By Fides
Bernardo A. Bitanga
Introduction
The paper contains a reflection on a
very important issue in Ethics today, particularly in the field of Medical
Ethics. This is the patient-physician relationship. It deals with the question – what should be the ideal patient-physician
relationship or physician-patient relationship?
This
issue is difficult since the interaction between a physician and a patient is
complicated by some factors. These factors could be (1) the influential (individual)
authority and expertise of the physician influencing patient’s condition and
decision, (2) the patient’s (personal) response as influence by his or her own
beliefs, interests and values, (3) the degree of competence and specialization
of the physician (with the full force of the medical services of the hospital) affecting
decisions on health care managed care, and (4) patient’s differing disposition
and level of understanding (as influenced and dictated upon by the community
and culture). All these factors subject people’s ethical capacity to the test.
In this paper, the student wishes to
stress also some points. These are the value of the responsive character of
ethics, the concept of human act (intellect and will), the concept of law, and
the concepts of reason and impartiality. It is hoped that with the review of
these concepts the ethical issue underlying the patient-physician relationship
is clarified.
Four Models of the Physician-Patient Relationship
In
the article “The Patient-Physician
Relationship”[1],
Ezekiel and Linda Emmanuel suggested that there could be four (4) models of the
patient-physician relationship. These are the paternalistic model, the
informative model, interpretative model, and the deliberative model. All these
models would show different degrees of physician-patient interaction,
obligations, values, and autonomy.
The
Paternalistic Model is also called
the paternal or priestly model. In this
model, the interaction between the physician and the patient is to ensure that
patients get the interventions that best promote their health and well-being.
The physician uses his or her skills to diagnose the condition of the patient,
and then presents his or her findings (with selected information) to the
patient in order to get the latter’s consent. At the extreme, the physician
AUTHORITATIVELY informs the patient when the intervention will be initiated. In
other words, the physician acts as the patient’s guardian, articulating and
implementing what is best for the patient.
The
Informative Model is also called the scientific, engineering, or consumer
model. In this model, the physician-patient interaction aims for the physician
to give the patient with all relevant information for the patient to select the
medical interventions he or she wants, and for the physician to do the selected
health care service. The patient is told about the state of his or her
sickness, the nature of diagnostic and therapeutic interventions, the nature
and probability of risks and benefits, and any uncertainty. In other words, it
is the physician’s obligation to provide all available facts, and the patient’s
values then determine what treatments are to be given.
The
Interpretative Model embraces the aim
of patient-physician interaction as something that elucidates the patient’s
values and what he or she actually wants, and to help the patient select the
available medical care that realize these values. In this model, the physician
becomes an interpreting individual assisting the patient in elucidating and
articulating his or her values and in determining what medical interventions
best realize the specified values, and therefore helping to interpret the
patient’s values for the patient. In short, the physician is a counsellor
supplying relevant information, helping in elucidating values and suggesting
what medical care would realize the values of the patient.
The
last model is the Deliberative Model.
In this model, the aim of patient-physician interaction is to help the patient
determine and choose the best health-related values that can be realized in the
clinical situation. In other words, this model embraces the features of the
other models. What makes it unique from the other three is the fact that there
is discussion and deliberation of diagnosis, treatment, alternatives,
availability of resources and health care services, values, and many more. This
model values the importance of dialogue leading to the best course of action.
What
should be the ideal model for physician-patient relationship?
The Responsive Character of Ethics
In attempting to come up with the
best model, it is important to have a clear idea of responsibility. What is
Responsibility?
In
talking about the responsive character of ethics, the topic does not only refer
to the ability to respond and react to certain circumstances. This character is
not only the vigilance to moral dilemmas. It does not only refer to its
operations, as to whether it is a faculty (the power to act in
anticipation/prevention) or a judgment (the power to evaluate and judge). It
rather speaks more of responsibility.
Ethics is difficult to explain in
isolation from the concept of responsibility or responsible freedom.[2] These
two words are linked to one another. One understands ethics if one knows what
responsibility is, and the understanding of responsibility leads to realization
of the necessity of an ethical life.
