Authority figures.

May-June 2012 To the Editor: In the SeptemberOctober 2011 issue, Daniel Groll addresses the question of what health care providers can know about patients’ interests (“What Health Care Providers Know”). He offers helpful refinements to my claim in Patient, Heal Thyself (Oxford, 2008) that generally health providers cannot know what serves patient interests. I am honored that a careful student of the patient-physician relationship has taken my arguments so seriously and has, for the most part, stated them accurately. Groll, for example, recognizes that the dispute about whether physicians can know patients’ interests is not about the priority of autonomy. Groll makes two key points: (1) when it comes to medically assessable means-ends disagreements, physicians really do know best, and (2) when it comes to patient ends, physicians are as good as anyone else in knowing what is best for the patient, not because of their medical expertise, but based on simple common sense. Both claims, however, are problematic. First, regarding physician knowledge of means-ends relations, medical experts are clearly expert in matters of medical fact: diagnosis, prognosis, and likely intervention outcomes. These would include what Groll calls medically assessable means-ends disagreements. I suggest, however, that these disputes, properly understood, almost never occur. What Groll considers disagreements about a means to medical ends (such as staying alive), are, when properly analyzed, really more likely to be disputes over subtle differences in ends. Consider Groll’s case involving physician and patient disagreement about whether amputation of a gangrenous toe will save a patient’s life. He claims the shared goal is “a gangrene-free [living] patient.” He claims, more or less correctly, that the physician is the real expert here in determining whether amputation is the best means to achieving this end. The problem, however, is that, if the goal is stated more precisely, the parties probably do not agree on it. For some (unstated) reason, the competent patient rejects that amputation. If the physician probed, the patient likely is really holding out for a slightly different goal, such as living without gangrene, but without the pain and disfigurement of the amputation, or living at a price he can afford. He may not even be committed to living. Every medical end offers multiple ways of pursuit. Each treatment option, however, offers some-