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In a JRSM paper last year, Salmon and Hall1 challenged the doctrine of patient empowerment, arguing that the consequent transfer of responsibility can be harmful. In their brief mention of medically unexplained symptoms they did not refer to evidence that 'empowering explanations' can have positive impact.2,3
There is a distinction between feeling responsible for the management of symptoms and feeling responsible for the cause of a disease. In patients with medically unexplained symptoms, empowering explanations are those that take the onus of responsibility for the cause of symptoms away from the patient.4
Responsibility implies culpability. We are teaching our patients to blame themselves for their illnesses. You have had a heart attack because you chose to smoke, ate the wrong foods, took too little exercise. In the past, people viewed illness as poor luck but we are now learning a new aetiology—that of individual behavioural determinism. The message is clear. Your heart attack is your own fault.
This is a deeply unpalatable message for the unwell and generates an emotionally charged conflict, especially apparent in syndromes of medically unexplained symptoms. The clinical challenge is to lessen patients' feeling of responsibility for the cause of the illness whilst at the same time helping them to establish a feeling of control and power over the symptoms. Salmon and Hall highlight the danger of empowerment when doctors and patients focus only on symptom control and ignore issues of aetiology. Empowering explanations must address both cause and control of illness if they are to alleviate rather than exacerbate the patient's distress.