Lecture 4

1. Lecture 4 Professional Responsibility (I): To the Client (Therapeutic Relationship)

2. Therapeutic Relationship Conflict in any relationship What to expect when you enter into a relationship? Therapeutic relationship as an instance of professional-client relationship Who decides what?

3. Medical decision involves value choices • Case 1: blood transfusion for Jehovah Witness patients • Case 2: Brian Clark, Whose Life is It, Anyway (1978) • Case 3: DNR and anticipated QOL

4. 5 Models of Therapeutic Relationship • Paternal model • Consumer model • Model of Partnership • Model of Friendship • Fiduciary model

5. PATERNAL MODEL • Just like parents treat their small children, the professional treat the client in such a way that s/he would not allow the client free choice, for the sake of benefiting the client. • medical paternalism – For the sake of restoring the health or saving the life of the patient, the healthcare professional would make all the therapeutic decisions for the patients

6. 2 important instances • Treatment; e.g., surgery or not? overriding refusals of treatment, overriding requests for treatment • Information; nondisclosure or partial disclosure of information e.g., disclosure of bad news, withholding truth to a terminally ill patients

7. Reasons to support medical paternalism: 1.   superior knowledge of the professional 2.   client is incapable of giving sufficiently voluntary and informed consent 3.   agreement in retrospect

8. disclosing of information is like transfusion of blood

9. However 1. Doctor knows best only in scientific knowledge; a patient is a person, not a bodily object in need of repair; persons have values; medical judgement is to be made in a nonmedical context, in which health is only ONE of the treasured values.

11. 31.10.2004

12. “Is this kind of life worth living?” • “Is it better off dead than to be in this condition?” • “Will life become too degrading to go on living?”

13. QOL is not a medical judgement, but a value judgment on the basis of a statement of empirical fact

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

15. Illustration for the 5 models • Cosmetic surgery – not a matter of life or death, not even a matter of physical health, but a matter of psychological well-being, self-esteem, aesthetic need, and/or career advancement.

16. Needs Augmentation?

17. What stuff should I put inside?

20. Silicone gel • Merit: looks and feels more natural • Disadvantage: long term safety not assured

21. Rupture….

22. Silicone injected to skinfill wrinkles, add volume to lips & cheeks

24. Saline gel • Merit: safe • Disadvantage: looks and feels less natural

25. Breast Implant & Paternal Model • Doctors have the responsibility to safeguard patients’ health • When the long-term effect of a procedure is not assured of safety, doctors should not perform the procedure for patients • “You want silicone gel breast implant? No way !!!” • “Doctors know best. You cannot choose. I’ll give you only saline gel implant.” • US Government restriction of silicone-gel breast implants, 1992 – present (Reading 2, pp.1918b-1919a)

26. CONSUMER MODEL • private practice in free market economy • consumer sovereignty • patients’ rights as consumers’ rights • self-determination and a person’s values • Brian Clark, Whose Life is it Anyway? 1978

29. Difficulties to be a prudent and intelligent consumer in healthcare service: 1. medical decision involves highly technical and complex knowledge 2. consumer intelligence presupposes emotional calmness

30. Breast Implant & Consumer Model • Sovereignty of consumer choice • Each consumer should weigh the benefits and risks of each treatment and decide for herself • A woman should have the freedom to take a little risk and get a more satisfactory breast augmentation. “It’s my body!” • “You want silicone gel? Yes, no problem.” • “You want saline gel? Yes, I’ll do it for you.”

31. MODEL OF PARTNERSHIP

33. Partnership in what sense? • Patient participation, not in decision making, but in self-care or discipline in lifestyle • equal partners?

34. Typical model of other joint ventures: • partners in business, dancing, bridge, tennis • Such partnership requires: 1.   equality (approximate, not strict), 2.   cooperation, 3.   shared rights and responsibilities, 4.   shared decision-making, 5. shared benefits and risks

35. However, therapeutic relationship is essentially unequal: 1.   medical knowledge; emotional stability; 2. risk is largely unilateral

36. Breast Implant & Partnership Model • No true partnership can be obtained

37. MODEL OF FRIENDSHIP • mutual understanding, mutual trust, genuine care • decision-making: sometimes mutual; sometimes the doctor is entrusted to do it unilaterally, in light of the values of the patients • admit that therapeutic relationship is unequal, doctor has to do most of the decisions, trust the doctor like trust a friend; • family doctor (cf. euthanasia in Holland) • shop around

38. However 1. not much choice in public hospitals and clinics 2. referral to specialist; rush to A and E (ER) 3. hospital – face many strangers • Hence, limited applicability – primary care in private practice

39. Breast Implant & Friendship Model • This model cannot apply because there is no history of friendship between the patient and the surgeon.

40. Two important considerations for a satisfactory model • consideration 1: unequal relationship, leading role of professionals • consideration 2: a patient to retain a certain degree of self-determination because of one’s own values.

41. FIDUCIARY MODEL • model in law • beneficiary (受惠者)– entrust some property or delegate some power to the fiduciary • Fiduciary (受託人)– to promote the interests of the beneficiary • stock-holders andcompany managers • defendants andlawyers • investors andinvestment company

42. patients are beneficiary, healthcare professionals are the fiduciary • entrust one’s health to the professionals for them to promote one’s health interest

43. Yet, we should not trust strangers open-endedly • No blank check • retain the right of some key decisions • patients do not decide, but consent; passive, yet involved

44. Informed Consent !!

46. Breast Implant & Fiduciary Model • Informed consent as a corner stone • The doctor provides the recommendation on medical ground (active), and seeks the patient’s authorization (passive) • “1st choice: saline; 2nd choice: silicone” • “You refuse the 1st choice? Okay, I’ll give you 2nd choice; but you need to consent to accept the possible side effects.” • “You refuse the 1st choice? Too bad, I can’t recommend another treatment. Try another doctor, if you want.”

47. To be worthy of patients’ TRUST: 1. honesty 2. candor 3.  competence 4.  diligence 5. loyalty 6.  fairness 7. discretion

48. Plagiarism • 「現在欺騙老師, 將來極可能會欺騙病人. 這是浸會大學及香港的悲哀 !! 」 • Moral virtues are necessary for good medical practice!

50. The practice of traditional Chinese medicine in modern society – which model of therapeutic relationship should we adopt? Paternal? Consumer? Partnership? Friendship? Fiduciary?