The doctor-patient relationship. Basic aspects
Gonzalo Herranz, department of Bioethics, University of Navarra, Spain.
Session at the I Course on Bioethics, department of Medical and Surgical Sciences, School of Medicine, University of Cantabria.
School of Medicine, University of Cantabria
Santander, February 8, 1991
Greetings and thanks.
The doctor/patient relationship, or rather, the doctor/patient relationship, has become so complicated, has established in recent decades so many contacts with factors so foreign in appearance to the simple relationship of yesteryear, that it is not easy to discern what is basic and what is adventitious, what is permanent and what is occasional. Some speak of professional/client relationships, others prefer to refer to Username relationships. And it is enough to cite these binomials to get a sense of how things have changed.
In any case, whatever the tensions and circumstances that electrify or deform the relationship between physicians and their patients, we can identify a core of essential elements, of basic aspects, which we should discuss here this morning. The problem presents itself to us not in determining whether or not a given element is essential to the relationship, but when we try to make a complete list of those elements. To get out of the way this morning, I will first refer to some of what is listed in the new Code of Medical Ethics and Deontology in its chapters II, III and V.
I do not mean to say that there are no essential elements of the doctor-sick person relationship in the other chapters of the Code: there are and there are plenty of them. But it is necessary to set a limit to what can be said in an hour.
What does the Code of Medical Ethics and Deontology tell us about the doctor-patient relationship?
The Code speaks of respect for the life and dignity of the sick person; of the obligation not to discriminate, that is, to treat everyone with the same conscience and application; of the priority given by the physician to the patient's interests; of the physician's obligation to refrain from inflicting harm intentionally or through negligence. The physician has to put the interests of the sick or injured person before any other need, both in emergency situations and in catastrophes and epidemics. He cannot abandon the sick when, by attending them, he runs a serious risk of death, or when he participates in strikes to claim his professional or labor rights.
The Code insists that the doctor/patient relationship is a free relationship, in which the doctor must be freely chosen by the patient, in which the doctor must respect the patient's convictions, in which the doctor must respect the patient's privacy, staff and body. The relationship is governed by mutual trust, so that the lack of this element is sufficient to suspend it in a correct and polite way.
The doctor/patient relationship is a relationship between moral adults, between whom there must be a communication that allows them to make decisions in conscience: in this relationship, understandable and loyal, delicate, circumspect and manager information plays a decisive role, which must be transmitted in such a way as to help the patient make decisions and exercise personal responsibilities, not to destroy the remaining moral courage, sometimes very little, that is left to the patient.
The doctor/patient relationship is a relationship based on authenticity, on respect for the truth. This applies both to certify the physician and to assuming full responsibility for the patient's attention . Medical anonymity is inadmissible: every patient, cared for by a team, has a physician who assumes full responsibility for the decisions. It is he who approves and implements, or rejects and cancels, the recommendations and plans of his colleagues.
The dignity of the doctor/patient relationship requires taking care of the environment in which the relationship takes place: the physical plant and the human environment of the office, outpatient clinic, hospital or clinic; to have the instruments, equipment, medical records and the material elements of diagnosis ready.
The patient has the right to quality medical care. This quality is twofold: scientific and human. The physician must offer the resources of current medical science. He must refrain from interventions beyond his capacity and must call upon a competent colleague when the good of the patient so recommends. The obligation to study in order to keep up to date is both an individual deontological duty of each physician and an ethical commitment of the institutions and societies involved in the regulation of the profession.
In the doctor/patient relationship, quality depends directly on the freedom enjoyed by the doctor to provide his patient in each case with the actions that are most favorable to him. The lack of technical means and freedom for an acceptably correct practice of medicine obliges the physician to denounce, to whom it may concern and eventually to the public, the unacceptable deficiencies.
Because Medicine is essentially progressive, which means that we are not doing it all right, that our knowledge is provisional, the Code humbly acknowledges that not everything is sound in orthodox Medicine based on natural science. It recognizes that some patients may derive some benefit from alternative medicines, the natural-scientific basis of which remains to be clarified. But it requires physicians who apply these remedies to be rigorous observers of their results and to honestly evaluate the efficacy of their methods. The strongest ethical condemnation falls on the falsification of science or the adulteration of Medicine that is charlatanism, fictitious practices and deception of the patient.
This is in brief outline what these chapters of the Code say about the topic that interests us today. But,
What are the basic ethical elements that justify them?
