THE PHYSICIAN-PATIENT RELATIONSHIP

Physician's Obligations and Virtues

Traditional Paternalistic Approach

As reflected in Hippocratic Oath

swear to "benefit" the sick and "keep them from harm"
nothing about respecting their rights

As with most medical codes of ethics develoved over the years

articulate standards physicians should be guided by
and virtues they should have and excercise
for instance

physicians are enjoined to "promote their patient's well-being"
but nothing is said

about a patients right to define their own well-being"
or participate in decisions affecting it

Physicain & Patient Stereotypes Implicit in Paternalistic Approach

patients

are dependent individuals

medically clueless
and emotionally distraught

obliged to trust the doctor's judgment
and follow "doctor's orders"

doctors being

wise & benevolent
objective & skillful

Physicians-Codes stressed the Dr's obligations

to benefit these patients
not to exploit their trust & dependence

Changing Relations & Attitudes

The Dr.-patient relationship has grown more impersonal

increased specialization
"growth of large depersonalized medical institutions" (p. 52)

"iatrogenic illnesses" (illnesses caused by medical treatments) among other things occasion patient mistrust
growing perception that physicians engage in practices which

place their own financial interests
ahead of their patients' interests

AMA 1990 Statement: "Fundamental Elements of the Physician-Patient Relationship"

acknowledges numerous patient rights
including the right to receive information relevant to one's own medical care

Paternalism and Respect for Patient Autonomy

Childress & Siegler

paternalism and respect for autonomy are not always compatible

conflict cases

only the physician considers cigarette addiction a "disease"
the Jehovah's Witness who refuses a blood tranfusion needed to save life

paternalism

tends to concentrate on care rather than respect
on patient's needs rather than their rights

purely paternalistic model is unacceptable (C & S)

weak paternalism: paternalism o.k. if the patient is at risk of harm and

the patient's autonomy is impaired
or if there's reason to suspect the patient's automony is impaired

metaphor of negotiation (not pure autonomy either)

negotiation respects the autonomy of both parties
the ongoing nature of the relationship

a patient might even "autonomously decide to turn the medical decision-making reins over to a physician willing to take them" (p. 53)

Terrence Ackerman

favors a weak construction of autonomy "that takes it to be essentially a principle of noninterference" (53)
illustrative conflict cases

a patient's ability to effectively deliberate impaired by their illness

their would-be decisions are

medically inadvisable
at odds with the patient's known "history of decisions and values" (53)

weak paternalism would be warranted

since patient's capacity to decide for themselves -- their autonomy -- is impaired
it's no usurpation of their autonomy "when decisions are made for the patient" (53)

physician and patient disagree about what constitutes the patient's well-being

example: cancer patient

physician views increased agressive treatment of patient's cancer as patient's best shot
patient wants to give up the unpleasant treatment
physician may be inclined to resort to paternalistic measures, e.g.,

exaggerating the chances of a cure
understating the further discomfort to be expected from the treatment

physicians dilemma: conflicting obligations

to act so as to best promote the patient's well-being as understood from an objective medical standpoint
to respect the patient's right of self-determination

danger: physicians assessment of patient's interests

may reflect personal biases & values
not just "objective medical" considerations

discussion of conflict cases

problematic "because of the constraining effect that illness has on autonomy" (54)
Ackerman recommends (contrary to avowed weak construction of autonomy?)

acting in such a way as to "restore the patient's autonomy" to the greatest extent possible
even if this involves some measure of paternalism

Ackerman stresses constraints on autonomy due to

psychological states (e.g., depression)
social factors (e.g., family influence)

Ackerman argues "physicians have an obligation to act in ways what will offset the effects of these constraints" (54)

when patient's autonomy really is diminished by such factors -- not clear any strong paternalism is being practices
danger in Ackerman's approach: self-fulfilling diagnosis of "diminished autonomy"

when patient disagrees with physician's recommendations
physician may conclude it's due to patient's diminished automony -- "if they were thinking straight obviously they'd agree with me, the all-knowing doctor"
when it reflects genuine difference in values, e.g., between

quality of life concerns of patient
with preservation of life concerns of the physician

