Lecture 4Lecture 4

Professional Professional Responsibility (I): Responsibility (I):

To the ClientTo the Client

(Therapeutic (Therapeutic Relationship)Relationship)

Therapeutic RelationshipTherapeutic Relationship

Conflict in any relationshipConflict in any relationship What to expect when you What to expect when you

enter into a relationship?enter into a relationship? Therapeutic relationship as an Therapeutic relationship as an

instance of professional-client instance of professional-client relationshiprelationship

Who decides what? Who decides what?

Medical decision Medical decision involves value choicesinvolves value choices

Case 1: blood transfusion for Jehovah Case 1: blood transfusion for Jehovah Witness patientsWitness patients

Case 2: Brian Clark, Case 2: Brian Clark, Whose Life is It, Whose Life is It, AnywayAnyway (1978) (1978)

Case 3: DNR and anticipated QOL Case 3: DNR and anticipated QOL

5 Models of Therapeutic 5 Models of Therapeutic RelationshipRelationship

Paternal modelPaternal model Consumer modelConsumer model Model of PartnershipModel of Partnership Model of FriendshipModel of Friendship Fiduciary modelFiduciary model

PATERNAL MODELPATERNAL MODEL Just like parents treat their small Just like parents treat their small

children, the professional treat the children, the professional treat the client in such a way that s/he client in such a way that s/he would would not allow the client free choicenot allow the client free choice, for , for the sake of benefiting the client.the sake of benefiting the client.

medical paternalism – For the sake of medical paternalism – For the sake of restoring the health or saving the life restoring the health or saving the life of the patient, the healthcare of the patient, the healthcare professional professional would make all the would make all the therapeutic decisions for the patientstherapeutic decisions for the patients

2 important instances2 important instances

TreatmentTreatment; e.g., surgery or not? overriding ; e.g., surgery or not? overriding refusals of treatment, overriding requests refusals of treatment, overriding requests for treatmentfor treatment

InformationInformation; nondisclosure or partial ; nondisclosure or partial disclosure of informationdisclosure of information

e.g., disclosure of bad news, withholding e.g., disclosure of bad news, withholding truth to a terminally ill patientstruth to a terminally ill patients

Reasons to support Reasons to support medical paternalism:medical paternalism:

1.   superior knowledge of the professional1.   superior knowledge of the professional

2.   client is incapable of giving sufficiently 2.   client is incapable of giving sufficiently voluntary and informed consentvoluntary and informed consent

3.   agreement in retrospect3.   agreement in retrospect

disclosing of information is disclosing of information is like transfusion of bloodlike transfusion of blood

HoweverHowever1.1. Doctor knows best only in scientific knowled Doctor knows best only in scientific knowled

ge; a patient is a person, not a bodily object in ge; a patient is a person, not a bodily object in need of repair; persons have values; medical jneed of repair; persons have values; medical judgement is to be made in a nonmedical conteudgement is to be made in a nonmedical context, in which health is only xt, in which health is only ONEONE of the treasure of the treasured values.d values.

31.10.2004

““Is this kind of life worth living?” Is this kind of life worth living?” ““Is it better off dead than to be in this Is it better off dead than to be in this

condition?” condition?”

“ “Will life become too degrading to go on Will life become too degrading to go on

living?” living?”

QOLQOL is not a medical is not a medical judgement, but a value judgement, but a value judgment on the basis of judgment on the basis of a statement of empirical a statement of empirical factfact

2.2. Since doctors deal with persons, not bodies, Since doctors deal with persons, not bodies, they have the responsibility to be skillful cothey have the responsibility to be skillful communicators as well as skillful healers. (Cmmunicators as well as skillful healers. (Cf. TCM !!!)f. TCM !!!)

Illustration for the 5 modelsIllustration for the 5 models

Cosmetic surgery – not a matter of life or Cosmetic surgery – not a matter of life or death, not even a matter of physical health, death, not even a matter of physical health, but a matter of psychological well-being, but a matter of psychological well-being, self-esteem, aesthetic need, and/or career self-esteem, aesthetic need, and/or career advancement.advancement.

Needs Augmentation?

What stuff should I put inside?What stuff should I put inside?

Silicone gelSilicone gel

Merit: looks and feels more Merit: looks and feels more naturalnatural

Disadvantage: long term safety Disadvantage: long term safety not assurednot assured

Rupture….Rupture….