For me, the entire internship of the physician is based on three basic elements: on medical respect for the patient in his or her weakness, on the duty of science and, finally, on the recognition of the patient as an adult moral agent.
I. Medical respect
Today there is much talk of respect as a core element of biomedical ethics. All the documents in which medical ethics has crystallized after the Second World War, that is, after the Declaration of Geneva, give respect a central position in the moral conduct of the physician. It is mentioned again and again in Codes and Declarations.
What does the ethical respect imposed by the professional deontology of the physician consist of? Much, and quite disparate, has been said about respect in philosophical ethics since Kant. We have, in Medical Ethics, magnificent programs of study on the elements of medical respect and the different senses in which the concept is used by the medical profession. To simplify things and as a starting point, we can accept that the respect most congruent with the ethos of Medicine is a basic moral attitude of the physician that allows him to discover and respond to the moral values enclosed in people and precisely in the significant circumstance of being ill. Both the abundance and the quality of the physician's professional moral life depend on his ability to perceive these values. The physician who cultivates respect has the sensitivity and judgment to discover, before each of his patients, which are the dimensions of his service. On the contrary, the lack of respect makes the physician obtuse to the ethical problems of medicine and rude or blind to the needs that each patient presents. Respect prevents the physician from hiding parts of reality and capriciously assessing conflicting values or manipulating his relationships with patients to his own advantage. Respect, finally, allows the physician to provide his services to the patient in all dignity, not because the patient can impose such responses by force, but because the respectful physician bows, before the value he recognizes in others, in a stately manner, in a plenary session of the Executive Council gesture of intelligence and professionalism.
Genuine respect for human life impels the physician, in the first place, to be an expert in perceiving it under the pleomorphic appearances in which it presents itself, to discover it in the healthy and in the sick; in the elderly and the terminal patient as well as in the child; in the embryo no less than in the adult at the height of its fullness. In all cases, it has before it human lives, enjoyed by human beings, all of whom are, irrespective of their legal rights, supremely and equally valuable. Whatever these human beings may lack in size, in intellectual wealth, in beauty, in physical fullness, all these, including all their deficiencies and handicaps, are made up for by the physician with his respect.
This is a constant of the physician's work . He does not have to deal with the healthy. To him go the sick, the handicapped, those who live the crisis fearful of losing their vigor, their Schools or their life. The physician is always surrounded by pain, deficiency, incapacity. The lives he encounters are painful or decayed lives. His respect for life is respect for suffering life. His proper role is to be the healer and protector of weakness.
This idea is very clear for the physician who follows the Hippocratic tradition. Respect for all patients without distinction was included in the Declaration of Geneva precisely in a clause of inexhaustible ethical content, logically transferred to our Code: the one that enshrines the principle of non-discrimination, by virtue of which the physician cannot allow his service to the patient to be interfered with by considerations of creed, race, social condition, sex, age or political convictions of his patients, or by the feelings that the patients may inspire in him, and he undertakes to provide competent attendance to all of them equally.
But reality seems to deny that physicians are willing to comply with such a lofty commandment, since there are many who cynically violate it or consider it to be of an unattainable moral stature. For this reason, it should be emphasized that the prohibition of discrimination is an absolute precept, which includes all human beings without exception. In other words, the right to life and health is the same for everyone, it is possessed by the simple fact of being human. The physician does not submit to the strong man because he has the power to demand his right to be respected, or disregard the weak man because he lacks strength and rights. He attends and serves everyone equally, not because he is an activist of political or social egalitarianism, but because Withdrawal, in the face of the fragility that disease creates in everyone without distinction, to take advantage of his position of power before them. We consider unethical the conduct of those physicians who select their patients, who accept some and reject others, who care for some and abandon others. The ethical tradition admits, however, not exceptions, but priorities within the rule of non-discrimination. One, for example, is that created by the status of urgency. Another is that which orders patients according to a scale of weakness, in order to provide more attentive and solicitous care to those who appear to be more unable to defend themselves because of their illness.
Today, the appreciation of weakness is at a low ebb. The medical profession, born precisely as a human response to the vulnerability of mankind, seems to be disinterested in the pain and handicap of the weak and allows itself to be dragged into an alliance with the powerful. For this reason, it is worth reconsidering in some depth the ethical value of weakness and suffering.
II. Respect for the weakness of the sick person
The physician, in each of his encounters with patients, is faced with a problem: to recognize in that suffering humanity all the dignity of man. Illness tends to eclipse dignity: it hides it and sometimes even destroys it. If being healthy confers, in a certain way, the capacity for full humanity, on the other hand, being sick implies, in a thousand different ways, a limitation of this capacity to become fully human.
