Are the sick people people or things? On ethical respect in medicine
Gonzalo Herranz
department of Bioethics, University of Navarra
lecture on the 50th anniversary of the high school Mayor La Estila University
Santiago de Compostela, 1999
1. On the necessary reification of the patient
2. From the doctor's binocular vision
Monocular vision and its causes
4. Patients' rights as a humanising project
5. To err is human. Humanising medical error
6. Ethical Respect in Medicine
Greetings and thanks
The question of whether the sick are people or things is a question that may seem strange to say the least, not to say bizarre. It does not seem to be a question that anyone in their right mind would ask. For the answer seems obvious: of course the sick are human beings! They may certainly be very ill, but a sick person never ceases to be a person! In every meeting doctor/patient we have, at least, two human beings who establish interpersonal relationships with each other, who ontologically are persons, who sociologically treat each other as persons, on a one-to-one basis.
And yet this question, so strange on the surface, does not seem out of place. It is a meaningful question, one that, in medical ethics, needs to be frequently asked. And, although the problem is not new, there is no lack of evidence today that the doctor/patient relationship is becoming depersonalised.
Patients sometimes complain that they have received a less than humane attention from their doctors, that they have not been treated like people. They are heard to say things like "He didn't ask me anything. He didn't even look me in the face: he turned around average , saw the X-ray in the light, and said: this is the same. I'm going to keep taking the pills for another three months. He wrote the prescription and shouted for the nurse to come in next. She wouldn't let me tell her anything.
And doctors also sometimes complain that they no longer practise, or are no longer allowed to practise, medicine as people, i.e. humanely, with individual style, in accordance with the law of the art. They say that they often do not come into contact with real people, as the oppressive burden of care often turns the hours of enquiry into a fast and frustrating parade of ghostly figures, of strangers. They say that they are unable to individualise the services they provide to patients, because, on the one hand, with all the guidelines for action that are circulating, they feel stripped of their own clinical judgement; and, on the other, they feel that their legitimate freedom to prescribe is increasingly curtailed, with the incentives of programme contracts and certain forms of rationing. Some feel that, to a large extent, evidence-based medicine is a conspiracy against the peculiarity of each sick person, whose individuality is absorbed into a kind of statistical anonymity that standardises everything.
There is, it is clear, considerable exaggeration in the complaints of both sides. But, purged of whatever hyperbolism they may have, they contain data and sufficient reasons to suspect that in medicine, if not the reality, then at least the risk of depersonalising the relationship between patients and doctors is present. And, in medicine, depersonalising often means reifying.
The question of whether patients are treated as persons or things is therefore a matter to which attention should be paid. Because, in the end, whatever conclusion one may come to, either as a doctor or as a patient, about the intensity of the depersonalisation-cosification phenomenon in medicine, it is a matter that offers us the opportunity to consider what it is and what manifestations ethical respect has in medicine.
In this talk I will touch on the following points:
1. The necessary reification of the patient. Although patients, i.e. human beings who come into contact with a doctor, are persons and must be treated as such, it is inevitable that, in the course of the medical act, at some point in it, they will have to relinquish their dignity and allow themselves to become objects of exploration and scientific analysis. This entails a certain Degree objectification, objectification, objectification of the patient.
2. But this necessary reification must always be accompanied by the necessary interpersonal relationship. For this reason, the doctor needs to have a binocular vision: he must see his patient with his scientific eye and at the same time he must contemplate him with his ethical, human-sensitive eye.
3. If this binocular vision fails, if the doctor sees only data in his patient and becomes blind to what is staff in him, the doctor falls into this average blindness, becomes one-eyed, suffers a pitiful reduction of his visual field.
4. Physicians run the risk of violating patients' rights when they reify them. These rights are very important, especially from an ethical point of view, because patients' rights carry within them a humanising project of the doctor/patient relationship.
5. Only in a truly humane doctor/patient relationship is medical error tolerated. To err is human, it is said, provided that the context in which the error occurs is human. If there is a lack of humanity and reification, the error becomes an occasion for revenge.
6. Many of the ills that afflict the relationship between doctors and patients today are due to failures, failures of respect.
1. On the necessary reification of the patient
The first ethical requirement for physicians is that they possess the necessary skill. The obligation of science precedes all others. It is unethical for a physician to act in an ignorant, outdated or technically unskilled manner.
For this reason, accusations that medical science is cold, distant and technologised are often unfortunate. Objective science is at least as necessary to the physician as his compassion, his humanity. In medicine, we must discard the anti-technological prejudice. It is unfair to say without further ado that devices and instruments increase the distance between doctor and patient, that medical technology tends to blunt the human side of medicine. This is a serious prejudice with dire consequences. The technification of medicine must be understood as a refinement of sensitivity, not only technical but also ethical; as an effort, full of humanity, an impulse of justice, with which to help more effectively the greatest issue. And I am not only referring to equipment and interventions, but also to the organisation and planning of primary care and hospital medicine, to health policy, and even to the need to face the very difficult problem of rationing health services.
