Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is on twitter: @drricharmitage
While corporations and retailers supply goods for their customers, and therapists and lawyers provide services for their clients, medical professionals of all denominations provide treatment and care for their cohorts of patients. The narrative of the patient, and the ensuing doctor-patient relationship, has long been foundational to the delivery of medicine. However, considering the beneficiaries of general practice as ‘patients’ may not always be conducive to improving their health outcomes. I suggest it is right for GPs to primarily regard their beneficiaries as ‘agents’ rather than ‘patients’ in the majority of consultations that take place in general practice. This shift in perspective has not been achieved by the recent navigation towards ‘patient-centred care,’ but instead necessitates a major transformation in how the beneficiaries of primary healthcare are fundamentally conceptualised by its frontline practitioners.
The patient narrative
What is a patient in the context of healthcare? While he is a conscious living being with inherent moral value, he is entirely unable to control the circumstances of his health. Some external power, entity or force freely wills itself upon him to remove his health status thereby rendering him sick. This may be an infectious agent, a traumatic injury, or a gradual process resulting in disease. Ill-health is simply ‘done’ to the patient, who is a helpless victim entirely unable to prevent, mitigate or overcome the assailant without the purposeful assistance of an empowered third-party. This authority is, of course, the practicing medical professional, who is uniquely positioned to counteract the disease through the provision of a good that ‘fixes’ the problem. This could be a surgical procedure, a course of antibiotics, or capsules and creams that restore the patient’s health. To summarise the patient narrative: the illness is done to the patient, who is a powerless victim who necessarily suffers (‘patient’ comes from the Latin ‘patiens,’ meaning ‘suffering’), and can only be restored to a full state of health through the provision of care from a medical professional.
The agent narrative
In contrast to a patient, an agent has the inherent capacity to actively influence his own health outcomes by reasoning, planning, and making informed decisions. While the extent of this influence may vary between agents, and no agent whatsoever harbours complete control of outcomes, all agents hold a non-zero capacity to influence their choices and act to as sovereign authors throughout their duration of mental capacity. This could be visualised as a ‘sliding scale of agency,’ which is inherently set to zero in the early phases of life, and pushes upwards towards maximum as the individual becomes an adult. While a variety of factors impact on individual agency – including personality traits, past experiences, and prevailing cultural norms – and ignoring philosophical debates about the (non-)existence of free will, all individuals harbour at least some capacity for self-governance, thereby rendering them agents with the ability to self-rule. In contrast to those who are considered to be patients – who are disempowered victims helplessly dependent upon doctors – agents actively participants in the navigation of their own lives and harness their inherent sovereignty to make self-authored choices.1
‘Agents,’ not ‘patients,’ in general practice
The patient is not separable from, but rather emerges out of, the agent.
The narrative of the patient is unquestionably the correct and appropriate story to adopt and apply to emergency situations and episodes of acute illness. Being rendered unconscious by collision with a vehicle is undeniably the product of an external force, and such an individual is truly unable to control his health circumstances, meaning his outcomes legitimately depend upon the actions of medical professionals. However, exempting situations of severe incapacitation – which are rarely encountered in contemporary general practice – most consultations in primary healthcare take place between general practitioner and an agentic individual. Consider a spectrum of potential agency: the unconscious road traffic collision victim at one extreme pole, and the independent sovereign self-governing agent at the other. While no individual operates at the ‘ideal’ latter end of the spectrum (we are all enmeshed in relationships with others, institutions and nations, and both act and are acted upon in a broader social context),2 rarely do we find ourselves in the position of the former. Certainly in the realm of modern general practice, the individuals we consult with lie closer to the agentic end than the patient end of the spectrum. While the immediate diagnosis may declare them to be patients – such as chest infections in smokers or foot ulcers in diabetics – these outcomes are not isolated from their pre-disposing factors which are often greatly influenced by patients’ agentic decisions. Insofar that chest infections and foot ulcers warrant doctors to attend to patients, the lifestyles that foreshadowed them require doctors to attend to agents. As such, the patient-agent dichotomy could instead be seen as an iceberg: while the immediate diagnosis (a foot ulcer) manifests above water as a patient, the more massive predisposing factors (lifestyle) are submerged as an agent. The patient is not separable from, but rather emerges out of, the agent. For the doctor to not treat the former would be cruel and unacceptable, yet to ignore the latter – from which the former initially emerged and will continue to do so cyclically – would be arguably more unethical and morally prohibited. Accordingly, since general practice principally deals with functional, chronic, and diseases of lifestyle, GPs should primarily regard their beneficiaries as agents rather than patients.
Rationale for ‘agents’ instead of ‘patients’
…recognising inherent agency is substantially more respectful than assuming complete powerlessness and an absence of personal sovereignty.
To clarify my position – I am not advocating for GPs to deny treatment to patients. Rather, I am calling for GPs to also consider them as agents, and to primarily do so in the majority of scenarios. While this is not applicable in its entirety to all cases, it is the optimal default perspective given the nature of general practice. This is the case for two reasons: firstly, recognising inherent agency is substantially more respectful than assuming complete powerlessness and an absence of personal sovereignty. By venerating self-governance as intrinsic to human nature, the GP regards this value higher than their expertise as a third-party outsider and prioritises self-knowledge and the right to self-rule; secondly, by harnessing an individual’s inherent agentic nature, the GP enables them to maximally control their outcomes. By regarding the individual primarily as an agent, they are afforded with a tool that the patient is denied. The patient is a victim and entirely disempowered, while the agent is a sovereign permitted to orchestrate self-rule. While the former creates a patient entirely dependent on doctor, the latter forges an actor motivated to proactively, sustainably and responsibly take control of the factors that influence their circumstances and health outcomes. While circumstances variably impact the degree of agency possible, it is simply the case that optimal health outcomes are never promoted by the creation of victims through the denial of their agency.
To successfully place patients at the centre of their care, they should be radically reconceptualised as agents in general practice. This shift in perspective sees agents emerge out of patients, and we are ethically obligated to care for both agents and patients. The inherent conflict of interest is undeniable. We depend upon patients to warrant our livelihoods, while agents are empowered to render us unnecessary. How, or even if, this limitation can be overcome is an age-old debate with no signs of resolution.3
- H Walach, M Loughlin. Patients and agents – or why we need a different narrative: a philosophical analysis. Philosophy, Ethics and Humanities in Medicine 2018; 13(13). DOI: 10.1186/s13010-018-0068-x
- Aristotle. Politics. Translated by H. Rackham. Loeb Classical Library 264. Cambridge, MA: Harvard University Press, 1932.
- L Buckman. Is doctors’ self interest undermining the National Health Service? BMJ 2007; 334: 235. DOI: 10.1136/bmj.39098.405602.BE