Culture of paternalism in the emergency department: a critical ethnographic study

Abstract

Background

Paternalism refers to the act of overriding an individual’s preferences or decisions under the justification of acting in their best interest or protecting them from harm. When paternalistic care is delivered, it can result in adverse physical, psychological, and social consequences for patients. This study aimed to describe, interpret, and critically examine the culture of paternalism within the context of the emergency department.

Methods

This critical ethnographic study was conducted in the emergency department of a public hospital in Khorasan Razavi Province, Iran. The research followed Carspecken’s method of critical ethnography, encompassing three preliminary and five main stages. Data were collected through participant observation, in-depth interviews, and document analysis to uncover the beliefs, values, actions, and power dynamics that reinforce paternalistic structures within the emergency care setting. Over 22 months of field work, empirical data were gathered and subsequently analyzed using reconstructive analysis. The identified systemic relationships were then interpreted in light of relevant sociological theories.

Results

Analysis of the data led to the identification of four categories: domination of the superior, facilitation of the domination of the superior, destruction of the inferior, and the echoes of paternalism.

Conclusions

The findings indicate the presence of an entrenched culture of paternalism in the emergency department—one that poses significant challenges to delivering humane and ethically grounded patient care. These results underscore the need to raise awareness among healthcare providers regarding the ethical dimensions of clinical interactions and to enhance their understanding of the social and legal issues related to patient care. Ultimately, such awareness can inform strategies to recognize and address structural barriers, promote respect for patient autonomy, and support adherence to patients’ rights.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13282-8.

Background

Paternalism is defined as the act of overriding an individual’s preferences or decisions under the justification of promoting their welfare or protecting them from harm [1, 2]. In the context of healthcare, medical paternalism arises from an inherently asymmetrical power dynamic in which the medical team occupies a position of authority, while the patient is viewed as dependent or vulnerable [3, 4]. Based on criteria such as respect for autonomy, the extent of intervention, and the patient’s capacity for decision-making, medical paternalism has been classified into various types. These include weak (or soft), strong (or hard), broad, narrow, pure, impure, moral, welfare-oriented, active, and passive paternalism [5]. Of these, weak and strong paternalism are widely debated in clinical practice. Weak or soft paternalism applies in situations where a patient lacks the competence or capacity to make informed, autonomous decisions. In such cases, healthcare professionals may intervene to protect the patient from harm and act in their best interests [6, 7]. A weak paternalist assumes that the patient, if fully informed and cognitively capable, would make the same decision as the one being made on their behalf. This form of paternalism is particularly relevant when patients experience significant cognitive impairments that compromise their ability to understand the consequences of their choices, even if they retain some decision-making ability [8]. Although such interventions infringe upon patient autonomy, they are generally considered ethically justifiable under the principle of beneficence, given their intent to prioritize patient best interests [9].

In contrast, strong or hard paternalism occurs when a healthcare provider overrides a patient’s decision despite the patient being fully capable of autonomous reasoning. In this model, the physician often assumes the role of an expert authority, while the patient is expected to comply with medical recommendations. Proponents of strong paternalism argue that individuals may lack the insight necessary to act in their own best interests and that restricting autonomy in such cases may prevent harm or undesirable outcomes [10]. However, this approach raises more serious ethical concerns than soft paternalism, as it entails a deliberate and often explicit violation of patient autonomy. It also rests on the assumption that the patient lacks sufficient competence to determine how their health and life should be managed [11].

Various studies indicate that healthcare providers often show a reluctance to share decision-making authority with patients, underscoring the persistent influence of the paternalistic model in patient–physician interactions [12–16]. This tendency has also been observed in research conducted within emergency departments [17–19].

A defining characteristic of emergency settings is the consistently high and growing patient volume, which significantly constrains the time available for shared decision-making [20]. In addition, patients in emergency departments are particularly vulnerable and often experience feelings of abandonment, exposure, embarrassment, neglect, and insecurity. They may also lose their sense of autonomy and self-determination [20, 21]. These defining features of the emergency care environment present significant challenges to patient-centered decision-making. Furthermore, the entrenched culture of paternalism in such settings poses a serious threat to the ethical delivery of care. Paternalistic practices can heighten patients’ anxiety and insecurity, diminish their confidence and sense of control, and ultimately contribute to dissatisfaction with care. These effects extend beyond the immediate clinical encounter, carrying adverse physical, psychological, and social consequences [22].

Notably, paternalistic values, beliefs, and healthcare behaviors may be expressed differently across cultural contexts. This highlights the need for context-specific inquiry, particularly in underexplored settings such as Iran. In light of this, the present study was undertaken to explore how and why a culture of paternalism is constructed within the emergency department. Specifically, it seeks to examine the individual and collective behaviors, beliefs, values, and norms that sustain this culture. Additionally, the study considers how the findings might be critically evaluated concerning broader historical, social, and economic structures and interpreted through the lens of relevant sociological theories.