What
is responsibility? The word ‘responsibility’ is always a point in the long history
of ethical debates. These debates, however, did not help in the clarification
of its meaning. It rather contributed to its vagueness.[3] In
an attempt for a clear and clean definition, Jean Paul Sartre said that responsibility is “the consciousness of
being the incontestable author of an event or of an object.”[4]
Connecting this definition by Sartre
to the models presented by the Emmanuels, the “responsible” physician appears
to be authoritarian in the practice of medical care. This may be good for the
first model – the paternalistic model. In here, an action is responsible if it
is not the result of any force or compulsion, but of the deliberate and free
decision of a person. But if this definition is good enough, why people could
not just forgive the acts and decisions of tyrants, authoritarians, and
dictators? There must be something wrong in it, or may be something in it to be
completed.
In
the literal sense of the word ‘responsibility’, it carries the idea that it
points to someone or somebody liable to give an answer for what one has done.[5]
The word shows that one has to give an answer, and one has to give an answer to
someone or somebody. To whom or to which authority a person is responsible?
This
is the question that lingers in all the four models above. For the
paternalistic model, Is the physician responsible to himself alone? In the
informative model, is the physician responsible to the patient alone?
Furthermore, is this responsibility a shared responsibility between the patient
and the physician as in the case of the interpretative model and deliberative
model? If it is shared, then to whom they are responsible?
A
responsible person (physician, patient, and other stakeholders in the field of
medical care) then is the person who gives appropriate answer to his or her
calling by God, institution, authority, or society.[6]
The Concept of Human Act
In attempting to come up with the
best model for patient-physician relationship and perhaps in consideration of
the informed consent, one has to have a good grasp of the nature of human acts.
What are human acts?
Human acts or actus humani are actions that proceed from insight into the nature
and purpose of one’s doing and from consent of free will. Or, to put it short,
these are acts which proceed from insight and free will.[7]
This is the concept that clarifies all the roles of the physician, patient, and
other stakeholders in the medical field. Following the dynamics of the
intellectual element and the volitive element of human acts, one comes to
understand the performances of each and every individual involved in the
patient-physician relationship.
The realization that the human
intellect and the human will is not perfect the more one has to be careful in
arriving at decisions, most especially when it comes to medical care and
life-situations. There is such thing as impairments of required knowledge.[8]
The human intellect could be impaired by ignorance, error, and inattention.
There is also such a thing as impairments of free consent.[9]
The will could be impaired by passion or concupiscence, fear and social
pressure, violence, and dispositions and habits.
The Concept of Law
The concept of law is also important
in attempting to come up with the best model for patient-physician
relationship. In the informative, interpretative and deliberative models, one
should not ignore the laws. Laws are to be part in the information given to
patients, these are to be interpreted, and these are to be discussed with the
patients. This emphasis on the significance of laws is not to insinuate that
one has to be legalistic. The awareness of laws in the medical field brings in
the idea of bureaucracy, protocols, order, and guidance. It brings into light
the communal aspect of ethical exercise.
Laws
are fair and objective since these are ordinances of reason; these are
reasonable. Laws are promulgated so that no one is deceived; these are made
public. Laws are from authorities who have care for the community, and
therefore these are not to serve tyrants and dictators. And laws are for the
common good, the well-being of the people.[10]
With
laws, physicians could not just do what they wish to do on their patients;
patients cannot just select the interventions they needed, management could not
just railroad every decisions in health care, and etc. Laws are legislated to
control, to guide, to discipline, and above all to allow the exercise of
freedom and responsibility.
Reason and Impartiality
The last point in this reflection is
something fundamental in ethical considerations. Basic in facing every ethical
issue is the person’s reason and impartiality. In dealing with the physician-patient
relationship, the moral judgments (as well as moral/ethical decisions) must be
backed up by good reasons, and these also require the impartial consideration
of each individual’s interests.[11]
Giving importance to moral
reasoning is prioritizing the search for the truth, the good, and even
perhaps the beautiful. This is to arrive at a certain degree of unity, whether
this unity is a unity in decision or unity to make the community stronger in
the face of issues or moral dilemmas. It is setting aside the enticing
influences of feelings and emotions.[12]
For example, in health cases, feelings toward the sick and the dying are so
enticing in the valuing and preservation of life even when there is no more
reason to prolong a fully gadget-dependent life; these are so powerful
influences in moral decisions. But feelings could present also danger in
decision-making and the achievement of the truth and the good. This is so not
only because feelings are irrational yet they may be nothing but the products
of prejudice, selfishness, or cultural conditioning.
