4. Doctor-patient relationship: moral values

Relationship models Paternalism vs. autonomy

Teacher:GeorgeCristian CurcaProfessorofLegalMedicineandMedicalEthics,MD,Ph.D.Dept.ofLegalMedicineandBioethics,UMPharmacy CD

doctor-society

doctor-doctor

Doctor-patientrelationship

• Therelationshipdoctor-patientisinthecentreofthemedicalethics• HippocraticOathattestedforthefirsttimethebirthofmedicalethics

notjustbecauseitisthefirstdocumentationaboutnormativeethicsinmedicinebutbecauseitstatesmoralvaluesinrelationshipwiththemedicalpracticeatthebedside(clinicalpractice)whichwas,ateachingandpracticemethodofHippocrate’s schoolitself.

• Medicalethicsteachesthemoralvaluesinthefollowingrelationships:• Imperatives(values)torespect:

– Moralvalues• One’sownconscience(individualmoralvalues)• Societyvalues• Professionalvalues

– legalvalues

• Doublenatureofdoctorcharacter(duality):humanityandcompetence(professionalism)

doctor-patient

1. Patientmanifestneedformedicalassistance

2. Patientmanifestaddressability3. Patientmanifesttrust4. Patientmanifestcompliance

totreatment5. Patienthasrights(liberty–

autonomy-,righttolife,tohealth,tointimacy,tobeinformed,etc.)

1. Doctormanifestempathy2. Doctormanifestdutyofdiligence3. Doctormanifestfidelity,4. Doctormanifestbenevolence,5. Doctormanifestbeneficence,6. Doctormanifestnon-maleficence,7. Doctormanifestjustice8. Doctormanifestrespectforpatient

humanity,dignity9. Doctormanifestrespectforpatinet’s

rights

Doctor’sdualityofcharacter

Basedon:1. Empathy

1. Benevolence2. Beneficence3. Non-maleficence (donot

harm)2. Respectforhumanbeing

Respectforhumanlife3. Patienthealthasthefirstduty

• Competence:capacitytohaveabilities,knowledge,selfimprovementinaparticulardomainwhereonehavelegalrightforpractice

• Profesionalism (4x4):1. Memberofaprofessionalbody2. Expertise(competence)3. Senseofduty4. Ethicalbehavior:

a) respectfortheclientasaperson(respectforthehumandignityofpatient,forhumanlife)

b) respectforthegoodoftheclient:thegoodwillisaboveallinterests

c) Thequalityoftheservice:qualityoftheserviceisaboveallconsiderations,becomesadutyitself.

d) Respectforthehonoroftheprofessionalbody:hehonorshiscolleaguesasbrothers andsisters

Theprofessionalpersonalwaysperformswithdilligence hisdutynomaterwhat,strivingforthebestqualityservicehemaydeliver(heismorethanacompetentperson) .

• Competence,professionalism• Humanity

Doctormoralvaluesshaping

1. Shapingofthevirtues:academicstudy2. Professionalmodelshaping:everydoctorsearchfora

modelinhisfirstyears3. Shapingaccordingtotheprofessionalbodyvalues:

medicalcodeofethics4. Shapingincontactwiththesocietyvalues(onrequest

base)5. Shapingonhisownvalues

1=asastudent2+3=asaresident4+5=asaspecialist

1. Responsibility* (forhisdecisionandhisactions)2. Professionalindependence(ownjudgement,inthebest

interestofthepatient)3. Competence(expertise)4. Readiness(toansweratrequestbase:i.e.emergencycall)5. Justitice (donotproduceinjustice,providingequityand

equalityinthehealthcare,withoutdiscrimination:thesameforall,thebestqualitythesystemcanprovide)

Societyvalues(whatsocietyaskfromthedoctor–intheorderofimportance-)

•Whyhaving responsibility? 2elements:legalandmoral:legallybecausethereisarequesttoprotectone’srights;morallybecausethereisarequestforprotectinghumandignityandhumanlifeasagood intentionandagoodaction

Moralobligation

Moralvaluesasvirtues

Moralvaluesasactions

Quoting

Sufference Empathy,compassion,beneficence

RegretCompassionEncouragement

“Weregret…”(regret)“Ithinkithirts…(compassionate)”.“Bebrave…(Encouragement)

Ownmistake

ReparationDonotharm(non-maleficence)

TruthAcknowledgementAskforforgivnessReparation

“Ihavetoadmit…Ihavetotellyouthetruthandthetruthis…(truthtelling)“Iamsorry…(Askforforgivness)“Don’tworry…IwillrepairwhatIdidwrong……”(Reparation)

Promise

Fidelity LoyaltyDutyDonotabandontosecurethetrust

“Trustme…Iwillcomebackimmediately,Iwillbehereforyou,staywithme…”(Promissformedicalcare,treatment,etc.)