Truth-Telling

Questionable (previously accepted) practices

lying to patients about their illnesses or prospects

for paternalistic reasons
because -- physicians argued -- the "patients did not want to know the truth"

alternating placebo injections with opiates

for paternalistic reasons
because

the placebo does have a therapeutic affect
and is much less dangerous than too frequent injections of the opiate

Question: "Are physicians ever morally justified in paternalistic lies or deceptive practices?"
Rule Utilitarian Analysis: Higgs

Proposed Rule: Lie to patients when you believe doing so is in the patient's best interest.
Would-be benefits (or avoided costs)

relating to the difficulty of conveying the technical facts and uncertainties to the medically untrained patient

patient apt not to understand sufficiently
and make costly wrong choices

most patients do not want to know the truth: their preference is being satisfied
the truth can harm patients: lying avoids this harm

Would-be costs (or benefits lost)

not impossible -- and even more beneficial -- if physician takes the time & effort to be sure the patient does understand

it's called bedside manner
a highly beneficial that physicians should develop

patients do want to know the truth -- it's their true preference
cases of the truth harming patients

are uncommon
and the harm can be diminished if it's done right (see bedside manner above)

the further harm of lying

patients ability to plan for the worst (if that's it) are impeded
trust in the medical profession is eroded

Is the anti-rule justified: Never lie to patients under any circumstances? (Higgs?)

where the patient has expressed a clear rational preference not to know?
or good evidence the patient would be seriously harmed by knowing?

A rule building in these exceptions: Never lie to patients unless the patient has expressed a clear desire not to know or there is good reason to believe the paitent will be seriously harmed by knowing?

Deontological Analysis

Strict Kantian -- perfect duty -- approach

since you should never lie under any circumstances
physicians should never lie to patients under any circumstances

Prima facie duty approach:

prima facie duty not to lie
can sometimes be overridden by some other prima facie obligation
physicians obligation to promote the patient's medical well being may sometimes be such an overriding obligation

Hardest case: Where it is plausible to think that knowing the truth

will destroy the patient's hope
and cause them to decline faster than they otherwise would have
Brody's reply

hope is resiliant
where there's no hope for survival
patients will find other things to hope for

a good death
a sweet parting

Informed Consent

Informed consent is "a relatively recent addition to the ethical constraints governing the physician-patient relationship

now both legally and morally widely accepted that
"competent adults ought not to be subjected to medical interventions without their informed and voluntary consent" (56)

Courts have ruled "physicians have a duty to `satisfy the informational needs of the patient'" (56)
Difficulties affecting the application of the requirement

Who is competent to give consent?

Are patients with 3rd degree burns over more than 60% of their bodies competent to rationally choose

between

a long and excruciating attempt to save their lives which may only end up prolonging their torture
just being medicated for pain and allowed to die quickly

in the first two hours when there is no pain because the nerves have been anesthesized?
after that, when the excruciating pain starts?

How much information do patients have to be given?

Information about every alternative procedure?
Statistical results of medical studies on each alternative procedure?
Information overload might confuse the patient and actually diminish patient autonomy?

When is consent volutary?

even perfectly rationally competent adults can be easiliy influenced by others

especially those with trappings of authority
to make choices they might not have made otherwise made
how to draw the line between

informing and advising the patient
and lobbying the patient to adopt a certain course

presently stress is being placed on the communicative nature of the informed consent process

as ongoing
and interactive:

don't just give the patient a pill bottle list of possible risks then shove a form under their noses to sign
encourage and invite questions & dialog

a conversation: sometimes called the conversation standard

too demanding to be made a legal standard Howard Brody argues
Brody advocates a legal "transparency standard" maintaining a physician has "provided adequate disclosure when his or her essential thinking about the medical situation has been made transparent to the patient."

Other Issues

Conflict of interest issues

patient interests against health-related interests of physicians

to what extent are physicians obliged to provide care
when doing so puts their own health at risk (Ebola patients)

patient interests against the financial interests of physicians

controversial practice of "joint venturing"
in which physicians refer patients to facilities in which they themselves have financial interests

patient's interests against societies financial interests

do Drs have an obligation to help curtail medical costs
that may conflict with their duty to provide for the patients medical needs

What are the patient's duties in the physician-patient relationship?