I haven’t blogged on the developing furor over the New Hampshire physician now being sued by a former patient for telling her - rather brusquely, it seems - to lose weight. But the longer this goes on, the more it seems to me the real problem is being missed.

The facts of this particular case aren’t clear, but apparently the doctor told the patient that if she didn’t lose weight she would suffer consequences to her health and her social life. The New Hampshire Union Leader explains:

Dr. Terry Bennett, who practices in Rochester, said he has “an obesity lecture for women” that is a stark litany designed to get the attention of obese female patients.

He said he tells obese women they most likely will outlive an obese spouse and will have a difficult time establishing a new relationship because studies show most males are completely negative to obese women.

Bennett said he tells them their obesity will lead to high blood pressure, diabetes, heart disease, gastroesophageal reflux and stroke.

My reaction has always been that this is rather out of line, and a patient is not amiss in taking offense. If the doctor actually is making hard-and-fast predictions of this kind, he is going beyond the facts to simply scare his patients into losing weight - not giving them information to make decisions, but deliberately pushing emotional buttons to get them to make the decision he wants, and doing so on the basis of predictions of future consequences he cannot know will be true for each patient. That’s not good doctoring, and it may certainly be offensive - lapses for which the doctor should be held accountable. But this is not what catches my attention about this case.

What is interesting is that the case has been discussed in the media almost entirely as a dilemma pitting the doctor’s responsibility against the patient’s negative reactions, or against the doctor’s liability for offending the patient. The harshest comments have taken the familiar “frivolous lawsuit” tack, while others have asked “how can doctors do their jobs?” if they cannot speak their minds to patients. (The “fat acceptance” community has had a different perspective, but one that has - predictably - been treated as freakish in its own right by the many commentators.)

This response assumes that bugging patients about their health is a doctor’s job. And, isn’t it? I’m not sure that’s so.

The move to the “shared decisionmaking” model of the provider-patient relationship, along with the decisive authority granted to the patient by the law and the autonomy movement, makes “the doctor’s job description” a much more malleable thing than in the past. Patients may simply choose not to address certain issues that are, arguably, unhealthy by some sort of “normal species functioning” physiological standard, but which the patient does not regard as incompatible with their own sense of health, or the curing of which is incompatible with the patient’s other goals. A doctor who insists on harping on some issue the doctor thinks should be an important part of the patient’s healthcare, but which the patient does not want to address, is overriding the patient’s goals for treatment and the treatment relationship - which under the current model of that relationship, the doctor may not do. What doctors are entitled to do is what patients authorize them to do, either explicitly or implicitly. Absent some contrary request, it is probably appropriate for doctors to raise “normal functioning”-type questions with patients when they meet those patients for the first time; there is a presumption in the “standard” treatment relationship, that is, that physiological issues are fair game for doctors, whom patients seek out, after all, because they are trained on precisely those issues. But when the patient has clearly indicated their goals and preferences for treatment - either at first meeting or over the course of an ongoing relationship - the “high autonomy” model requires that the doctor accept the patient’s goals for treatment and focus their efforts accordingly.

The question to be asked is not whether nagging (or insulting) patients is within the bounds of a doctor’s appropriate efforts to get the patient to act in a healthy manner - the question is whether “getting the patient to act in a healthy manner” is appropriately the doctor’s goal or responsibility. That is, the question is whether the treatment relationship and its content are defined by the doctor’s understanding of the health needs of the patient, or by the patient’s own preferences and goals regarding their own health - whether we endorse the “doctor knows best” model or the “high autonomy” model of healthcare goal-setting.

To that question, my answer is an unequivocal endorsement of autonomy. My argument for this position will have to wait (hopefully, for my dissertation, and, hopefully, in the foreseeable future), but the general argument for autonomy is well-known by now. And from this perspective, doctors not only may not attempt to force or cajole the patient into health goals the patient does not value, but doctors also should not attempt to scare, manipulate, or trick patients into health goals - even, arguably, physiologically beneficial ones - that the patient has not endorsed, on the assumption that the patient would endorse them if asked.

All it would have taken for this doctor in New Hampshire to have avoided the whole problem was to have asked the patient “You know your body weight is above average - is that something you want to work on?” Instead, he worked up an entire (almost literal) song and dance predicated upon his patient’s presumed resistance to an issue that he also presumed they would want to address - if only they could make themselves act on the values he assumed they shared with him. All he had to do was ask.