Not long ago, we admitted an elderly man who had a laundry list of medications which the medical resident (a doctor training to become an internist) on duty faithfully reproduced on the admitting orders so that he could continue taking them while he was confined in the hospital. A few hours later, the patient’s blood pressure plummeted, and he had to be transferred to the intensive care unit. Fortunately, he survived. Upon further interview, the man sheepishly admitted that he had not been taking his medications properly, including three antihypertensive medications at near-maximum doses.

In the old days of medicine, the relationship between doctors and patients was seen as patriarchal. The doctor had near-godlike knowledge, and the patient would follow whatever he or she said. There was no internet, and the only way a patient could do “research” was to hit the library and look at medical textbooks, which were written in highly specialized language but were almost always a few years behind the latest scientific breakthroughs.

Nowadays, anyone can search the internet for any medical topic, and you can even get an AI summary of what was being said. While these summaries are fairly accurate, they are quite general and should not be applied to individual cases, which may have all sorts of nuances. When I was in medical school from 1996 to 2001, the paradigm shift from a patriarchal to a patient-doctor partnership was in full swing. We were taught the ethical framework in which to handle our care of each patient based on four principles: beneficence, non-maleficence, justice, and autonomy. Prior to these ethical frameworks, doctors could recommend just about anything to a patient, and the patient was expected to follow.

Beneficence means that the recommendation needs to be grounded in credible evidence showing a good effect on the patient. After all, why take something of dubious efficacy? Doctors working on this premise need to make sure that there is good scientific evidence of a positive effect, and they should also explain to the patient if something is not as clear-cut. An instructive example is vitamin supplements. Vitamins are good for you if you don’t get enough of them in your diet. People with vitamin deficiencies get sick easily and can have disease manifestations if the deficiency is severe. Someone who eats a proper diet, however, does not need to take vitamin supplements. Therefore, when recommending vitamin supplements, a doctor needs to consider a patient’s nutrition, health status, and lifestyle.

Non-maleficence is ensuring that any recommendation we give does not cause harm. In instances where some harm can ensue, it should be vastly outweighed by the benefit. Going by the example of vitamins, taking excessive doses of vitamin A can harm your liver. Taking too much vitamin C beyond the recommended daily allowance (90 mg for men, 75 mg for women) can result in hyperacidity and kidney stones. Vitamin C is particularly contentious because many people believe that mega-doses of vitamin C can boost the immune system. Though the overall body of scientific evidence does not bear this view out. Another example is chemotherapy. Many forms of chemotherapy have horrific side effects. Therefore, it should not be given to people in whom there is uncertainty about the diagnosis or in whose disease there is limited evidence of efficacy. Some patients want to try anything and everything, even if the evidence is lacking, and doctors should withhold treatment that they know is toxic if there is no demonstrable benefit.

Justice means treating every patient equally, regardless of their race, religion, political beliefs, or capacity to pay. This means doctors should exert the same amount of effort and due diligence on a charity patient and a private patient. This does not remove the obligation to pay fair professional fees if they choose to be under private care. There are instances where doctors can refuse care if there is a clear and present danger to themselves. Doctors can also refuse to take care of non-emergency patients for whatever reason, as long as they can recommend another doctor who can properly take care of that patient.

Autonomy is perhaps the trickiest of the four. We hear a lot about “informed consent” before treatment, but it is much harder to pin this down. Just how much information is enough for a person to be well-informed about a medical decision? What is considered a good source of information? With so much fake news and pseudoscience on social media, we often see patients in the clinic bringing a thick ream of printouts from the internet. Some of these are well-researched and use valid scientific methods, but a lot are from dubious sources or give inadequate and sometimes dangerously biased viewpoints. For instance, the link between autism and vaccines has repeatedly been debunked, but some patients continue to believe fringe conspiracy theories on the subject. Some of the distortion is also done by doctors for whatever reason, which further confuses patients.

Informed consent at the bare minimum is the doctor giving the patient a good understanding of the risks and benefits of the intervention and a realistic and reasonable estimate of the expected outcome. There should be an opportunity to ask questions, and the patient should be able to change their mind at any time, even during the intervention. An inappropriate use of autonomy is to present the risks and benefits and ask the patient to decide without making a recommendation. Since the doctor has specialized training and greater knowledge, it is important for us to guide the patient as to what we think will be of the greatest benefit in light of the illness. Autonomy also means not forcing them to accept the treatment if they don’t want to, even if you think it is in their best interest, for as long as it is properly explained and the patient is mentally competent. I once had a patient with a healthcare background who was diagnosed with HIV. I recommended starting antiretroviral medications, but he refused. He continued to follow up with me, and every time I offered meds, his answer never changed. I screened him for depression, and he saw a psychiatrist who maintained that he was decisional and had enough mental capacity to make medical decisions. Eventually, we had to admit him for a severe opportunistic infection, and he unfortunately passed away recently. With the patriarchal model of medicine, some physicians may have asked the patient’s family to force him to take the medicine, but this is not something that we can ethically do nowadays.

The practice of medicine continues to evolve, and it is important for both patients and doctors to see their relationship as a partnership. Doctors have the knowledge to make recommendations to promote health and prolong life, and it is up to patients to decide if they will follow their recommendations. With good rapport and a healthy amount of empathy, the best possible outcome can be reached.