वैद्य नारायण हरर

Vivekananda Arogya DhamRamakrishna Mission

NARAYANPUR

Models of Doctor-Patient Relationship

• There are three different kinds of models:

1. PATERNALISTIC

2. CONTRACTUAL

3. FIDUCIARY – Related to Trusts and Trustee

• http://www.carroll.edu/~msmillie/bioethics/modelsdocpatrelation.htm

Paternalistic model:Strengths and Weaknesses

• Paternalistic model: The doctor is the professional. He/she gives the order, the patient obeys.

• Strengths: Emphasizes the expertise and knowledge of the doctor

• Weaknesses:• Ignores the autonomy of the patient

• Ignores non-health related but morally legitimate values of the patient

Contractual model:Strengths and Weaknesses

• Contractual model: The doctor and patient "contract" for each other's mutual benefit; the patient determines or agrees to the doctor’s decisions.

• Strengths:• Highlights the autonomy of both patient and physician• Acknowledges cooperative/shared aspects of medical

decision-making

• Weaknesses:• No "contracts" developed or signed in real doctor/

patient relationships• Model doesn’t allow for at trusting relationship

Fiduciary model:Strengths and Questions

• Fiduciary model: The patient confidently entrusts his/her health care to the doctor, who takes on the obligation of working for the benefit of the patient (Fiduciary: relates to a holding of something in trust for another)

• Strengths:• Preserves the freedom and autonomy of both patient and

physician• The legitimate role of physician knowledge• The important role of trust in the doctor/patient relationship

• Questions raised by skeptics:1. Patient trust may be manipulated for further economic gain.2. Patient trust may undermine consumer’s awareness of need

for self-protection3. Serious illness and fear of death diminish patient autonomy

and power to contract any relationship.

Principles

1. Beneficence

2. Non-Maleficence

3. Autonomy

4. Truth telling

5. Confidentiality

6. Preservation of Life

7. Justice

Principles of Biomedical Ethics• 1. Principle of Beneficence:

- Does it solve the problem that it aims to?

• 2. Principle of Non-Maleficence:

- Does it cause any harm?

• 3. Principle of respect for Autonomy/Swaraj:

- Does it foster autonomy?

• 4. Principle of Justice:

- Does it reduce inequality?

“Remain pure all your life; guard your own honour and never transgress the honour of others. Be very tranquil, but when necessary, harden your heart.”

– Bhuvaneswari Devi to her son Narendranath Datta (later Swami Vivekananda)

• Remain pure all your life :Beneficence

• Guard your own honour :Non-Maleficence

• Never transgress the honour of others. :Autonomy

• Be very tranquil, but when necessary, harden your heart :Justice

Beneficence

• The practitioner should act in “the best interest” of the patient - the procedure be provided with the intent of doing good to the patient

Non maleficence

• “Above all, do no harm,“ – Make sure that the procedure does not harm the patient or others in society

Autonomy• Patient has freedom of thought, intention

and action when making decisions regarding health care procedures

• For a patient to make a fully informed decision, she/he must understand all risks and benefits of the procedure and the likelihood of success.

Justice

• The distribution of scarce health resources, and the decision of who gets what treatment “fairness and equality”

• The burdens and benefits of new or experimental treatments must be distributed equally among all groups in society

Ethics are not …

• Ethics is not the same as feelings

• Ethics is not religion

• Ethics is not following the law

• Ethics is not following culturally accepted norms

• Ethics is not science

Ethics are …

• Moral Principles

• What is good and bad

• What is right and wrong

• Based on value system

• Ethical norms are not universal – depends on the sub culture of the society

Ethics: What is right?

• Moral - comes from Latin ‘mos’(mores);

• Ethics - comes from Greek ‘ethos’

• Both have meaning of customs, or generally accepted social norm

• But ‘What is right’ is not just a matter of social norm (e.g. slavery was a social norm at one time)

• Professional norm is not always right, it does revise over time

• What is legally permitted is not always right

Sri Ramana Maharshi -

• Whatever is done lovingly,

• with righteous purity

and

• with peace of mind, is a good action.

• Everything which is done with the stain of desire

and

• with agitation filling the mind is classified as a bad action.

Ethics as Code of Conduct for Morality

• Ethics is generally defined as the study of good or right conduct.

• It is more concerned with life as it ought to be lived than with life as it is actually lived.

• Since the moral life is a struggle of good against evil, it belongs to the realm of imperfection or relativity.

• No one can ever be moral and at the same time perfect.

• Struggle through contradiction is the very basis of morality.

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• Does Ethics Drive the Law orDoes the Law Drive Ethics?

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You are on a sinking ship and there is only ONE lifeboat available. Posted on the side of the

lifeboat is a sign which reads, “Maximum Occupancy” - 8 persons…this boat will sink if

over occupied.” Standing on the deck and waiting on board the lifeboat are nine adults and one

child.You must decide who dies. Be prepared to defend

your decision.

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Persons on deck• You

• A young mother and her infant son

• A 75 year old retired physician

• His 68 year old wife

• A 17 year old, pregnant girl

(this counts as one person)

• A professional athlete (male)

• A member of the clergy

• A middle aged school teacher and

• Her husband, a banker

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Two questions when faced with a dilemma:

• Behavior: What should I do?

• Motivation: Why should I do it?

An Universal Law Of Ethics

• An Indian philosopher broadly defines virtue as what is conducive to

the welfare of others, and vice as what causes suffering to others.

• अष्टादश पुराणेषु व्यासस्य वचनद्वयम ्| परोपकारः पुण्याय पापाय परपीडनम ्||

The Concept Of YAJNA(Sacrifice)

• त्यजेदेकं कुलस्यारे्थ, ग्रामस्यारे्थ कुलं त्यजेत ।ग्रामं जनपदस्यारे्थ आत्मार्थ ंपथृर्थव ं त्यजेत॥

. never being selfish but always ready to help others” have become the principal values of medical ethics.

Unselfish Loving Service. You CANNOT Serve Without Some Sacrifice.

Unselfishness is more paying, only people have not the patience to practise it.

That which is selfish is immoral, and that which is unselfish is moral – SWAMI VIVEKANANDA• Selfishness is the chief sin, thinking of ourselves first.

• He who thinks, "I will eat first, I will have more money than others, and I will possess everything", he who thinks, "I will get before others" is the selfish man.

• The unselfish man says, "I will be last, I do not care if by doing so I can help my brothers.“

• This unselfishness is the test.

• He who has more of this unselfishness is more ethical.

ॐ सवे भवन्तु सुखिनः सवे सन्तु ननरामयाः ।• Viveka – Discrimination.

• Mother is the Best ETHICIST.

• Trust in Doctor-Patient Relationship.

• Unselfishness is the yardstick of Morality and Ethics.

• Loyalty to the Law and Morality in Ethics may not go together.

• An Universal Code of Ethics. – Mahabharata.

• Sacrifice Yourself to Serve Others.

• Selfishness is Crime, Selflessness is Love.