PHI 227 Biomedical Ethics

Traditional conception of doctor-patient relationship

1. Hippocratic oath
   1. It sets two sets of duties: i. Duties to the patient: "benefit" the sick and keep them from harm." prohibitions: abortion and poisoning. ii. Duties to other doctors
   2. It is doctor-centered
   3. Silent about patient rights
2. American Medical Association codes prior to 1960.
   1. Built on the Hippocratic Oath
   Also silent about patient rights



Paternalism

Both the Hippocratic Oath and the American Medical association codes prior to 1960 are paternalistic. The principles of beneficence and nonmaleficence take priority over principle of autonomy.
1. The doctor is a quasi-parent
   1. He is benevolent
   2. He always knows best
   3. The control he exercises over the patient is in the best interest of the patient
   4. He is skilled and wise. He is an authority not only in medicine but also in morality.
2. The patient is a quasi-child
   1. He is dependent
   2. He is incapable of understanding complex medical information
   3. He is incapble of making a wise choice concerning his health
   4. It is in his best interest to be left out of the decision-making process.



Changing attitude toward doctor-patient relationship

Paternalism is slowly losing ground. Much of U.S. medical ehtics of the past forty years consists of a critique of paternalism and defense of patient rights. The principle of autonomy has priority over the principle of beneficence.
1. Critique of paternalism.
   1. Doctor's duty of beneficence may conflict with the principle of respect for patient autonomy.
   2. Patient and physician may disagree on the relative value of health in comparison with other values such as religion.
   3. Doctors are not infallible
   4. Some issues dealing with health care are not strictly medical and doctors are not necessarily more qualified than the patient to make decisions about them.
2. Respect for patient autonomy
   1. Non-interference with patient's choices
   2. Treating patient as an end in himself
   3. patient is an adult
   4. Capable of making his own choices, self-determination
3. What changed the attitude towards doctor-patient relationship:
   1. Doctor-patient relationship has grown more impersonal
   2. Growth of managed care
   3. Publicity surrounding health problems caused by medical interventions
   4. Growing perception that physicians place their own financial interests ahead of their patients' interests
   5. Abuse of medical research by the Nazis and others.



Alternative models of doctor-patient relationships

The paternalistic model of doctor-patient relationship is obviously inadequate; patients ought to be treated in a way which respects their individuality and their capacity to choose. What kind of relationship ought the doctor and the patient have?
1. Elements of doctor-patient relationship:
   1. Questions of power,.ie., who has the authority to make important decisions
   2. The role of the care-giver
   3. The role of the patient
   4. What to do what the values of the patient and those of the doctor conflict
2. Robert Veatch's models In an influential article "Models for Ethical Medicine in a Revolutionary Age", Robert Veatch distinguished four models of docto-patient relationship
   1. Engineering model
      1. The patient makes all the important decisions
      2. The doctor is a "hired gun." His job is to provide factual
      3. information and carry out the patient's wishes.
   Priestly Model
   1. The doctor makes all the important decisions; he is the patient's guardian
   2. The doctor always knows what is best for the patient both in medical and in moral matters
   3. The doctor always does what is best for the patient
   4. Patient accepts the authority of the doctor passively
   2. Collegial Model
      1. Doctor and patient are colleagues; they share the same goals
      2. They participate equally in solving problems
      3. Relationship is built on trust
   3. Contractual Model
      1. Doctor and patient enter into an agreement to pursue mutually acceptable goals using mutually acceptable means
      2. Patient makes decisions that are important and reserves the right to withdraw from the contract if his values and those of the doctor conflict
      3. Doctor provides technical expertise and skills but reserves the right to withdraw from the contract if his values and those of the patient conflict.
3. Assessment of Veatch's models
   1. Engineering model
      1. Strengths
         1. Respects patient's autonomy
         2. Emphasizes doctor's knowledge and expertise
      2. Weaknesses
         1. Doctor may be asked to perfom actions with which he does not agree
         2. Gives the patient too much power
   2. Priestly model
      1. Strengths
         1. Emphasizes doctor's knowledge and expertise
      2. Weaknesses
         1. Ignores the autonomy of the patient
         2. Makes the doctor an expert in morality
   3. Collegial model
      1. Strengths
         1. Emphasizes the importance of shared decision-making
         2. Emphasizes the importance of trust
      2. Weaknesses
         1. Patient's trust may be abused
         2. Doctor;s knowledge outweigh that ogf the patient
   4. Contractual model
      1. Strengths
         1. The values and rights of the doctor and those of the patient are equally important.
         2. Emphasizes the importance of shared decision-making
      2. Weaknesses
         1. Does not encourage a trusting relationship between the doctor and the patient; it is too legalistic.
         2. It is too individualistic

Questions about the readings

1. Compare and contrast the different models of doctor-patient relationship put forward by Veatch and Ezekiel and Ezekiel.
2. What model of doctor-patient relationship do you think is best? Explain.