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Consent or Obedience? Power and Authority in Medicine
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     A recent biography of the social psychologist Stanley Milgram (The Man Who Shocked the World, by Thomas Blass)

    details the "obedience experiments" that made Milgram famous. These studies demonstrated that ordinary people could

    be induced by an authority to deliver to a victim what they believed were increasingly harmful electric shocks.

    Milgram's contribution was not in showing that human beings obey authority, but in demonstrating how powerful and

    potentially dangerous that predisposition is. It doesn't take evil or deranged people to do awful things to others;

    normal people will act that way if commanded by a legitimate authority. Sadly, although these were laboratory

    experiments, the results are substantiated by daily experience.

    (Figure)

    One of Milgram's Research Subjects at the Shocking Machine.

    Courtesy of Alexandra Milgram.

    Milgram's work taught us something profoundly revealing about human nature: how prone we are to obey the commands

    of an authority even when they conflict with our expressed desires or moral principles. Here was a common, perhaps

    universal, human characteristic that came as much as a surprise to psychologists and physicians as it did to

    others. Indeed, the real surprise may be how little research-confirmed knowledge there is about everyday human

    behavior.

    Milgram's research carries implications for at least two important issues in the hierarchical world of medicine:

    the role of inappropriate obedience as a source of abuse in the teaching hospital and the effect of obedience on

    patients' autonomy and consent. In the hospital, faculty members have jurisdiction over house staff, house staff

    have authority over students, and all these people are seen as authorities by patients. There is probably no

    physician or medical student who has not seen or participated in callousness (or worse) in the treatment of

    patients in response to an order of a resident or an attending physician.

    We might simply feel bad, and let it go at that, when patients are mistreated because of undue obedience on the

    part of health care personnel, if it weren't for other findings of Milgram's research. For not everybody obeyed.

    Some research subjects who thought they were hurting someone refused to continue. In general, more subjects refused

    to obey when the victim was brought physically closer to them, with the greatest disobedience occurring when the

    subjects could touch the victims. Perhaps we should expect episodes of bad treatment of patients by people

    following the orders of remote authorities. Accepting this fact is necessary in order to prevent ill treatment. To

    some degree, obedience is a requirement of training, but abuses of authority do not have to happen in medical

    institutions; appropriate disobedience can be taught. It is important that this problem and its solutions be

    discussed and integrated into training programs.

    Milgram's studies also bear on the issue of patients' autonomy and consent to treatment and research. The past 30

    years have seen the gradual disappearance of the model of the autocratic, paternalistic physician who extracts

    consent from patients — a model that has been superseded by the concept of patient autonomy, widely translated as

    freedom of choice. But such a view neglects the complexity of the social world that acts on all of us. This

    complexity has led to increasing questions about what autonomy means in medical settings.1

    The question of how often patients' consent really reflects their best interests (as they understand those

    interests) rather than representing obedience to the physician's authority is made more urgent by the results of

    Milgram's research. Physicians want to believe that their authority resides in their expert advice, not their

    social power, and that consent to their inclinations reflects acknowledgment of that expertise. Physicians do not

    like the word "obedience" — even "compliance" has fallen from favor — because they reject the image of the

    authoritarian physician and the dependent patient that it evokes.

    But the matter is not so simple. First, patients provide consent not only about the big things that require signed

    forms or other formal processes. In the course of an illness, sick patients, especially if they are hospitalized,

    consent innumerable times to interventions that they would rather not undergo — from taking medications to

    enduring painful procedures. Second, medicine is primarily about sickness, not health. Considerations of authority,

    autonomy, and consent must be informed by what we know about sick patients and their relationships with physicians.

    Serious illness is marked by losses of normal function in many dimensions of existence, including the ability to

    reason and to act (without which "autonomy" loses meaning).2 Sick people do not do things primarily because they

    have single-mindedly reasoned their way to decisions based on appraisals of the relevant information, but because

    an authority helps them to decide.

    In the aftermath of Milgram's work, other researchers attempted to explain the subjects' obedience. They described

    six possible sources of an authority's social power: coercive power that is also a potential source of punishment,

    the power to reward that is a potential source of approval, legitimate power with its right to prescribe behavior,

    power in authorities that are admired, power that derives from expertise, and power that follows from information

    given in a convincing manner.3,4 Although these studies, like Milgram's, involved experimental subjects, not

    patients, we can easily identify these sources of power in the medical world — and add the power that comes from

    the hospital setting and the trappings of medical authority. Such power can be enhanced, diminished, used well or

    ill, but it cannot be disowned. For example, sometimes, in seeking consent from patients, physicians merely tell

    them the options and ask them to choose one. Aside from being insensitive to the facts of illness, this method

    complicates sick patients' efforts to be obedient, for they must first divine which option their doctors prefer.

    Bearing in mind the effect of sickness on function, we should accept the propensity of sick patients to seek our

    approbation, celebrate our expertise, and acknowledge the legitimacy of our authority by doing as they think we

    wish. These tendencies present us with the difficult responsibility of, first, probing carefully to discover what

    patients believe to be best for them and, second, ensuring that their best interests guide both what we ask of them

    and our own actions.

    To date, the field of bioethics has been limited in its understanding of the nature of responsibility and its basis

    in human relationships. Milgram's research serves medicine well if it makes us aware of the breadth of our

    responsibilities to sick patients. We are responsible for knowing, among other things, what patients are doing out

    of obedience rather than because it is best for them. The biggest thief of autonomy is sickness. One of the

    functions of medical care is to help patients reassert their autonomy — including their ability to make authentic

    decisions.

    The Man Who Shocked the World: The Life and Legacy of Stanley Milgram, by Thomas Blass, was published in 2004 by

    Basic Books, New York.

    Source Information

    Dr. Cassell is a clinical professor of public health at Weill Medical College of Cornell University, New York.

    References

    Schneider CE. The practice of autonomy: patients, doctors, and medical decisions. New York: Oxford University

    Press, 1998:xxii, 307.

    Cassell EJ, Leon AC, Kaufman SG. Preliminary evidence of impaired thinking in sick patients. Ann Intern Med

    2001;134:1120-1123.

    French J, Raven B Jr. The bases of social power. In: Cartwright D, ed. Studies in social power. Ann Arbor: Research

    Center for Group Dynamics, Institute for Social Research, University of Michigan, 1959:150-67.

    Blass T, ed. Obedience to authority: current perspectives on the Milgram paradigm. Mahwah, N.J.: Lawrence Erlbaum,

    2000.(Eric J. Cassell, M.D.)