By Doug Olsen, PhD, RN, associate professor, Michigan State University College of Nursing, and AJN contributing editor. Olsen regularly addresses topics related to nursing ethics. His most recent article for AJN was “Helping Patients Who Don’t Help Themselves” (July issue; free until August 15).
Why does the American Medical Association’s recognition of obesity as a disease (AMA, 2013) stir strong feelings? People are just as heavy as before, their health is suffering as much, and the therapies for obesity remain the same. The main difference is that the label may give clinicians a better rationale to seek reimbursement for obesity-related services, which might help increase treatment rates. No one yet knows if the new label will really have an effect on treatment rates; in any case, this is not what people are concerned about.
The issue is what labeling a health problem with a behavioral component as a “disease” implies about personal responsibility—or what people think it means. How does personal responsibility relate to individual suffering?
The relationship between decision making, suffering, and personal responsibility is at the heart of bioethics as it is practiced in the United States. But bioethics didn’t invent our cultural tendency to connect personal responsibility and sympathetic regard for suffering, and our current approach to the issue was developed through 28 centuries of increasing focus on the individual as the center of the moral universe in Western thought.
In the West, we are heavily invested in considering humans as autonomous—beings that act deliberately and are internally self-directed. In bioethics, the principle that clinicians should respect patient autonomy, patients’ deliberate, self-directed decisions, has preeminence over all other principles. Many critique this preeminence as a shortcoming, some deny its truth, and some defend it as right and proper. Patient autonomy can be ethically denied, but only with substantial justification.
But patient autonomy has another implication that’s less often discussed—people are considered responsible for the consequences of autonomously made decisions. Autonomy over health decisions and the concomitant responsibility for health decisions has emotional consequence that take a toll on clinical relationships (Olsen, 1997).
People tend to feel diminished sympathetic regard for the suffering of persons they hold responsible for that suffering—possibly because of the sense that the suffering is deserved. Suppose you tell a friend that John really hurts over his divorce from Mary, and your friend replies, “He treated her poorly and brought it on himself.” Is there any doubt about the friend’s lack of sympathetic regard for John’s suffering, although feelings were never mentioned, only a formulation about responsibility.
For nurses, the tendency to tie sympathetic regard for patient suffering to their personal behavior and choices has two potentially negatives effects on the clinical relationship. On one hand, nurses who blame patients for their pathology may have less caring concern for the patient.(Olsen, 1997) When patients sense this, they can feel marginalized and judged. Read the rest of this entry ?