Methods

This qualitative study was grounded in the critical paradigm, which was deemed appropriate given the research focus. The critical paradigm enables researchers to examine power relations embedded within the culture of paternalism and, importantly, to explore the potential for transformation in these dynamics, particularly within the high-stakes context of the emergency department. To this end, a critical ethnographic approach was adopted in the present study.

In critical ethnography, the researcher immerses themselves in the natural setting of participants to observe and explore the phenomenon in depth, aiming to generate rich, contextualized insights into the culture and uncover the meanings embedded in social behaviors. Simultaneously, the researcher critically examines how power dynamics and structures of domination influence production, reproduction, and reflection in social life [23, 24].

The critical ethnographic method employed in the present study was developed by Carspecken in 1996. This approach aligns closely with the aims and research questions of the study, as it is rooted in critical theory. It seeks not only to understand and interpret social realities but also to critique and, where possible, initiate transformative change [25, 26]. Carspecken’s critical ethnographic method comprises three preliminary stages followed by five principal stages. Each of these was followed systematically throughout the research process (Table 1), guiding both data collection and analysis.

Table 1.

Stages of the critical ethnography of carspecken [27–29]

Carspecken’s Critical Ethnography
Preliminary stages	Preparation of a list of questions
	Determination of the required information
	Researcher value orientation test
Main stages	Compiling the primary record
	Preliminary reconstructive analysis
	Dialogical data generation
	Describing system relations
	System relations as explanations of findings

Research field and participants

This study was conducted in the emergency department of a public hospital in Khorasan Razavi Province, Iran, chosen for its role as a referral center serving a culturally, economically, and socially diverse patient population. The heterogeneity of this setting offered a rich context for observing expressions of paternalism in healthcare. With an average monthly admission of 3,618 patients, each clinical shift was staffed by a multidisciplinary team including nurses, medical interns, emergency medicine residents, a specialist, and administrative staff. Participants encompassed all individuals directly engaged in patient care—patients, family members, nurses, physicians, and other providers—enabling a comprehensive analysis of the cultural dynamics sustaining paternalism.

1. Preliminary stages

Following Carspecken’s critical ethnographic method, two preparatory lists were developed: a list of guiding questions to structure data collection and a list of potential sources. To address researcher bias, a reflexive interview was conducted with the primary researcher by a qualitative expert. This audio-recorded and transcribed interview was critically analyzed, and its findings were incorporated throughout the study to ensure reflexivity and methodological rigor.

• 2. Main stages

• Compiling the Primary Record: Fieldwork

In ethnographic research, data collection is primarily conducted through immersive fieldwork, which allows the researcher to gain first-hand experience of the cultural group or community, thereby revealing embedded cultural patterns. Fieldwork involves multiple techniques—participant observation, note-taking, interviews, group discussions, and document analysis—while also attending to sensory and affective elements such as sounds, lighting, spatial arrangements, and moods [26, 30, 31].

In this study, following Ethics Committee approval and introduction to the head nurse, the researcher entered the emergency department as a nursing researcher. After explaining the study’s goals, she established trust through transparent and respectful engagement, emphasizing voluntary participation and confidentiality. Participant observation, the main data collection method, was integrated with active participation in routine nursing care, including medication administration, IV catheterization, cardiac monitoring, and CPR. Observations spanned all shifts, weekdays, holidays, and significant cultural events to capture contextual variation. Detailed field notes included contextual details—date, time, temperature, odors, lighting, and emotional tone—along with non-verbal cues like facial expressions, gestures, and vocal tone. A reflexive journal documented the researcher’s evolving interpretations and was used to monitor and mitigate personal bias throughout the fieldwork period.

• Dialogical data generation

In this study, dialogical data were primarily generated through informal conversations that emerged organically during participant observation. As Spradley notes, ethnographic interviews often arise unexpectedly and unplanned from routine interactions in the field. He emphasizes that the most effective approach to such interviews is to treat them as friendly conversations. Rapid or structured questioning can disrupt this dynamic, transforming the exchange into a formal interrogation and potentially discouraging participant engagement [32]. A semi-structured interview protocol—developed using Carspecken’s critical ethnographic guidelines and refined through expert feedback—was implemented at the end of fieldwork for data triangulation. All interviews were in-depth, conducted privately, and scheduled according to participant preference. Informed consent was obtained, and interviews were audio-recorded for transcription and analysis. The English version of the protocol is available in Supplementary File 1.

Additionally, organizational documents were analyzed to explore how institutional structures and communication practices reflected paternalistic norms. According to Lindlof, documents were treated as institutional artifacts serving various communicative and regulatory functions [31]. Documents included official announcements, clinical records, patient feedback, and procedural guidelines. This analysis enriched the ethnographic inquiry by enabling cross-verification of findings. In total, the researcher’s sustained fieldwork over 22 months.

In this article, to maintain consistency in data collection methods, I present the dialogical data generation before the analysis.

