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
[Picture]
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