Logic of care

Balancing evidence-based medicine and patient preference is of huge importance to the current practice of family medicine. Certainly, family physicians must not act as “controller[s] of the decision-making process.”¹ But I disagree that family physicians act as mere “broker[s] of choices.”¹

In her book The Logic of Care, ethnographer Annemarie Mol argues against a focus on patient preference and patient decision making. Her “logic of care” actually aligns more with the way I think we ought to practise family medicine: “to act without seeking to control. To persist while letting go.”² For example, she describes a physician who warns a patient with poorly controlled diabetes about blindness, but counsels another patient with diabetes who is too hard on himself that he cannot always expect to have a blood sugar level of less than 11 mmol/L. “Caring professionals” seek to cultivate patients’ minds. We convey insights, ask probing questions, or try to reassure; we “try not just to reflect back what [the patient] thought already. In the hope of making [the patient] more balanced, [we] give counterbalance. [We] encourage [the patient] to take good care of [himself], without feeding the illusion of control.”² Family physicians play an important role in collaborating with our patients’ knowledge and values, jointly “exploring ways of shaping a good life”² in the face of disease and illness. Furthermore, an emphasis on patient choice leads to 2 difficulties. First, it gives the false hope that control is always a possibility—sometimes there are limits to what can be chosen or changed. Second, sharing the responsibility for medical decision making can impose a considerable burden on patients.

While I believe that Canadian family physicians often practise using a logic of care, I think exploring Mol’s theory and arguments more deeply in the Canadian primary care discourse would be worthwhile.