For much of human history and across multiple cultures, ethical behavior has been guided by the Golden Rule: do unto others as you would have them do unto you. When we act with empathy and compassion, we draw on this cherished principle. But the rule is imperfect. People vary greatly in their values, lived experiences and sense of what is acceptable. What you would want in a given situation may not be what another person desires at all.
In the arena of medicine, the stakes for making or influencing choices for others can be especially high. Such choices impact people’s quality of life and even their chances of survival. As health care becomes less paternalistic and more individualized, the time seems right for a new ethical guideline. Enter the “platinum rule,” proposed by Harvey Max Chochinov, a professor of psychiatry at Canada’s University of Manitoba: do unto others as they would want done unto themselves.
Chochinov, an expert on palliative care, eloquently describes this principle in his essay “Seeing Ellen and the Platinum Rule,” published last year in JAMA Neurology. He begins with a story about a health crisis affecting his late sister Ellen, who was severely disabled by cerebral palsy. The intensive care doctor managing her case, after seeing her twisted body and respiratory distress, was weighing whether to insert a breathing tube when he asked Chochinov a peculiar question: Did Ellen read magazines? “The subtext was chilling,” Chochinov writes, because “this was not an attempt to get to know Ellen ... but rather a cryptic way of deciding if hers was a life worth saving.” Ellen, her brother knew, read widely and relished many simple pleasures of life, but the gulf between her life as a frail person who uses a wheelchair and the physician’s sense of what he would want in her situation was too vast to be bridged by the Golden Rule.
“When the lived experience of another, the sensibility and perspective of another, varies widely from your own perspective, that’s when using yourself as this infallible barometer of what another might need or want begins to break down,” Chochinov explained to me. “We have to acknowledge the ways in which our own personal biases can shape the way we perceive and respond to patients.”
Those patients can differ from health-care workers by more than their abilities or disabilities. Their values can also be shaped by race, culture and experience. In a diverse society, doctors ought not project their values and presumptions onto the patient “as if the patient were a blank screen or clone of the doctors themselves,” observes Catherine Frazee, a disability advocate, author and emerita professor of disability studies at Toronto Metropolitan University. Medical practitioners, she adds, “are well educated, well respected and well paid. Those three things alter the way you see the world. So there is a real bias.”
The platinum rule is not entirely new. But in medicine, it pulls together current ideas about patient autonomy, equity and diversity in a succinct formulation that “is quite brilliant” and well suited to being taught to health practitioners, says medical ethicist Joseph Fins of Weill Cornell Medicine. Indeed, within weeks of writing about the idea in JAMA Neurology and in the Journal of Palliative Medicine, Chochinov began to hear of its uptake at a medical ethics conference and, before long, in other journal articles.
Making the effort to understand a patient’s personal needs and wishes does not mean catering to all of them. Medicine can’t be “a take-out service,” Chochinov says. “Not all patients can receive all things at all times. That’s the reality of living with a health-care system that has limited resources.” One of those limited resources is time, and there’s no denying that getting to know a patient as an individual—as opposed to the generic host of a disease—means investing additional minutes or hours. Still, Fins believes that such investment is usually cost-effective: “If we know what patients want, we will spend less time giving them things they don’t want.”
There are benefits for the clinician as well. “When doctors emotionally connect to their patients, they do a better job,” Chochinov says. “And we have data to show there is heightened job satisfaction and less burnout.”
In cases where patients cannot speak for themselves and where loved ones are uncertain of their wishes, clinicians may find it hard to apply the platinum rule. But, as Frazee sees it, there is value in the effort: “At the very least, your attempt to work through it will ensure that you have sufficient humility about the wisdom of your choices.”