Relationships with Patients

Philosophy 2803

Lecture V

Feb. 12, 2003

Objectives

To consider the strengths & weakness of some possible models for relationships between patients and doctors/nurses

To consider the notion of paternalism and when, if ever, paternalistic behaviour is justified

How Should Doctors Behave?

 An Ancient Suggestion: The Hippocratic Oath

– Hippocrates:  'semilegendary' Greek figure (400-300’s B.C.)  

– Doesn't say "first, do no harm"

Some duties:

– teach others – honour your teachers as parents – keep the sick "from harm and injustice"

More Duties

– not to "give a deadly drug to anybody if asked for it" nor to "make a suggestion to this effect"

– not to give "a woman an abortive remedy" – confidentiality – to remain free, in "whatever houses I may visit ... of all

intentional injustice, of all mischief and in particular of sexual relations with both male and female persons, be they free or slaves."

Hippocrates viewed the physician as 'captain of the ship' and the patient as someone to take orders. – Is this the right way to view the doctor's role? – How about other health professionals?

Some Models for Relationships with Patients

Doctor-Patient– Engineering– Paternalistic– Friendship– Contract– Collegial (See Childress & Seigler)

Nurse-Patient– As above– Domestic– Advocate– Physician surrogate (See Storch)

We’re leaving emergency situations aside

1. Paternalistic

To treat someone paternalistically is to treat the person in a way that ignores or discounts his/her wishes but aims at promoting the person’s best interest.

Model = Adult-Child (like Hippocrates' view)

Doctor/nurse as expert to be obeyed

Focus is on care, rather than autonomy

Problems with the Paternalistic Model

• (i) How do we know what is in the patient's best interest?

• e.g., giving up smoking, retiring from hockey

• Big Philosophical Issue: Is self-interest a subjective or objective notion?

• (ii) Lack of patient autonomy

– Generally, paternalism in medicine is viewed as being a bad thing these days. Although, more on this later

 2. Partnership

Model = Adult-adult  

Views patient and partner as equal participants in treating patient (although doctor/nurse of course has special expertise)

Increased Patient Autonomy  

Discussion of what is in the patient's best interest

Problems with the Partnership Model

(i) Unrealistic - Are doctor/nurse and patient really equal?

(ii) Time consuming– May not be suited to many actual situations – Do patients even want to spend the time to become well

enough informed to function as even a near equal?

(iii) Still not enough autonomy?– Aren't competent patients always right about their own best

interests? (If so, then don't we need advisors, not partners?)

3. Technical

Model = Engineer-client  

Doctor/nurse presents options. Patient decides.  

Doctor/nurse is completely out of the business of making value judgments.  

Maximum autonomy for patient, minimum for doctor/nurse.

Problems with the Technical Model

(i) Patients aren't experts– Will they be out of their depth?–

(ii) Unrealistic?– How can all options be presented?– Can we get value judgments out of medicine?– Recall Lecture 3 - “What is Health?” 

(iii) Lack of physician's autonomy

4. Friendship

Charles Fried - doctors are "limited, special-purpose friends"

The doctor/nurse takes on the interests of the patient  

Bridges gap between paternalism & partnership– A friend will sometimes do something 'for your own good'

even if that's not what you want.

Intended to highlight equality and autonomy for both

Problems with the Friendship Model

• (i) Is friendship a good model?

• 'Friendship' is only one-way here• Does payment make a different here (does it

matter whether public/private payment?)

• (ii) Too vague?

• Is this just trading on the good things we associate with friendship?

5. Negotiation

Recommended by Childress & Seigler

Both parties indicate their values. – E.g., views about birth control, blood transfusions,

abortion, longevity vs. enjoyment, ...

Doctor and patient may agree on any one of the previous models (and this may change over time and situation)

Problems with the Negotiation Model

• (i) Assumes wide choice of doctors.

• (ii) Assumes time to negotiate.

• (iii) Assumes patients & doctors are willing and able to negotiate.

The negotiation model has much to recommend it as an ideal, but implementing it will often be unrealistic

Is Paternalism Always Bad?

Notice that, in many cases, problems with the models are connected with concerns about acting paternalistically

This is because acting paternalistically has come to be viewed in a very bad light

In both medical and non-medical contexts, to say someone is acting paternalistically is to generally to say something bad about that person’s actions.

In Defence of Paternalism But there are occasions when paternalistic

behaviour is appropriate or even required

– Parenting (‘Parentalism’)– Caring for Incompetent Friends/Relatives

Some would say that these cases don’t involve paternalism since the people being cared for aren’t competent

However, there are times when paternalistic behaviour seems appropriate even when we are dealing with a competent person

Hard Cases Consider first non-medical cases in which we are

confident that a competent friend or family member is about to make a bad decision

Here, we typically cannot control the person’s ultimate decision, but would think it wrong not to at least try to change the person’s mind.

– ‘I can’t let you… drop out of university/go out with him/eat that week old pork chop.’

In these hard cases, some degree of paternalism seems appropriate.– We at least feel obliged to resist the person’s autonomous

desires.

‘The Myth of Perfect Autonomy’

But why is it morally okay to attempt to override your friend’s/family member’s original intention in some cases?

Because, despite what philosophers might say about the importance of autonomy, we are rarely, if ever, wholly rational ‘self-rulers’

A General Rule of Thumb: The further a person is, in a particular situation, from being a rational self-ruler, the more paternalistic behaviour is morally appropriate.

Autonomy & Paternalism

Our typical ways of thinking about capacity/competence treat it as an on-off notion.

– We set a legal line as a cut-off for taking a person’s desires as authoritative.

This is a useful legal device, but it hides the morally important fact that capacity comes in degrees.

Keeping this in mind is crucial if we want to understand the proper relationship between autonomy and paternalism.

The Rule of Justified Paternalism**Stolen from Dr. Daryl Pullman

AUTONOMY

PATERNALISM

“The amount of paternalistic intervention justified or required, is inversely proportional to the amount of autonomy present”

Autonomy & Patients

The usual situations in which doctors encounter patients are situations that threaten a patient’s ability to function as a rational self-ruler.

– Lack of understanding– Fear– Sickness

What does this tell us about the place of paternalism in the doctor-patient relationship?

– Makes a strong case for the friendship model when negotiation is not possible