Silicone injected to skinSilicone injected to skinfill wrinkles, add volume to lips & cheeksfill wrinkles, add volume to lips & cheeks

Saline gelSaline gel

Merit: safeMerit: safe Disadvantage: looks and feels less Disadvantage: looks and feels less

naturalnatural

Breast Implant & Paternal ModelBreast Implant & Paternal Model Doctors have the responsibility to safeguard patients’ Doctors have the responsibility to safeguard patients’

healthhealth When the long-term effect of a procedure is not assured When the long-term effect of a procedure is not assured

of safety, doctors should not perform the procedure for of safety, doctors should not perform the procedure for patientspatients

““You want silicone gel breast implant? No way !!!”You want silicone gel breast implant? No way !!!” ““Doctors know best. You cannot choose. I’ll give you Doctors know best. You cannot choose. I’ll give you

only saline gel implant.”only saline gel implant.” US Government restriction of silicone-gel breast US Government restriction of silicone-gel breast

implants, 1992 – present (Reading 2, pp.1918b-1919a)implants, 1992 – present (Reading 2, pp.1918b-1919a)

CONSUMER MODELCONSUMER MODEL

private practice in free market economyprivate practice in free market economy consumer sovereigntyconsumer sovereignty patients’ rights as consumers’ rightspatients’ rights as consumers’ rights self-determination and a person’s valuesself-determination and a person’s values Brian Clark, Brian Clark, Whose Life is it Anyway?Whose Life is it Anyway? 1978 1978

1. medical decision involves highly technical 1. medical decision involves highly technical and complex knowledgeand complex knowledge

2. consumer intelligence presupposes 2. consumer intelligence presupposes emotional calmness emotional calmness

Difficulties to be a Difficulties to be a prudent and prudent and intelligent consumer intelligent consumer in healthcare service:in healthcare service:

Breast Implant & Consumer ModelBreast Implant & Consumer Model

Sovereignty of consumer choiceSovereignty of consumer choice Each consumer should weigh the benefits and risks of Each consumer should weigh the benefits and risks of

each treatment and decide for herselfeach treatment and decide for herself A woman should have the freedom to take a little risk A woman should have the freedom to take a little risk

and get a more satisfactory breast augmentation. “It’s and get a more satisfactory breast augmentation. “It’s my body!”my body!”

““You want silicone gel? Yes, no problem.”You want silicone gel? Yes, no problem.” ““You want saline gel? Yes, I’ll do it for you.”You want saline gel? Yes, I’ll do it for you.”

MODEL OF MODEL OF PARTNERSHIPPARTNERSHIP

Partnership in what sense?Partnership in what sense?

Patient participation, not in decision Patient participation, not in decision making, but in self-care or discipline in making, but in self-care or discipline in lifestylelifestyle

equal partners?equal partners?

Typical model of other Typical model of other joint ventures:joint ventures:

partners in business, dancing, bridge, tennis partners in business, dancing, bridge, tennis Such partnership requires:Such partnership requires:

1.   equality (approximate, not strict), 1.   equality (approximate, not strict),

2.   cooperation, 2.   cooperation,

3.   shared rights and responsibilities, 3.   shared rights and responsibilities,

4.   shared decision-making, 4.   shared decision-making,

5. shared benefits and risks 5. shared benefits and risks

However, therapeutic However, therapeutic relationship is essentially relationship is essentially

unequal:unequal:

1.   medical knowledge; emotional stability;1.   medical knowledge; emotional stability;

2. risk is largely unilateral 2. risk is largely unilateral

Breast Implant & Partnership ModelBreast Implant & Partnership Model

No true partnership can be obtainedNo true partnership can be obtained

MODEL OF FRIENDSHIPMODEL OF FRIENDSHIP mutual understanding, mutual trust, mutual understanding, mutual trust,

genuine caregenuine care decision-making: sometimes mutual; decision-making: sometimes mutual;

sometimes the doctor is entrusted to do it sometimes the doctor is entrusted to do it unilaterally, in light of the values of the unilaterally, in light of the values of the patientspatients

admit that therapeutic relationship is admit that therapeutic relationship is unequal, doctor has to do most of the unequal, doctor has to do most of the decisions, trust the doctor like trust a friend; decisions, trust the doctor like trust a friend;

family doctor (cf. euthanasia in Holland) family doctor (cf. euthanasia in Holland) shop around shop around