Obligation Fidelity LoyaltyDuty

Itismyduty…Beconfident…(expressingthedutyofcare)

WEMANIFESTDUTIES TOANOTHERHUMANWHEN:

Moralobligationsa) Sufferance:Empathy

a) Regretb) Compassionc) Encouragement

b) Mistakea)Acceptanceb)Forgivenessc)Reparation

c)Promisesa) Dutyb) Fidelity,nonabandonc) Loyalty

d)Obligationa)Dutyb)Fidelityc)Loyalty

WMA*DeclarationofGeneve,1948(moralvalues):• Isolemnlypledgetoconsecratemylifetotheserviceofhumanity(beneficence,respectfor

humandignity,autonomy);• Iwillgivetomyteacherstherespectandgratitudethatistheirdue(gratitude,justice,loyalty,

respect,honor);• Iwillpracticemyprofessionwithconscienceanddignity(beneficence,honor,humandignity,non-

discrimination,non-maleficence,autonomy,professionalindependence, responsibility);• Thehealthofmypatientwillbemyfirstconsideration(beneficence,non-maleficence,respectfor

life,fidelity,loyalty,duty);• Iwillrespectthesecretsthatareconfidedinme,evenafterthepatienthasdied(fidelity,loyalty,

duty);• Iwillmaintainbyallthemeansinmypower,thehonorandthenobletraditionsofthemedical

profession(fidelity,loyality,duty,respect,honor,beneficence,non-maleficence,justice)• Mycolleagueswillbemysistersandbrothers(respect,honor,beneficence,professionalbody);• Iwillnotpermitconsiderationsofage,diseaseordisability,creed,ethnicorigin,gender,

nationality,politicalaffiliation,race,sexualorientation,socialstandingoranyotherfactortointervenebetweenmydutyandmypatient(non-discrimination,justice);

• Iwillmaintaintheutmostrespectforhumanlife(respectforlife:non-euthanasia,non-abortion);• Iwillnotusemymedicalknowledgetoviolatehumanrightsandcivilliberties,evenunderthreat

(respectforlife,humandignity,non-discrimination,non-euthanasia, non-torture,humanimmoralexperimentation);

• Imakethesepromisessolemnly,freelyanduponmyhonor(honor,justice,responsibility).

*WorldMedicalAssociation[http://www.wma.net/en/10home/index.html],accessed19th March2014

Patient

Sufferance,medicalneed

needforcare

Rights,respect

Doctor

Humanity

Rights,respect

Sistemmedical

trust

Ethics

Competence

professionalism

MORALVALUESOFTHERELATIONSHIPDOCTOR-PATIENT

Trust

• Thepatientofferstrust,willingtoreceivethetreatment,compliance

• Thedoctoroffers:benevolence,beneficence,non-maleficence,autonomy,justice,fidelity,dignity,respect,etc.

• Trust>confidences>information>fidelity>confidentiality>multipliedtrust

therelationshipdoctor-patientbecomesecure

Fidelity,loyalty• Fidelity(faith,thequalityofbeingfaithfulor loyal). Respectforfidelity(avirtue:theactionis

loyalty)• Fidelity>moralobligation=duty>loyalty.Dutyasamoralobligation,dutyasadiligenceina

professionalway(deontology),dutyasaresponsetothepatienttrust• Heismydoctor…he/she ismypatient…callmewheneveryouareinneed…Iwillhelpyou….• Conflicts:

– Conflictofinterest(alwayssolvedinfavorofloyaltyandtheinterestofthepatient)– Doubleloyalty:i.e.patient interest/publicinterest(solvedinfavorofthepatient:thebest

interestofthepatientisabovetheinterestofsocietyandscience),confidentialitytothepatient/publicinformation(solvedinfavorofthepublicinformationforwhat ispublicinformationandpersonaldataprotectionforwhat ispersonaldata),dutytotheparentsvs.loyaltytothechild(solvedinfavorofthechild),pregnantwomanvs.child

– Patientinterest(public)vs.personalinterest(solvedinfavorofthepatientinterest)

Patient interest Public interestLoyaltyimplies:1. Tofollowthebestinterestof thepatient2. Toputthepatientinterestsaboveofinterests(professionalism)1. Patienthealthismyfirstconsideration (duty, loyalty)2. Confidentiality