In front of his patient, the doctor does not behave primarily as a compassionate being. The doctor is not a loving mother. His primary function is to analyse, with precision and objectivity, the data he observes and the signs he reveals. He must inevitably turn the patient's account of his ailments into a medical history; he must to some extent depersonalise this experiential narrative in order to translate it into the abstract language of scientific categories. In the course of proper medical care, there must always come a point at which the physician must set aside the primary human relationship with his patient and, abandoning the I-Thou, interpersonal, dialogical plane, focus his attention on an I-That relationship. He has to turn the patient into an object of observation and management, for only then can the doctor obtain an exact, knowledge , scientific-natural goal, of the pathological process and the corresponding treatment.
In this way, an element goal is installed in the doctor-patient relationship, which not only requires physical exploration, invasion of the patient's intimacy with strong questions staff, subjecting the patient's body and blood to analytical programs of study , but also disconnecting as completely as possible all feelings of pity, all affectionate consideration. The doctor could not be a good doctor with tears in his eyes and sorrow in his soul. What may seem like inhuman objectivity is the beginning of a truly humane relationship.
For the duration of the physical examination or any other diagnostic or therapeutic examination, the patient relinquishes control staff over his or her own body and agrees to turn it into an object on which the doctor applies his or her professional gestures. In the act of undressing, the patient manifests a transitory Withdrawal to his human dignity and accepts that the doctor uses him as an objective, impersonal and depersonalised reality.
This moment goal of the doctor-patient relationship has a marvellous protective effect on the dignity and purity of medicine. This scientific approach, pure and simple, is the salt that protects the medical act from corruption. Never can the physical intimacy with the patient's body demanded by examination (the detailed and alert visual inspection, palpation) have the slightest erotic connotation for the physician. The clauses of the Hippocratic Oath "I will live and practice my art with purity and sanctity. Whenever I enter a house, I will do so for the good of the sick. I will abstain from any wrongdoing or injustice" have long eliminated the risk that feelings might play tricks on the doctor at that crucial moment in the doctor-patient relationship. The examination is carried out on a "depersonalised", "necessarily reified" body, precisely in order to disconnect it from any affective attachment.
And although, as we shall see in a moment, this depersonalisation is the seed of the dehumanisation of some doctors and the factory-like structure of some hospitals and clinics, it is an ethical element of high dignity, a manifestation of refined humanity, of solicitous care.
Medical science is not only a legitimate source of professional pride for doctors. Technology is kind, it has within it the capacity to humanise the doctor/patient relationship, to take the heat out of it, to make it more effective, curing it of the harsh, brutal, drastic nature of medical and surgical interventions of the past.
This is the reality. And, despite the few voices from the soft or utopian medicine world condemning the predominance of technology, the vast majority of people base their vote of confidence in today's medicine and doctors on technical efficiency. Trust in doctors is no longer based primarily on certain personal qualities, such as a good-natured friendliness or a clinical eye, which were highly valued in the past, but rather on their scientific objectivity, on the reliability and currency of their knowledge, on their skill, on their familiarity with tried and tested analytical and therapeutic methods. This leads to the seemingly paradoxical fact that the patient's maximum subjectivity, his trust in the doctor, is based on the maximum objectivity, i.e. on his scientific information and his skill technique. It is therefore necessary to eliminate the false confrontation between the doctor's technical skill (objectivity, experience and science) and his human qualities (character and ethical integrity). Precisely the true suitability, the legitimate moral authority of the physician, consists in bringing together both fields of skill, which are inseparable in the good physician.
The lesson must be learned on both sides. That medicine sometimes has to be tough is something that certain squeamish, emotionally fragile, emotionally fragile patients, who are offended by nothing, abnormally susceptible, must know. All patients can do with a little stoicism and equanimity in the face of the misfortune of illness. That medicine must be both strong and delicate is a lesson to be learned by many doctors who have become desensitised or even brutalised by the routine of the technical chain work .
2. From the doctor's binocular vision
Thus, in front of the patient, the doctor has to solve an enigma: that of recognising in the patient, whatever his condition, all the dignity of a human being. Illness tends to eclipse, to a greater or lesser extent, the patient's human dignity: it limits it, conceals it and even threatens to destroy it. If being in good health gives us, in a certain way, the capacity to achieve a relative human fulfilment, being ill means, in a thousand different ways, a small or large reduction in the capacity to develop the project of man that each one of us cherishes. We are limited by minor ailments and indispositions, which rob us of the joy of living or make us cower before the work that remains to be done. We are limited, above all, by chronic illnesses, which incapacitate or cause physical or moral suffering that is not easy to bear, which discourage or depress.
This is why we physicians must understand that disease does not consist only of biological disorders. It is true that diseases have, as we study in pathology textbooks, causes and mechanisms; they are expressed in an infinite variety of molecular or cellular disorders, disorders of correlations that can be analysed and quantified, and which we can influence with the many resources in our therapeutic arsenal.