A serious, incapacitating, painful disease, which undermines our humanity, does not consist only of molecular or cellular disorders: it also constitutes, and mainly, a threat to our integrity staff or a permanent limitation of it. It subjects us to test as men. We should not forget this when being, or caring for, ill. The Hippocratic tradition, enriched by the Christian ethos, saw in the breakdown of humanity that is being sick the root of the fundamental mandate to use all available means to restore the sick person to human wholeness and health, or, at least, to alleviate as far as possible the consequences of that threat. The physician acts on behalf of and on behalf of mankind to save and relieve the suffering person. Often, the medical attendance cannot be reduced to a mere technical-scientific operation, but must contain a projimal dimension, it must be a response staff to the threatened staff of the sick person.
Res sacra miser. With this denomination of Christian-Stoic origin, the special status of the sick person in the field of tensions of human dignity has been magnificently expressed. It beautifully translates into medical language the general notion of the sacredness of human life. When the human condition of the sick person is considered in this light, we recognize the inviolability and, at the same time, the neediness of the sick person and the linked responsibility of the healthy person to the sick. Respect for the sacredness of the sick person does not render him intangible, but impels us to pity, to compassion, to make him the object of active love.
Certain mentalities, then as now, are blind to the ethical value of weakness. The philosophies of power and vitality, ancient-pagan or modern, have always shown their contempt for the sick and the weak, sometimes disguised as compassion. Nietzsche, who has more disciples than it seems, by elevating the will to health and life to the category of a general principle, established that the sufferer is not a res sacra, but a res detestabilis. The instinctive and vital will to live of the healthy man expresses itself, before the sick, not in respect and consideration, but in contempt and rejection. Conversely, attention, care, compassion, and love for the weak and the small belong for Nietzsche to the slave morality of a decadent and instinctually impoverished humanity.
I think that there is a specific dignity of the patient that deserves a special subject of respect. One can speak of a specific dignity of the patient due to the fact that the sick human being's human dignity is threatened. The specific dignity of the patient, that is, of the sick person who comes into contact with a physician, stems from his legitimate demand for protection of his precarious humanity, from his human right to recover as much as possible of his staff integrity. The physician's respect must be proportionate to this need: the patient has the right to the physician's attention, to his time, to his ability, to his skills. And, throughout the course of the doctor-patient relationship, while fulfilling, in the name of humanity, his official document healing official document , the physician must apply, together with his compassion, his science.
But before going on to discuss the duty of science, it is important to insist on this essential point. Today, not a few of the weak (the insane, malformed children, abandoned elderly, comatose patients) are at risk in medicine. There are physicians who have allied themselves with the powerful and no longer respect everyone equally. They have allied with fertile parents to eliminate by abortion or neonatal infanticide deficient children or those with the modern and incurable weakness of being unwanted. They have allied with infertile parents to create for them an ardently desired child through assisted reproductive techniques. It does not matter that several embryonic siblings die in the attempt, sacrificed as if they had no staff destiny in the Cosmos. In conclusion: some physicians have become agents at the service of the strong in order to expropriate the weak of their remaining human dignity.
It is evident that the weak have few true friends and this may be due to the fact that today very little is thought and written about the dignity of the weak. Perhaps there are very few medical schools in the world that dedicate at least one class hour in some corner of the curriculum to teaching the ethical significance of weakness. But we cannot go on like this. It is necessary to explain and enrich, for example, the doctrine that I have summarized in outline . Not long ago, the French National Ethics committee for Life and Health Sciences published a statement condemning the performance of experiments on patients in a chronic vegetative state. In it, the committee made a strong defense of sick human beings and accorded their weakness a high ethical value. Among other things, the committees report stated: "Patients in a chronic vegetative coma are human beings who are all the more entitled to the respect due to the human person because they are in a state of great frailty. They may not be used as a means for scientific progress, whatever the interest or importance of the experiment that is not aimed at improving their condition". The concept of the direct proportional relationship between weakness and respect is expressed here with precision: the greater the weakness of the patient, the physician must respond with greater dedication, with more careful attendance , with the most scrupulous rejection of any manipulation or abuse.