• Preliminary reconstructive analysis

This inductive process begins with the analysis of unstructured data, during which deeply embedded cultural elements are reconstructed into explicit representations [27]. In the present study, data were analyzed using preliminary reconstructive analysis following Carspecken’s method, implemented in three sequential phases: low-level coding, initial meaning reconstruction, and horizon analysis. The analysis was applied to approximately 1,000 pages of field notes.

Initially, low-level coding with little abstraction was performed on the primary records. Next, to reconstruct the initial meanings, in light of the progress with low-level coding, meaningful segments were selected from the field notes. The selected segments should effectively capture behavioral patterns, highlight deviations from expected norms, or uncover the underlying norms governing routine events [27].

In the next step, meaning fields were constructed for each selected segment. The purpose of this initial meaning reconstruction was to replace the observed action with the words the actors might have used if they had attempted to verbally express the meaning of their actions, rather than conveying it through facial expressions, vocal tone, gestures, posture, timing, or prosodic features [27].

Following this step, horizon analysis was carried out for each meaning field. Horizon analysis is grounded in the notion that every act or utterance opens up a distinctive horizon of meaning, shaped by the cultural context in which it occurs. In some instances, such horizons reflect and reinforce the prevailing cultural milieu [33]. During this process, the possible meanings of actions were interpreted through both horizontal levels —comprising objective, subjective, normative-evaluative, and identity claims—and vertical levels, which include foreground, intermediate, and background levels of horizon analysis. Accordingly, high-level codes were derived from the horizon analysis of meaning fields. Codes with similar meanings were then consolidated to form intermediate categories, from which the main categories emerged through further abstraction [27] (3)

Table 3.

Intermediate categories and the categories obtained from the analysis of results

Main categories	Intermediate categories
Domination of the superior	Dehumanization of the patient
	Representation of the authority of the superior
Facilitation of the domination of the superior	Nature of emergency
	Reflection of social beliefs
	Challenges of medical education
Destruction of the inferior	Perception of powerlessness
	Despair
	Distrust
Echoes of paternalism	Defensive medicine
	Attempt to balance power.

Following Carspecken’s guidelines for conducting horizon analysis, particular attention was given to analyzing interactive power relations. These included normative power—where subordinates accept authority based on culturally embedded norms; coercive power—where compliance is driven by the force or sanction; contractual power—where subordinates consent to authority in exchange for anticipated rewards; and charismatic power—where authority is accepted due to the superordinate’s compelling or inspirational personal qualities [27].

• Describing system relations, System relations as explanations of findings

The fourth and fifth stages of Carspecken’s method correspond to the discussion section of the article. These stages will be elaborated upon in detail in connection with the study’s findings.

Table 2.

An example of preliminary reconstructive analysis

Primary records	Low-level codesa	Meaningful segment	Meaning fields	Validity Horizons	High-level codes	Intermediate categories	Categories
Field note:
10:00 AM in the emergency department: The patient is a 40-year-old man who was admitted to the emergency department due to abdominal pain. The surgeon arrived at the patient's bedside for a consultation. After reviewing the abdominal ultrasound report, while writing something in the patient's file, the surgeon addressed the patient:Surgeon: "You need to undergo surgery. We need to remove your gallbladder."	The doctor’s anger in response to the patient's question Failure to establish proper communication with the patientThe doctor’s failure to provide explanations to the patient	Physician: Am I the doctor, or are you?	[Regarding the patient's condition, I am the sole decision-maker] AND/OR [I know everything about the patient] AND/OR [There is no need for communication with the patient] AND/OR [I must maintain my authority over the patient] AND/OR [The patient’s trust in my decision should be accepted unconditionally] AND/OR [The patient does not possess the necessary expertise and skill to diagnose their illness].	OF: I do not involve the patient in treatment decisions. OB: I am a doctor. SF: I became angry at the patient’s question. NF: The patient must comply with the doctor’s decisions (coercive power).NF: Decision-making about the patient’s treatment is solely the physician's authority (normative power).	The physician as omniscient
The patient, surprised, asked: "Why do you want to perform surgery on me? I used to experience stomach pain before, and they would give me an injection, and I would feel better. Why do you want to operate on me?"				NIN: Physicians should not be questioned by the patient. VB: The patient's opinion regarding the treatment of their illness is insignificant (value-based).IIN: I am an experienced physician.
The surgeon looked at the patient angrily and said, "Am I the doctor, or are you?"

^aInitial meaning reconstruction is performed simultaneously with the Low-level coding

O Objective, S Subjective, N Normative, V Value, I Identity, F Foregrounded, IN Intermediate, B Backgrounded

Rigor

To enhance the validity of the findings, Carspecken emphasized the importance of prolonged engagement as a critical strategy for bolstering the researcher’s validity claims [27]. Prolonged engagement allows the researcher to identify key routines, values, norms, and beliefs, facilitating the reconstruction and interpretation of cultural meanings [27]. In the present study, the researcher’s long-term presence in the emergency department (22 months) supported the achievement of this goal.

