involved in pertinent decisions when they have no or insufficient medical knowledge. It is crucial to emphasize that this present proposal does not ask patients to decide on treatment regimens, which is unreasonable and impossible, but empowers them to engage in every stage of medical procedures as a co-producer and equal party. The patient’s role refers to decision makings, not medical practices. In other words, co-production does not expect patients to perform surgery or prescribe a medication, which must be done by clinicians, but allows them to discuss all available medical options with healthcare professionals. ²¹ Even though this description seems very similar to informed consent or shared-decision making, the unique aspect of co-production is to accept patients as equal partners in the picture and to stress its significant impact on positioning healthcare professionals and patients in the therapeutic relationship.

Co-production aims to encourage patients to be actively involved in decision processes and take responsibility for their health through a suitable framework. The patient’s active involvement in healthcare encompasses several benefits, including respecting human dignity. ³⁸ As Ann Gallagher underscores, respect for dignity is twofold: “respect for the dignity of others [other-regarding value] and respect for one’s own personal and professional dignity [self-regarding value]” (p. 587). ⁴⁰ Current decision-making processes (informed consent, shared decision-making, etc.) mostly focus on the patient’s other-regarding value and overlook the patient’s self-regarding value. Ignoring respect for the patient’s own dignity (by ignoring or underestimating the patient’s role and position in the therapeutic relationship) directly and negatively influences the patient’s participation in her/his treatment decisions through the perception of “the physician knows best,” and indirectly and negatively impacts respect for the patient’s dignity as well because it opens the door to authoritarian approaches. ⁴¹ In this context, acknowledging the patient as a co-producer and equal partner would positively affect both the patient’s other-regarding value and self-regarding value. However, fulfilling this needs a paradigm shift in healthcare professionals’ perceptions and perspectives, which requires doing this in the first place by revisiting education in medical, nursing, and other healthcare-related schools.

Conclusion

Healthcare professionals should be authoritative to facilitate patients’ cures while avoiding becoming authoritarian in their relationships with others. However, the psychological aspect of playing God, the increasing power of medicine through new medical, technological, and pharmaceutical developments, and the current social system have generated authoritarian attitudes among healthcare professionals and toward patients. ⁶ Preventing authoritarian attitudes and behaviors entails revisiting the language used in medicine to correctly define the role and duty of each pertinent stakeholder. At that point, the problem would be alleviated by underscoring the team-based notion of contemporary medicine and regarding patients as leading players or members of the team, which can be boosted with the concept of co-production. The implementation of co-production in healthcare has great potential to change the perception of healthcare professionals and patients about each party’s role in the therapeutic relationship. In particular, describing the patient’s function as Donabedian does would urge healthcare institutions to accept patients as co-producers of healthcare services with an equal partnership with healthcare professionals. In this view, co-production in healthcare would improve the therapeutic relationship, decrease ethical violations, and promote the patient’s dignity.

Ethical problems, conflicts, and uncertainties not only hurt patients but also healthcare professionals. For instance, nurses face many ethical challenges stemming from unethical acts of other professions, issues among healthcare professionals, and patient-related matters in their daily practices. ⁴² Redefining the role of the patient in accordance with co-production and equal partnership would help to alleviate such everyday ethical challenges because it necessitates healthcare professionals to abandon authoritarian attitudes and demands patients to actively engage in all decisions. Therefore, the expected outcomes of co-production in the therapeutic relationship would also reduce the moral distress and pressure on healthcare professionals, including nurses.