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Addressing “Difficult Patient” Dilemmas: Possible Alternatives to the Mediation Model


Davis, Arlene M.; Rivkin-Fish, Michele R.; & Love, Deborah J. (2012). Addressing “Difficult Patient” Dilemmas: Possible Alternatives to the Mediation Model. American Journal of Bioethics, 12(5), 13-14.


Fiester raises two crucial points in her important paper: recognition that patients’ perceptions of having been morally wronged may underlie their “difficult” behaviors; and that a mandate to address these perceived harms and related conflicts lies squarely with clinical ethics consultation. In doing so, Fiester rightly upsets conventional views of “problem” patients (or family members) and expects clinical ethics consultants to do the same. We agree that “the conventional view that locates the source of patient–provider conflict in the patient’s mental or physical pathologies is not
only weak as an explanatory model, but ethically irresponsible for the way it undermines our resolve to explore more nuanced causal dynamics and redress them” (Fiester 2012, 2).
Our commentary takes issue with the primacy that Fiester gives to mediation as the consultant’s tool in addressing the ethical issues related to “difficult patient” situations. We see three concerns: that the process of constructing a “third story” may not reveal the crux of the conflict; that the concept of the ethics consultant as “impartial” observer may not adequately capture the range of perspectives and insights consultants bring to the process of resolving difficult patient dilemmas; and that mediation is a culturally specific model of engagement that may not be relevant or sufficient for all patients or families


Reference Type

Journal Article

Year Published


Journal Title

American Journal of Bioethics


Davis, Arlene M.
Rivkin-Fish, Michele R.
Love, Deborah J.