Also, to minimize bias during data reconstruction, peer debriefing was conducted throughout the analysis. The researcher regularly consulted with colleagues, supervisors, and advisors to critically assess interpretations. Participants were also asked to clarify terms they used, fostering richer contextual understanding. Interview recordings were systematically reviewed and cross-checked with observational data, and both data sources were validated through member and peer checks, ensuring consistency and transparency in interpretation.

Furthermore, Reflexivity was also integrated to strengthen trustworthiness. As Olson (2011) argues, reflexivity underpins credibility in critical ethnography, prompting researchers to consider their positionality and ownership of the data [34]. Similarly, Parahoo (2006) characterizes reflexivity as an ongoing process of self-examination regarding one’s assumptions, behaviors, and presence in the field [35].

In this study, the lead researcher participated in a pre-entry qualitative interview to identify prior assumptions and biases before data collection began. Reflexive practice continued during fieldwork through systematic journaling, capturing evolving thoughts, emotional responses, and interpretive reflections during observations and interactions.

Results

In this study, through horizon analysis, high-level codes were identified, leading to the development of ten intermediate categories and, subsequently, four overarching main categories (Table 3). The findings presented below are supported by illustrative excerpts drawn from interviews, conversations, field observations, and relevant documentation, offering a rich and contextualized account of the data.

First category: domination of the superior

The first main category identified is domination of the superior, which highlights the hierarchical power structures within the emergency department, characterized by the dehumanization of patients and the reinforcement of professional authority. Patients were often reduced to clinical abstractions—identified by bed numbers or diagnoses—while an overreliance on biomedical technologies further marginalized relational aspects of care. Dehumanization was also evident in limited communication, as providers frequently withheld explanations or selectively engaged with patients, reinforcing their passive role in the care process. One medical student highlighted how patients’ socioeconomic status influenced the extent to which information was shared with them:

The amount of information we share with patients often depends on their socioeconomic background. Patients in private hospitals, who are generally more educated, tend to ask more questions, which encourages us to provide more detailed explanations. On the other hand, patients in public hospitals, who often come from disadvantaged backgrounds and may have lower levels of education, typically ask fewer questions and may find it harder to understand complex medical information. Over time, we’ve become used to offering them less detailed explanations about their treatment.

Field observations and interviews revealed that physicians often maintained both physical and psychological distance from patients. These behaviors reinforced systemic power dynamics, preserving professional dominance through verbal and non-verbal cues that inhibited patient engagement and silenced their voices. One nurse commented on this practice:

Doctors often discourage communication from patients and their companions, maintaining a clear distance in their interactions. They tend to treat them in a way that discourages questions or further conversation, often ignoring what the patient is saying, as if their voice is not being heard at all.

Researcher observations indicated that physicians were perceived as the primary authority figures in the emergency department, with patients and their companions routinely excluded from medical decision-making. This hierarchical model was explicitly endorsed by staff, reinforcing a paternalistic structure that minimized patient involvement. A supervisor articulated this hierarchical stance:

• No one should interfere in medical affairs. The patient’s role in medical decisions is very insignificant. If the patients trust the doctors, they should remain silent at all stages. The patient has come to the hospital and should obey our orders. They do as we say. If we order them to stay, they stay. If we order them to go, they go. They aren’t allowed to comment. The patients have come to us, so they should do as we say.

Second category: facilitation of the domination of the superior

The second main category, facilitation of the domination of the superior, captures the structural, cultural, and contextual enablers of paternalistic care. Environmental factors and linguistic and cultural diversity impeded meaningful interaction and reinforced hierarchical, one-way communication. Additionally, a pervasive reverence for the medical profession, viewed as sacrosanct, discouraged both patient dissent and peer critique. As one medical student explained:

Medicine is regarded as a sacred profession, and not everyone is seen as worthy of being called a doctor. There is a strong belief that the dignity of the medical field should be preserved, and that society should show trust and respect toward it because of its revered status.

In addition to cultural and structural conditions, challenges within medical education, such as reliance on algorithmic decision-making and medical students’ inability to translate complex medical terminology into plain language, often overshadowed individualized, patient-centered care. An intern recounted:

Due to the long hours we spend in medicine, our language gradually shifts—we begin to think and speak in medical terms, which makes it difficult to translate concepts into everyday language. I remember a young woman who came in with deep vein thrombosis (DVT) and asked why it had occurred. I struggled to find a simple way to explain a coagulation disorder in lay terms, and as a result, I couldn’t provide her with a clear explanation.

