Written in collaboration with Linda Trietler, MSN, RN – PhD student. 

Review of Kalisch, B. J. (1975). Of half-gods and mortals: Aesculapian authority. Nursing Outlook, 23(1), 22-28.

As we work to develop a collaborative and patient centered health care system we must remain aware of where we started and why the system needed to change. In 1975, thirty-nine years ago, Kalisch wrote that the traditional patient-physician relationship is based on the phenomenon of “Aesculapian Authority.” Aesculapius is the ancient Roman “god of medicine” and as such, was revered and wielded great control over people’s lives. It is interesting to note that the author, a nurse, states that the inspiration for the paper was her own experience as a patient and being hospitalized.

In her paper, Kalisch described three types of authority combined in Aesculapian power:

• Expert authority – Doctors are the experts by virtue of their training, and as such, believe that laymen could not possibly understand medical information and would probably harm themselves if they tried. By virtue of this authority, patient rights did not exist until the early 1960’s, and physicians did not feel the need to explain a medical condition or treatment. Patients were deemed to need no medical information because they could not understand it, and could not act on it if they did understand it, because of laws regulating “physician orders.”
• Moral authority: When physicians swear to uphold the Hippocratic oath, they are claiming they will always act in the patients’ best interests. However, to do so, they need to control the patient because only they have the necessary knowledge.
• “God-given” authority: The mysteries and unpredictability of life, health, and death are unfathomable to many people. In American culture, the fear of death is a powerful motivator. The physician has a power within him or her to relieve suffering and prevent, or at least postpone, death. That power accounts for reverence given to Aesculapian authority.

Kalisch indicates that within this traditional physician-patient relationship, patients often give up their self-determination. They take on a culturally-defined “sick role” and allow things to be done to them that strip them of dignity and cause pain, distress, and embarrassment, all of which may or may not solve their medical problem, and they have to pay for it as well. Until the mid-twentieth century, this could be done without consent! Fortunately, we now have a patient bill of rights and strict rules about informed consent. Physicians (and other providers) are beginning to view their roles as collaborative with the patient, less authoritarian and more like a teacher.

However, many people still give their power to their physicians. Kalisch links the difficulty of resisting authority face-to-face with non-compliance (Note: this is now called non-adherence) after leaving the physician’s office. Kalisch cited Davis (1968), a researcher who studied factors related to patient non-compliance, who reported that a physician’s attitude related to controlling the patient was influential in patient follow-through. Patients have trouble facing up to Aesculapian authority, but do exert their self-determination after they leave the doctor’s office.

Although this paper discussed only one aspect of the power of the physician, that of Aesculapian authority, the model explains possible sources of the reverence with which physicians are treated in this society, and the behavior of patients in giving their autonomy and decision-making power to a physician (or nurse) while meekly taking on a “sick role.”

Almost 40 years later this paper will resonate with both providers and patients as we work to create a health care environment that supports collaboration.

References

Kalisch, B. J. (1975). Of half-gods and mortals: Aesculapian authority. Nursing Outlook, 23(1), 22-28. http://www.truthaboutnursing.org/images/kalisch/half_gods_and_mortals.pdf

Papers cited by Kalisch:

Davis, M. S. (1968). Variations in patients’ compliance with doctors’ advice. American Journal of Public Health, 58, 274-288.

Milgram, S. (1973). Obedience to Authority: An Experimental View. New York: Harper & Row, p. 168.