Double Loyalty

Double loyalty:– Parents vs. child, pregnant woman vs. child– Other individuals (institution, government, citizens) – Conflict in the double loyalty is solved always by

protecting the most vulnerable and by non discrimination

Goodofthemother Goodofthechild Goodofthepatient

Goodoftheindividuals

Moralsvaluesofbioethics

Beneficence1. Topreventthebad2. Toeliminatethebad3. Todogood

1. Toactionforthegoodofthepatient2. Tomaximizethebenefitsandminimaze therisks3. Concernforpublichealthorforvulnerablepersons

Nonmaleficence (todonoharm)AutonomyJustice

Tosaythetruth(veracity)

• Tosaythetruthisaduty:adutytothetruthitself,adutytothepatient,adutytous(nottolie)

• Thedutytocommunicatethemedicalerror• Sayingthetruthweinform,informingweprotectone’sliberty(ifautonomousandlegallycompetent)

Totreatvs.nottotreat• Beneficencevs.autonomy• Beneficence/non-maleficence• Appearsespeciallywhenthepatiententrustustomakedecisionfor

him(interpretativerelationship)orthepatientiswithoutautonomy• Thedoctorhastobalancebenefitsandrisks:beneficence/non-

maleficence• Patientwish,patientpreferences(hisbestinterest)(utilitarian

approach:dutytobeintheserviceofthepatient)• Medicalcodesaskforadutytoprotectandtopreventpatient

health:goodwill+actingfromDuty=moralvalueofactions(Kantianapproach:dutyinthedutytoprovidehealth(deontology)

• ProfessionalindependenceisprotectedbytheKantianapproach(deontology)andignoredbytheutilitarianapproach

Therapeuticprivilege:foranautonomouspatienttodecidenottotellthetruthandtobeginthetreatmentprotectinghisbestinterestsupondoctor’s

judgement

Criteria totake into considerationtheTP:1. Certainlethal diagnosisand

prognosis2. Patientcapabletoabandonorto

inflict selfharm3. Patientpersonality (depressive)

CriterianottakingintoconsiderationtheTP:1. Patientautonomouswhoask

explicitely forthetruth(fightingpersonality)

2. Patienthasaninfectiousdiseasewhichahas tobedeclaredAIDS,TB

3. Patientneedsanothermedicaloperationwhichasfortheinformedconsent

TPisanexception:autonomyrules. Theconflictisbetweenbeneficencevs.non-maleficence

Modelsofrelationshipbetweendoctorandhispatient

1. Paternalistmodel:basedonpaternalisticattitudeofthedoctor

2. Informativemodel:basedonpatientautonomy;thedoctorisasimpleconsultant

3. Interpretativemodel:basedonthepatientautonomybutthedoctorisaninterpretofthepatientneedsandvalues

4. Deliberativemodel:basedonthedevelopmentofa“friendship”relationship(doctorsarespecialpurposefriends)

Autonomy• Autonomyisatriplefoldconcept:

– aprincipleofmorality(Imm.Kant)expressthehumanreasonprimordialityandthehumandignityandintrinsicvalueoftheindividual;

– aconceptofjustice:emergefromtherightforlibertyandforlife:selfdetermination.Becauseofthisrighteveryonemaytakedecisionstorunhisownlifeinliberty(libertyimpliesinformation)

– aprincipleofbioethics(ofmorality)whichtriplefoldamanifestationofthehumanpsychiccapacity:

• Capacitytoreceiveandtounderstandinformation• Capacitytobevoluntary(voluntariness),mostlyawishthanacapacity• Capacityofdecision:triplefold:

– Tosubstantiateoptions– Totakeachoicebetweenoptions– Theoptionchosenishisbestinterests

Withitsautonomyeverypersonhasthelegalcapacity(legalcompetence)toselfgovernandtomakedecisionconcerninghisownlife(i.e.signingwills,informedconsent,etc.)

Wheneverapersonisautonomoushaslegalcompetenceandviceversa.Whenapersondoesnotlegalcompetencehasnoautonomyandthatiswhyrelativesofnativeparents,etc.hastotakedecission (theyareentitledlegallyasrepresentatives,thereforelegallyobliged–tortlaw-).

Itispresumedthatweallhavefullpsychiccapacity,autonomy,legalcompetence.Thecontraryistobeproven.

• Doctormustbeassuredthatthepatientisabletoselfgovern,wishtoselfgovernandthenbelefttoselfgovern

• Doctorhasthedutytoassistthefreeexerciseofautonomyofhispatient.Howeverwheneverthepatienttakeawrongdecisionthedoctorhastoconvincehimofhiswrongfuldecisionwithoutforcing(beneficencevs.autonomy);

• Asmuchasthepatienthasautonomyhisdecisionsmustbefollowed.

• Whenthepatientisnotautonomousthedoctormustasktherelativesortakehimselfdecisioninemergencies(whentherelativesaremissing)