Ethics is first and foremost of
consulting reason. In the four models, the consulting of reason is seen more in
the informative, interpretative, but most of all, in the deliberative. In the deliberative
model, there are exchanges of explanations and reasoning with the hope of a
unified moral reasoning for the best course of action. There is an attempt for
a certain logic that must be accepted by everyone regardless of their positions
in every moral issue.[13]
Furthermore, moral reasoning or judgments are not expressions of personal
tastes. These are sound logic – a good reasoning.
What is a good reasoning? It is
getting one’s facts straight.[14]
And the facts needed are those existing independently from personal wishes.
This is not easy but it is a requirement. In responsible moral thinking, these
facts are to be seen as they are.
After getting the facts, a careful
insertion of moral principles can now be brought into play. In this way, moral
principles are applied to the facts of particular cases. This is also the phase
one could analysed the facts against moral theories and frameworks, like:
Kantian Ethics, Utilitarianism, Virtue Ethics, and others. This procedure is
also not easy. A very great responsibility is place in philosophizing or in
thinking. This is because the moral agents, most especially stakeholders in
health care, could not be wrong nor could be allowed to be wrong.
Impartiality, out of good reasoning,
includes the basic idea that each individual’s interests are equally important.
There is no privileged idea, entity, nor person. Therefore, each stakeholder in
health care must acknowledge that their welfare is as valuable as other’s
welfare.
Impartiality rejects the idea of
selfishness, bias, racism, discrimination, and among others. It is a rule
against arbitrariness in dealing with people.[15]
In many hospitals, there are so many stories on medical decisions made because
of color or race, poverty, ignorance, dishonesty (by hiding some available
hospital resources and services in the name of personnel and hospital
management), not being transparent (selecting only few information for the
patients about their conditions), and others.
In other words, it is a rule that
forbids people from treating one person differently from another when there is
no good reason to do so.
Conclusion
One may insist that the four models of
the physician-patient relationship (paternalistic, informative, interpretative,
and deliberative) are all good and can still be operative in case to case
basis. But seeing the four models in the light of some moral principles (laws,
human acts, responsibility, reason and impartiality), one perhaps could prefer
the Deliberative Model. This model is far from perfect, but its dialogic
character creates more space for other stakeholders or moral agents in the
decision-making. It also allows moral principles to be more at work. It
therefore guarantees the better course of action as compared to the other three
models.
SOURCES
Emmanuel, Ezekiel & Linda Emmanuel, “The Patient-Physician Relationship” in
JAMA, Vol. 267,
2221-2226.
Peschke,
Karl H., Christian Ethics (Manila:
Catholic Trade, 1986).
Rachel,
James, The Elements of Moral Philosophy
(Boston: McGraw Hill, 1984).
Sartre,
Jean Paul, Being and Nothingness
(London: Darton, Longman, and Todd, 1969).
[1] Ezekiel & Linda Emmanuel, “The Patient-Physician Relationship”
in JAMA, Vol. 267, 2221-2226. Both authors are Medical Doctors and Doctors
of Philosophy.
[2] Karl H. Peschke, Christian
Ethics (Manila: Catholic Trade, 1986), 66.
[3] Ibid.
[4] Jean Paul Sartre, Being and
Nothingness (London: Darton, Longman, and Todd, 1969), 32.
[5] Peschke.
[6] Ibid, 67.
[7] Ibid, 247.
[8] Ibid, 252.
[9] Ibid, 255.
[10] Ibid, 176-186.
[11] James Rachel, The Elements of
Moral Philosophy (Boston: McGraw Hill, 1984), 11.
[12] Ibid.
[13] Ibid, 12-13.
[14] Ibid.
[15] Ibid, 14.
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