Third category: destruction of the inferior

The third category, destruction of the inferior, reflects the emotional and psychological harm caused by paternalistic care, manifesting in patient feelings of powerlessness, frustration, and despair. These dynamics not only reinforced perceptions of inferiority but also deepened existing class-based inequalities. One patient, in a brief conversation, shared their experience of being dismissed and disregarded:

Doctors are not always forthcoming in their responses; now that they hold the title of ‘doctor,’ they no longer seem to see us as equals. As the saying goes, ‘birds of a feather flock together.’ We’re often left feeling that we just have to endure it. Perhaps they see us as workers, poor, uneducated, from rural backgrounds, and unworthy of attention. The working class is frequently overlooked and devalued, and that reality is deeply painful.

This perceived inequality and exclusion often resulted in deep distrust of the healthcare providers. Patients and their companions frequently sought guidance from non-specialists or consulted external physicians, reflecting a broader erosion of confidence in the formal healthcare system.

Fourth category: echoes of paternalism

The fourth and final category, echoes of paternalism, describes the impacts and adaptive behaviors stemming from the deeply rooted paternalistic culture in the emergency department. These effects appeared in both provider conduct and patient responses. One prominent manifestation was defensive medicine, practiced to avoid legal liability, which often compromised patient-centered care. This defensive approach was internalized early in medical training, as one intern explained:

From the very first year of medical school, we are repeatedly taught to avoid actions that could lead to legal consequences. This emphasis on protecting ourselves from potential lawsuits is so persistent that, over time, it becomes more deeply ingrained than the motivation to act in the best interest of the patient. We learn to be cautious above all else.

This mindset often led to excessive documentation and bureaucratic practices. Field observations highlighted those physicians, and particularly nurses, devoted significant time to completing multiple forms and obtaining repeated signatures and fingerprints from patients. One such field note illustrates this behavior:

I observed a nurse taking fingerprints from a patient who was preparing to leave the ward. The nurse then asked both the patient and their companion to sign and fingerprint multiple documents. When I asked why so many signatures and fingerprints were needed, the nurse explained: In case something happens to the patient and we are taken to court, we need to have sufficient documentation. We try to collect any paperwork that might be required legally.

In parallel, patients and their companions developed counterstrategies in an attempt to rebalance the perceived power asymmetry between themselves and the medical staff. This included assertive behaviors such as shouting, threatening, or displaying aggression to compel responsiveness and accountability from healthcare providers. These behaviors were often tactical rather than emotional, reflecting a strategic attempt to secure better care within a system they perceived as indifferent. In some cases, individuals attempted to recalibrate the power dynamic through more subtle means, such as adopting particular modes of dress or speech that conformed to perceived social expectations of higher status. One field note offers a revealing example:

The patient was an elderly unconscious woman on ventilation, cared for by her daughter, who sat beside her. Unlike most companions in public hospitals, the daughter was well dressed and wore light makeup. She remarked, “Believe me, if you come to the hospital dressed nicely and speak politely, they will treat you much better. This was my experience” (laughs).

Such responses reflect the complex interplay between institutional authority and patient agency within a context shaped by systemic paternalism.

Discussion

In Carspecken’s method, the fourth stage aims to describe system relationships within a broader context [26]. The emergence of the cultural themes can often be understood through historical analysis and by examining the broader social, economic, and political contexts in which individuals live and work [36]. In the present study, the existing structural conditions are first examined in light of the research findings. Subsequently, the relationship between the cultural forms derived from the study field and those observed in other social sites is explored. The influence of media and cultural commodities on the emergent field concepts is then critically examined. Finally, the consequences of actions and cultural forms produced within the field are analyzed in terms of their impact on broader social networks. In the fifth stage of the Carspecken method, the findings are discussed and interpreted through the lens of general social theories to explain the insights gained from stages one through four.

The findings of this study indicate that the persistence of paternalistic care in the emergency department is shaped by an interplay of individual, organizational, and cultural factors. In this context, the patient was excluded from the decision-making process, and existing power imbalances between healthcare providers and patients were reinforced. A key driver of this dynamic was the lack of effective communication and the failure to provide patients with essential information, which positioned them as passive recipients of care. This pattern reflects the broader paternalistic culture embedded in emergency healthcare settings. Supporting this finding, the research by Omidvari and colleagues also confirmed that insufficient communication by physicians and nurses is one of the main causes of patient dissatisfaction in emergency departments [18].

Moreover, elitist attitudes and the perceived supremacy of medical knowledge act as obstacles to the development of reciprocal, empathetic communication, thereby perpetuating hierarchical power relations [12]. Similar conclusions were drawn in studies by Sadati et al. and Ruberton et al., where the sense of professional superiority among physicians was found to foster paternalistic communication patterns and reinforce asymmetrical power structures between doctors and patients [37, 38]. These dynamics are deeply rooted in the historical trajectory of the Iranian medical profession, which has long been shaped by aristocratic influences. As Rahmani notes, the profession’s high social status—rooted in its association with health, emergency conditions, and a spiritualized conception of healing—discouraged criticism of physicians [39]. In this regard, Floor highlights that medicine in Iran has historically been viewed as a science deeply entwined with the supernatural. Consequently, physicians were not merely seen as medical experts but as mystic healers endowed with spiritual significance. Based on this historical trend, the ancient “Hakim” model, a specialist in both physical and spiritual healing, has persisted in Iran until today. Therefore, Physicians are still often viewed in a role analogous to that of temple priests, whose presence and ritualized interventions are deemed essential to safeguarding health and well-being [40].

