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 (400-300’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"

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) • We’re 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 person’s 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 person’s 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 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

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 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.

19. ‘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.

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 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.

21. The Rule of Justified Paternalism**Stolen 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 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