Relationships with Patients

1
Relationships with Patients

• Philosophy 2803
• Lecture V
• Feb. 12, 2003

2
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

3
How Should Doctors Behave?

•  An Ancient Suggestion The Hippocratic Oath
• Hippocrates  'semilegendary' Greek figure
  (400-300s 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"

4
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?

5
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)
• Were leaving emergency situations aside

6
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 persons
  best interest.
• Model Adult-Child (like Hippocrates' view)
• Doctor/nurse as expert to be obeyed
• Focus is on care, rather than autonomy

7
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

8
 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

9
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?)

10
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.

11
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

12
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

13
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?

14
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)

15
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

16
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
  persons actions.

17
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 dont involve
  paternalism since the people being cared for
  arent competent
• However, there are times when paternalistic
  behaviour seems appropriate even when we are
  dealing with a competent person

18
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 persons
  ultimate decision, but would think it wrong not
  to at least try to change the persons mind.
• I cant 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 persons
  autonomous desires.

19
The Myth of Perfect Autonomy

• But why is it morally okay to attempt to override
  your friends/family members 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.

20
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
  persons 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.

21
The Rule of Justified PaternalismStolen from
Dr. Daryl Pullman
The amount of paternalistic intervention
justified or required, is inversely proportional
to the amount of autonomy present
AUTONOMY
PATERNALISM
22
Autonomy Patients

• The usual situations in which doctors encounter
  patients are situations that threaten a patients
  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