Furthermore, a form of cultural ethnocentrism has emerged within the medical profession, whereby the norms, values, and beliefs of the medical community are perceived as inherently superior to those of other social groups. This entrenched sense of cultural superiority has contributed to a diminished capacity among physicians to recognize, engage with, or understand the values and worldviews of their patients [39, 41]. This tendency intensified after medical education in Iran was moved under the Ministry of Health in 1985, which reduced interdisciplinary training and exposure to the humanities. Consequently, many medical students develop a narrow epistemological framework, often accompanied by a heightened sense of professional self-importance and a lack of sensitivity to social and cultural complexity [42].

In this context, it appears that medical education structures, with their focus on the biomedical model and algorithmic decision-making based on protocols, marginalize patients’ subjective experiences [43]. Greenhalgh argues that during medical training, physicians are trained to present the advantages and disadvantages of treatment options in alignment with evidence-based guidelines. These guidelines often emphasize algorithmic rules and relatively strong recommendations, thereby limiting opportunities for incorporating patients’ values, preferences, and lived experiences into the decision-making process [44]. As a result, the high status afforded to scientific evidence in clinical reasoning may inadvertently promote a “cookbook medicine” approach, where medical practice becomes a mechanistic execution of predefined protocols, marginalizing the humanistic aspects of care [45].

In a cultural climate that amplifies physician authority and prioritizes algorithmic reasoning in medical education, the emergency department (ED) becomes a prime setting for the reinforcement of paternalistic care. As the first point of clinical decision-making, the ED plays a pivotal role in the patient’s healthcare trajectory, often influencing deeply personal and social outcomes. Its inherent unpredictability—compounded by urgency, limited patient history, and heavy workloads—heightens patient vulnerability [20]. Moreover, communication challenges arising from multiple care providers and patient conditions such as pain, fear, and anxiety contribute to ethical complexities that are distinct to the ED and less prevalent in other clinical settings [20, 46, 47]. These special characteristics of the emergency department serve as a fertile ground for the entrenchment of paternalistic care.

Moreover, the physical environment of the emergency department plays a crucial role in shaping the quality of ethical care, a finding corroborated by the present study. Features such as open layouts without walls, staff stations designed like aquariums, the use of “curtain walls,” overcrowding, high patient throughput, and the placement of patients in hallways all pose significant obstacles to safeguarding patient privacy and confidentiality [48]. For instance, a study by Karo et al. reported that 41% of emergency department patients overheard interactions between other patients and staff, while 4% of patients reported withholding or altering information due to concerns about being overheard [49]. Schriver and colleagues further emphasize that emergency department personnel operate under constant presence, not only by other patients and their families, but also by paramedics and police, heightening the pressure on clinical interactions [50]. Taken together, these physical and contextual challenges compromise the conditions necessary for preserving patient trust and confidentiality, thereby fostering an environment where paternalistic and ethically compromised care may prevail [51].

Conversely, the technological dominance characteristic of emergency departments appears to undermine effective communication between healthcare providers and patients, thereby contributing to the delivery of paternalistic care. Consequently, nurses are often relegated to the role of machine operators, and physicians increasingly rely on diagnostic data over patient narratives. This fosters biomedical reductionism, wherein patients are perceived as malfunctioning bodies rather than individuals with lived experiences [52]. In turn, such technological mediation reinforces a power asymmetry that hinders the development of meaningful patient-physician relationships [53]. As a result, clinical encounters risk dehumanizing the patient, who is no longer perceived as a suffering human being or as “lived bodies,” but rather as “biological organisms” or “malfunctioning machines” whose parts can be replaced or repaired [52]. Herrera describes this as “body fragmentation,” where patients are reduced to isolated body parts, such as a damaged leg or a malfunctioning heart. Therefore, such circumstances lead to a dehumanized and depersonalized process of care [46].

Language barriers further complicate effective communication in the increasingly multicultural environment of emergency departments. This challenge was evident in the current study conducted in Mashhad, Iran, a major religious pilgrimage site that annually receives diverse domestic and international visitors. As a result, Mashhad’s emergency departments have become inherently multicultural. Similar challenges are reported in other pilgrimage cities like Mecca. For instance, Bakhsh et al. found that 25% of emergency physicians in Mecca routinely faced language barriers, and 54.4% reported that communication issues led to poor patient outcomes [54].