Finally, it is necessary to offer a serious philosophical justification for the phenomenon of human frailty and biological handicap, that inevitable companion of human life, the acceptance of which is the most human of adventures. No matter how much progress is made in rehabilitation techniques, no matter how generous the budgets for health and preventive services, it will never be possible to eliminate frailty from the earth, nor to abolish suffering, illness and death. It is illusory to think that the slogan "Health for all" can change the essentially weak and vulnerable condition of man, since being a man is tantamount to receiving an inevitable lot of pain and disability. The life of every man, his human destiny, includes the capacity to suffer and the acceptance of limitation. Faced with the inexorability of weakness in the world, the physician strives to reduce the pain, anguish and handicaps of his patients, knowing that he will never know enough to completely defeat his enemies. Herein lies the human core of medicine. As demanding of science and skill is the operation of applying the most modern therapeutics, almost miraculous in their efficacy, as is that of administering palliative care, which requires a great deal of knowledge and mastery of what I believe to be the most difficult aspect of the medical art: knowing how to tell patients that man is made to bear the wounds that illness and the passage of time inflict on his body and spirit, and that acceptance of these limitations is part of the process of humanization. One is not truly human if one does not accept a certain Degree of weakness in oneself and in others. This is required of us as part of fulfilling the duty of being human.
III. The duty of science
Before his patients, the physician must maintain a binocular vision, which allows him to see things in depth, with perspective. He must keep awake his awareness that he is dealing with a human being, that his relationship with the patient is a person-to-person relationship, an I-you relationship. But, in addition to being taken into account by the physician as a person, the patient must be examined and considered as a biological object, in which certain disorders develop. The patient can never be reduced to a collection of disarranged molecules or bewildered organs, or as an enigmatic diagnostic problem or a simple therapeutic essay opportunity. He is those things and, at the same time, a person.
Therein lies the greatness and the risk of medical respect. There is an inevitable and necessary reification of the patient required by the scientific structure of medicine. It is necessary that in the course of the doctor-patient relationship there is a greater or lesser shift from the main I-thou relationship, i.e. from the human, interpersonal plane, to an I-thing relationship, when the patient is conventionally converted into an object of observation and scientific-natural manipulation, by which the physician tries to obtain an exact, goal, purely scientific-natural knowledge of the pathological process and of the corresponding treatment. The naked body, the object of physical examination and instrumental invasion, symbolizes this objectification of the doctor-sick person relationship, which, by its very nature, demands the most complete disconnection possible from all subjective considerations. The physician could not be a good physician if he did not do things this way.
The dazzling progress of modern medicine with its incredibly effective diagnostic and therapeutic methods has only made this aspect, the absolute necessity of scientific objectification of the patient, even more evident. Each of us must be on guard against the terrible temptation to despise technology, which is preached by those who speak loudly of a dehumanization of modern medicine or of the factory-like structure of today's hospitals. Those who say that this forced reification of the patient constitutes a loss of humanity in the physician are unjust. They are wrong, because, at bottom, it is a prodigious manifestation of humanity, a lofty ethical act, full of application and skill. One often hears criticisms, as well-intentioned as they are empty of substance, against the cold technology of modern hospitals and the apparent distancing of the physician who is separated from his patient by equipment and collaborators. And it is said that all this has made medicine lose its humanity. Today, as in the past, effective medical attendance is only possible when the patient trusts the physician. But today, this trust is not based primarily on a given subject of the physician's friendly friendliness, but rather on his scientific objectivity, on the reliability of his knowledge, his skill, his familiarity with the accepted methods of treatment.
Today, for the vast majority of patients, there is the apparently paradoxical fact that the maximum of subjectivity, trust, is supported by the maximum of objectivity, that is to say, by the scientific reliability and the skill and skill of the physician. We must dispel the false confrontation between the physician's technical skill , critical experience and science, which must necessarily be objective, and his human, character and ethical qualities. Precisely the true suitability and authority of the physician consists in the meeting of both fields of skill, which are inseparable in order to be a good physician. Insensitivity to the human needs of the patient is just as much of a blemish as diagnostic botch-ups or the arrogant empiricism of the doctor who thinks he knows it all and does not study every day, humbly, to keep himself up to date, to continue his scientific Education .
I will end now. Someday the accounts of what our time has meant for the development of Science, of truly human Science, will be drawn up. Lewis Thomas, that most brilliant and paradoxical figure of American biological thought, has given us a revealing part of that judgment. "A society may be judged by the way it treats its most unfortunate members, the least liked, the insane. As things stand, we are going to be regarded as a very sad lot. It is time to make amends for our mistakes.