Blog | Friday, August 16, 2013

Slave doctors and slave patients: Plato on patient autonomy

[Author's Note: Thanks to Matthew Wynia at the American Medical Association who distributed to a group I'm involved with the following quote from the Dialogues of Plato about doctor-patient communication. I believe the translation is from Jowett, 1937, but I'm not sure.]

In the LAWS, Book 4 [says Wynia in a summary], we have the following discussion between the Athenian and Cleinias regarding patients lacking autonomy (because they are ruled by others) and autonomous (self-ruling) patients.

The Athenian asks: "You are aware that there are these two classes of doctors?"

Cle. To be sure.

Ath. And did you ever observe that there are two classes of patients in states, slaves and freemen; and the slave doctors run about and cure the slaves, or wait for them in the clinic. They never talk to their patients individually, nor do they allow them to talk about their own individual complaints. The slave doctor diagnoses and prescribes a remedy on an empirical basis, [but does so] as if he had exact knowledge; He gives his orders [to the patient], like a tyrant, and then rushes off, to see some other slave who is ill, all the while projecting an air of confidence and assurance;…

But the other doctor attends and practises upon freemen; and he carries his enquiries [with his patient] far back, and goes into the nature of the disorder in a scientific way; he enters into discourse with the patient and with his family, and is at once getting useful information from the sick person, and also instructing him as far as he is able. [The physician] will not prescribe for the patient until he has first convinced him; at last, when he has brought the patient more and more under his persuasive influences and set him on the road to health, he attempts to effect a cure.

Now which is the better way of proceeding in a physician and in a trainer? Is he the better who accomplishes his ends in a double way, or he who works in one way, and that the ruder and inferior?

Cle. I should say, Stranger, that the double way is far better.

There is much to note here. First is the distinction between slaves and freemen, not just among patients but among physicians. And the two are paired: a slave doctor deserves, so to speak, a slave patient, or perhaps the two are yoked together, each deserving no better than the other. For Plato, as we know from the Republic, is wedded to the hierarchy.

We can take away at least two lessons to our own day. First is that our care, in our enlightened republican democracy of the U.S. as much as in Greece, is inseparable from the economic stratum of its provision. It is a universally known but much hidden and ignored truth that the poorest and disadvantaged get the least care, a problem I discuss at length in my book. Further, though, we can read the terms "slaves" and "free [people]" more broadly. When a patient and provider can look beyond what others have called the "tyranny of the acute" and focus on the deeper issues that affect health, both become free to find the cure at the end of healing.

That, in closing, is the idea that fascinates me the most here. While, in my practice today, I think about treatment as inseparable from a cure (thinking about a correct treatment entails considering a cure), the account in the Laws seems to suppose something else. Only once a patient is on the "road to health" can the physician "effect a cure." I am not sure how to take this, but I find attractive the notion of cure as a process brought about by a long-term relationship between doctor and patient.

Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins School of Medicine. His research interests include doctor-patient communication, bioethics, systematic reviews, and the role of the primary care provider in cancer care. He is also the author of "Talking to Your Doctor." This post originally appeared at his blog.