Ethical guidelines may justify paternalistic decision-making in emergencies or cases of impaired patient cognition, aligning with beneficence to protect patients [55, 56]. However, the present study found such paternalism also occurs in non-emergency situations where the patient was competent to make decisions. This was most evident in the process of obtaining informed consent, where the ritual of repeated form-signing often supplanted meaningful dialogue and patient engagement. These practices reflect defensive medicine and legal caution rather than respect for autonomy, indicating that institutionalized paternalism and authoritarian care models remain entrenched in emergency medicine culture.

Carspecken, in his discussion of system analysis, emphasizes the importance of examining how cultural forms within one social site relate to those found in other sites. He argues that these additional sites—consistently referenced by study participants—offer critical insights into the broader cultural context [36]. The present study shifts its focus to an analysis of care delivery in public and private hospitals, a direction informed by participants’ frequent references to perceived disparities between the two systems.

The patient in the study consistently expressed greater satisfaction with private hospital care, citing respectful treatment, better communication, and more personalized service. In contrast, public hospitals were often associated with impersonal care and neglect. These perceptions were mirrored by healthcare providers, who reported adjusting their behavior in private hospitals due to patients’ higher social status and institutional pressures to maintain reputation and profitability. Thus, class-based distinctions significantly shape the delivery and experience of care.

The broader literature supports these findings. Studies repeatedly highlight higher satisfaction rates in private hospitals. Research by Fazaeli et al. linked this preference to the presence of skilled staff, effective communication, and enhanced amenities [57]. Varmaghani similarly found that physicians in private settings were more accessible and responsive, particularly for patients requiring frequent monitoring [58]. These disparities are rooted in differences in organizational culture. Private hospitals, driven by market incentives, prioritize patient satisfaction to secure financial success and institutional reputation. Conversely, public hospitals face chronic underfunding and high patient loads due to low service tariffs. This limits their capacity to meet individual patient needs, leading to longer wait times, diminished service quality, and reduced provider-patient interaction. Consequently, despite its broader coverage, the public sector is often perceived as less responsive and efficient, prompting a shift in patient preference toward the private sector [59, 60]. This analysis provides insight into the cultural narratives voiced by study participants when comparing care experiences across public and private hospitals, and it helps elucidate the institutional and structural drivers underlying these disparities.

According to Carspecken (1996), it is essential to consider the influence of media and other cultural products, as they affect interpersonal relationships and patterns of discourse within the research setting [27]. In the present study, two major media events significantly shaped the study’s findings by influencing public perceptions of healthcare. During fieldwork, healthcare providers observed that these events raised patient and companion expectations while intensifying mistrust toward physicians, resulting in more frequent complaints. The first event was the satirical TV series In the Margin, which criticized the healthcare system. Patients often echoed the show’s themes when expressing dissatisfaction, while physicians condemned the series for undermining public trust and linked it to increased emergency department complaints. This led many to adopt defensive medical practices to avoid criticism and liability. The second event involved viral social media reports of medical errors, which emboldened patients to challenge the healthcare system. In response, providers employed strategies to reduce complaint risks. Collectively, these media influences fueled the rise of defensive medicine and heightened physicians’ concerns about legal vulnerability.

Regarding the analysis of the consequences of an action established by cultural forms on larger social networks, it can be said that the actions and concepts arising from the emergency department can mutually and potentially intensify and reproduce social, class, and geographical inequalities. For example, this study illustrates how disparities in the quality of care and the attitudes of healthcare professionals toward patients of varying socioeconomic backgrounds serve to deepen such divisions. Specifically, variations in the allocation of resources and differential treatment based on patients’ economic status contribute to the entrenchment of class and economic disparities on a systemic level. As a result, spatial and social inequalities intersect in ways that disproportionately disadvantage patients with limited financial means, granting them access only to substandard services and thereby perpetuating a stratified, wealth-based social order.

In the final analytical stage, the study integrates Carspecken’s stages four and five with Habermas’s theory of communicative action and Giddens’s structuration theory, particularly focusing on the four categories of action conditions: objective-external, subjective-external, cultural-internal, and institutionally-mediated [28]. Furthermore, actors engage in action based on their respective levels of power, knowledge, capability, and volitional strength concerning the prevailing conditions of action. Moreover, they form their relationship with the conditions of action based on these factors. Consequently, human actions are inherently meaningful, with their meanings constituted through claims to objective, subjective, and normative validity. Actions also produce a range of intended or unintended consequences, which are mediated through the social system. These consequences, in turn, may either reinforce and reproduce existing conditions of action or transform them by generating new ones, for example, through the alteration of prevailing beliefs or norms [61].