HoweverHowever

1. not much choice in public hospitals and 1. not much choice in public hospitals and clinicsclinics

2. referral to specialist; rush to A and E (ER)2. referral to specialist; rush to A and E (ER)

3. hospital – face many strangers3. hospital – face many strangers

Hence, limited applicability – primary care Hence, limited applicability – primary care in private practicein private practice

Breast Implant & Friendship ModelBreast Implant & Friendship Model

This model cannot apply because there is no This model cannot apply because there is no history of friendship between the patient history of friendship between the patient and the surgeon.and the surgeon.

Two important Two important considerations for a considerations for a satisfactory modelsatisfactory model

consideration 1consideration 1: unequal relationship, : unequal relationship, leading role of professionalsleading role of professionals

consideration 2consideration 2: a patient to retain a certain : a patient to retain a certain degree of self-determination because of degree of self-determination because of one’s own values.one’s own values.

FIDUCIARY MODELFIDUCIARY MODEL

model in law model in law beneficiarybeneficiary ( ( 受惠者受惠者 )– entrust some propert)– entrust some propert

y or delegate some power to the fiduciaryy or delegate some power to the fiduciary Fiduciary Fiduciary (( 受託人受託人 )) – to promote the interes– to promote the interes

ts of the beneficiaryts of the beneficiary stock-holders stock-holders andand company managerscompany managers defendants defendants andand lawyerslawyers investors investors andand investment companyinvestment company

patientspatients are are beneficiarybeneficiary, healthcare , healthcare professionalsprofessionals are the are the fiduciaryfiduciary

entrust one’s health to the professionals for entrust one’s health to the professionals for them to promote one’s health interest them to promote one’s health interest

Yet, we should not trust strYet, we should not trust strangers open-endedlyangers open-endedly

No blank checkNo blank check retain the right of some key decisionsretain the right of some key decisions patients do not decide, but consent; passive, patients do not decide, but consent; passive,

yet involvedyet involved

Informed Consent Informed Consent !!!!

Breast Implant & Fiduciary ModelBreast Implant & Fiduciary Model

Informed consent as a corner stone Informed consent as a corner stone The doctor provides the recommendation on medical The doctor provides the recommendation on medical

ground ground (active)(active), and seeks the patient’s authorization , and seeks the patient’s authorization (passive)(passive)

““11stst choice: saline; 2 choice: saline; 2ndnd choice: silicone” choice: silicone” ““You refuse the 1You refuse the 1stst choice? Okay, I’ll give you 2 choice? Okay, I’ll give you 2ndnd choice; choice;

but you need to consent to accept the possible side but you need to consent to accept the possible side effects.”effects.”

““You refuse the 1You refuse the 1stst choice? Too bad, I can’t recommend choice? Too bad, I can’t recommend another treatment. Try another doctor, if you want.” another treatment. Try another doctor, if you want.”

To be worthy of patients’ To be worthy of patients’ TRUSTTRUST::

1. honesty1. honesty

2. candor2. candor

3.  competence3.  competence

4.  diligence4.  diligence

5. loyalty5. loyalty

6.  fairness6.  fairness

7. discretion 7. discretion

Plagiarism Plagiarism

「「現在欺騙老師現在欺騙老師 , , 將來極可能會將來極可能會欺騙病人欺騙病人 . . 這是浸會大學及香這是浸會大學及香港的悲哀 港的悲哀 !! !! 」」

Moral virtues are necessary for good medicMoral virtues are necessary for good medical practice!al practice!

The practice of The practice of traditionaltraditional Chinese medicine in Chinese medicine in modernmodern society – which model of therapeutic society – which model of therapeutic relationship should we adopt?relationship should we adopt?

Paternal?Paternal?

Consumer?Consumer?

Partnership?Partnership?

Friendship?Friendship?

Fiduciary?Fiduciary?

Which model of therapeutic Which model of therapeutic relationship do these tracts relationship do these tracts

indicate? indicate?

Paternal?Consumer?Partnership?Friendship?Fiduciary?

Mid-term Test Mid-term Test

March 15 (Wednesday)March 15 (Wednesday) Short questions and one-page answersShort questions and one-page answers Choices: 5 out of 6Choices: 5 out of 6