4. doctor-patient relationship: moral values relationship ... relantionship... · ahasto be...
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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
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)