In the present study, the relationship between the conditions of action and participants’ experiences of paternalistic care in the emergency department—and the resulting consequences—was interpreted and analyzed through the theoretical lenses of Anthony Giddens’ structuration theory and Jürgen Habermas’ theory of communicative action. Concerning the dimensions of structural conditions, the findings reveal that patients and their companions lacked access to the necessary resources and rules to challenge the paternalistic culture imposed by the medical team. These resources and rules were asymmetrically distributed, predominantly favoring physicians and healthcare providers. As a result, patients operated within a framework of limited interactive power, while the healthcare team exercised high levels of authority and interpretive control. Within this dynamic, the actions of both healthcare professionals and patients produced meanings shaped by claims to objective, subjective, and normative validity. These intentional and unintentional actions gave rise to both individual and social consequences. Structurally, the unique context of the emergency department, intertwined with the educational limitations of medical training and prevailing social beliefs, reinforced the hierarchical dominance of medical professionals. On an individual level, the actions of healthcare providers and the structural nature of emergency care contributed to the dehumanization of patients, who reported feelings of inferiority, distrust, and powerlessness. These entrenched paternalistic practices have also contributed to the rise of defensive medicine and the proliferation of legal frameworks that overwhelmingly protect healthcare providers. In response, patients and their companions, feeling disempowered in defending their rights, resorted to various strategies to rebalance power dynamics. While these actions reflect individuals’ agency within the dialectic of control, they remained insufficient to bring about substantive change in the structural conditions of practice, due to a lack of adequate rules or resources. Ultimately, the unintended consequences of patient and healthcare provider actions created new action conditions that marginalized patients’ lifeworlds and reproduced authoritarian decision-making structures.

These findings underscore the failure of the healthcare system to realize a comprehensive and emancipatory vision of health and care—one that genuinely acknowledges and integrates patients’ narratives, perspectives, and capacities.

Limitations

This study was conducted in a single referral hospital located in Khorasan Razavi province, which may limit the transferability of the findings to other healthcare contexts. To ensure methodological rigor and enhance the trustworthiness of the findings, the research design incorporated thick description, providing rich and detailed contextual information about the methodology and context. This allows readers to assess the potential transferability of the findings to other settings [62, 63]. Nevertheless, Future research is recommended to conduct comparative qualitative studies across various healthcare environments, to further explore the relevance of the findings in diverse settings.

The researcher’s positionality also introduced both advantages and limitations. With two years of clinical nursing experience and over 15 years as a nursing educator, the researcher held an insider-outsider status—external to the emergency team but internal to the nursing profession. This duality facilitated access and deepened interpretive insight but also risked analytical blind spots due to habituation. To mitigate this, a deliberate process of defamiliarization was undertaken, treating routine clinical practices as unfamiliar to uncover implicit cultural norms. As Inglis notes, defamiliarization allows researchers to step outside the lifeworld and examine it as though encountering it for the first time, revealing patterns and practices that might otherwise remain invisible [64]. This reflexive strategy—supported by field notes, reflective breaks, peer debriefing, and pre-fieldwork interviews—helped surface often-overlooked structural and behavioral patterns.

Conclusion

This study highlights the persistence of a paternalistic culture in the emergency department, which compromises ethically grounded, patient-centered care and undermines patients’ rights and dignity. Structural and cultural barriers limit patient involvement in decision-making, reducing them to passive recipients of care. Since autonomy depends on informed, voluntary participation supported by effective communication, the existing dynamics in emergency settings significantly hinder its realization.

In line with critical methodology to challenge power imbalances, the study underscores the need to raise awareness among patients and families about their rights as a step toward empowerment. At the same time, healthcare providers must be equipped through targeted training in ethics, communication, and the human dimensions of care. Healthcare providers also carry a professional responsibility to advocate for and safeguard the rights, values, and well-being of their patients.

Also, institutional reform should include revising physician-centered legal frameworks and developing laws that protect patient rights. The establishment of non-governmental organizations may further accelerate legal reform and enhance public awareness. Importantly, the study’s ethical critique is not a rejection of providers’ contributions but a constructive effort to improve care processes. Its findings offer a foundation for reshaping healthcare structures toward more ethical, equitable, and patient-responsive care.

Abbreviations

DVT

Deep Vein Thrombosis

ED

Emergency Department

Authors' contributions

ND collected the data; performed the analysis; wrote the paper. NDN contributed to analyze and interpret the data. MSZ contributed to interpret the data. NF contributed to interpret the data. PFC contributed to analyze the data. All authors read and approved the final manuscript.

Funding

This study was a part of a thesis that was performed in the School of Nursing and Midwifery, Tehran University of Medical Sciences. This study was financially supported by the Research Deputy of Tehran University of Medical Sciences [grant number 25906].

Data availability

All data generated or analyzed during this study are including in this published article.

Declarations

Ethics approval and consent to participate

This research is derived from a doctoral thesis submitted in partial fulfillment of the requirement for the degree of Ph.D. in Nursing at Tehran University of Medical Sciences, Tehran, Iran. The Ethics Committee of Tehran University of Medical Sciences approved the project following the tenets of the Helsinki Declaration and the national ethical guideline for medical research (ethics code: IR.TUMS.REC.1395.2756). Written informed consent was obtained from the participants for excerpts from their interviews to be published with the guarantee of anonymity.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.