In discourse around modern healthcare, “patient empowerment” is held up as a gold standard. This is the ideal of active, informed individuals taking charge of their health, engaging in shared decision-making and collaborating confidently with their care teams. This vision is deeply tied to the concept of an internal locus of control: the belief that one’s actions, decisions and effort shape health outcomes.

But what if this model of empowerment, however well-intentioned, reflects a narrow social reality? What if the “empowered patient” is not a universal figure, but a product of particular class, educational and cultural contexts? And what if, as a result, most people in most settings, perhaps even in Western societies, operate not from a place of personal agency, but from an external locus of control?

This article looks at the limitations of the empowerment ideal and calls for a broader, more inclusive understanding of how people experience control in healthcare.

The Myth of the Universally Empowered Patient

To be an “empowered patient” in the conventional sense requires more than just good intentions. It assumes a specific set of conditions:

·       Health literacy: Understanding medical terminology, test results and treatment actions.

·       Educational background: Critical thinking, self-advocacy, information-seeking / research skills.

·       Social comfort: Confidence interacting with professionals, questioning authority and asserting needs.

·       Cultural alignment: Feeling at ease with individualist values like autonomy and independence.

In other words, empowerment is not evenly distributed, it is also socially stratified. The patients most likely to embody this model tend to be middle- to upper class, well-educated and culturally familiar with institutional navigation. By this, we mean being attuned to the rituals of the healthcare professional – patient consultation, to the expected behaviours and choreography of the encounter.

By contrast, patients from marginalised backgrounds, including those with limited education, recent immigrants and older adults, may not possess or prioritise these traits. While many may lack agency, for some, however, their agency is structured differently.

The Prevalence of External Locus of Control

If empowerment, as suggested above, requires privilege, then it follows that many patients, perhaps most, operate from an external locus of control, at least within the healthcare system.

This perspective is not inherently pathological or passive. Instead, it reflects a worldview shaped by:

·       Social and structural barriers: Experiences of poverty, systemic inequality or disenfranchisement can teach people that effort does not guarantee results.

·       Cultural values: In collectivist societies, decisions are often made in deference to family, community elders or spiritual beliefs.

·       Medical power dynamics: The structure of healthcare often places authority with the provider, reinforcing patient deference.

·       Life circumstances: Illness itself, especially serious or sudden illness, can push people into a liminal state where control feels distant, if not irrelevant.

Far from being unusual, then, an external locus of control may be the default orientation in many healthcare interactions. This would be especially so in contexts where patients feel vulnerable or culturally disoriented.

Why The Patient Empowerment Model Falls Short

Healthcare systems that idealise internal control may unintentionally alienate or disadvantage those who do not, or cannot, operate within that framework. Some of the consequences include:

·       Seeing Patients as Noncompliant

Patients who defer to doctors, rely on faith or resist making decisions are often labelled as “noncompliant” or “unengaged”. In reality, they may be behaving in ways that are culturally appropriate or psychologically protective.

·       Overburdening Patients with Responsibility

Expecting every patient to “take charge” can be overwhelming, especially during serious illness, when people may feel emotionally unmoored or socially unsupported. In such times, a push for autonomy may fee more like abandonment than empowerment.

·       Excluding Valid Worldviews

Models that privilege autonomy and choice may devalue relational, spiritual or fate-based ways of making sense of illness. For many people, belief in external forces is not a sign of helplessness, but a source of meaning and comfort.

Towards a Broader Understanding of Empowerment

To move beyond the narrow model of the “empowered patient”, we need to expand our understanding of what empowerment can look like and for whom.

·       Recognise Structural Limits to Control

Not all patients can be empowered through information or encouragement alone. Socioeconomic factors, language barriers and systemic discrimination limit people’s ability to act, even when they want to. True empowerment includes addressing these structural inequities.

·       Value External Control as Adaptive and not Deficient

Belief in spiritual or communal authority can be psychologically adaptive. In uncertain or traumatic circumstances, surrendering control may reduce anxiety and encourage acceptance. Healthcare professionals can support these frameworks while still offering care that is compassionate and evidence-based.

·       Tailor Interventions to Accommodate Diverse Control Orientations (Internal, External)

Rather than imposing a one-size-fits-all model, healthcare professionals can:

o   Ask patients how they prefer to make decisions and with whom.

o   Explore cultural and spiritual beliefs about illness and healing.

o   Frame recommendations in ways that align with patients’ values, such as emphasising duty to family or spiritual stewardship rather than personal control.

Rethinking Empowerment in Practice

Empowerment does not always mean putting the patient in charge. Sometimes, it means offering protection, clarity or spiritual reassurance. It may mean deferring to family, validating faith, or offering structured guidance when a patient is overwhelmed. In short, empowerment means meeting patients where they are not dragging them to where the system thinks they should be.

This means redefining patient agency in ways that are culturally inclusive, context-sensitive and socially aware.

Control as a Spectrum?

The empowered patient, as currently imagined, is a product of cultural, class and educational privilege. While internal control can be empowering for some, it is not the universal key to health engagement. For many, an external orientation is not a failure of will, but a rational, adaptive and meaningful stance towards life and health.

Healthcare systems that truly value equity and inclusion must move beyond rigid definitions of empowerment. They must recognise that control is contextual, empowerment is relationship and agency comes in many forms.

Empowerment, at its best, is not about telling patients they are in charge. It is about listening deeply, understanding fully, and supporting each person to find strength, meaning and dignity, on their own terms.

Thank you for reading,

Mark Gibson

Leeds, United Kingdom, May 2025