But, it must be stressed, illness is, in addition to all this and at the same time, sometimes almost exclusively, a threat to integrity staff, which subjects the sick person to test and plunges him or her into an existential crisis. For this reason, medical care cannot be reduced to a simple technical-scientific operation. It often includes an interpersonal dimension. For it is not only about neutralising or destroying the cause of the illness, relieving pain or alleviating the symptoms that come from Structures impaired biology. It also has to suppress the threat of loneliness, handicap and helplessness that the disease threatens to bring. The doctor often needs to administer hope and comfort, peace and warmth along with his medicines.
There is an expression that seems to go back to Seneca and St. Augustine, which sample very eloquently describes this status of the sick man, this inextricable coexistence of physical injury and spiritual need: Res sacra miser. The sick person is a sacred thing and, at the same time, worthy of compassion. This term, which Vogelsanger has revived, expresses in a magnificent way the special status humanity of the human being who is a victim of serious illness, including terminal illness. It is a wonderful expression of the coexistence of the sacredness and dignity of all human life with the misery of the organic decay caused by illness.
When the physician sees the sick person as someone who is unconditionally worthy, though fallen into deep misery, then he is looking at him with binocular vision. People want to be cared for by doctors who are scientific enough to understand and solve the problems of their biology and who are human enough to understand and solve the problems of their existence in crisis.
But people often complain that many doctors have become one-eyed.
Monocular vision and its causes
This is not the occasion to list the acts of omission and commission arising from monocular vision. I will briefly refer to the most elementary one. In the colloquial language of many doctors, there is hardly any talk of people, of beings with proper names: names are replaced by diagnostic labels, by operative terms. In the corridors and lifts of hospitals, one hears talk of the two nephrectomies this morning, of the primary biliary cirrhosis that has just been admitted, of yesterday's catheterisation, of going up to see the two mummies we have in the ICU, of discharging the patient with unstable angina, or of whether the Prader-Willi's picture has been taken yet. Sometimes patients are blamed for the failure of medical interventions: "her husband received the best combination of chemo currently available, but did not take advantage of it", "this subject was a high-risk case: we could see it coming", "if he does not unclog tonight, he is going to have a very hard time", "the patient disobeyed the therapeutic plan and relapsed in the I.C.C.". Perhaps this is spoken in order to maintain professional secrecy in some cases, and in others, as an unconscious mechanism to preserve mental health, ego, or professional pride.
In any case, denying a person a name is the first step towards his or her reification, the beginning of robbing him or her of humanity: the man is thus hidden and only his or her problem is dealt with. The long-term effect deadline of this reductionist resource is not only to disregard everything that is relevant to the assigned label , but also to establish prejudice as guide of action. The label replaces, as a mental category, the person. It would be interesting to investigate what contingent of iatrogenic harm corresponds to this biased attitude.
You will say to me: But this is a way of working, very widespread, in hospitals and, to a lesser extent Degree, in primary care. Yes, I know, and I think it is due to a serious omission in the medical Education .
In Spain, medical students and young doctors receive a very demanding Education in the scientific field. However, since 1976, they have been subjected to a lacking per diem expenses in terms of human and ethical-professional training . In that year of that very special time of political transition, the Deans of the Schools of Medicine, as an expression of that incipient university autonomy, decided to revise the Study program of the licentiate degree, in order to adapt it to the new time. And, at a time when, in the United States and other advanced countries, Medical Ethics was becoming an obligatory and very significant discipline in the Education of future doctors, here, instead of applying an energetic cure of modernity and content to the decaying discipline of Medical Deontology and converting it into a Medical Ethics in keeping with the times, they decided to remove it from the curriculum.
The consequences of that unfortunate decision are clear: the causes and mechanisms of diseases are studied in infinite detail and interpreted at core topic of molecular and cellular biology. Diseases are understood as biochemical disorders, whose main protagonists are a highly complex set of molecules that initiate, enhance, inhibit or divert processes. Faced with the patient's story, the young doctor reacts by asking himself where the data obtained in the interrogation or revealed by the patient point to in terms of organs or systems, functions and regulations, cellular or molecular mechanisms. He is not very interested in what the disease means in terms of existential crisis for the patient, nor is he concerned about the impact, negative or positive, that it may have on the patient's life staff or family life. This is irrelevant for the time being: among other reasons, because it does not enter into the selective test of spanish medical residency program.
But this training, harshly technical and scarcely human, creates an intellectual habit from which it is not easy to escape: the disease and, consequently, the sick are seen in a reduced field of vision, in which the staff is eclipsed by the biological. A student, who has heard about complex families of drugs or the classification of very rare congenital metabolic disorders, can finish her degree program without anyone having talked to her or invited her to reflect on what it is, how it manifests itself and what demands it makes on us, that which is called human dignity. No one has helped her to acquire a friendly, welcoming vision of patients' rights: at most, they have heard about them as a strategy of political opportunism.
It is logical, therefore, that ethics plays a secondary role in our hospitals and outpatient clinics, since the majority of doctors in them have already been trained in ignorance of the medical Humanities . The way patients are treated as people is not only less than optimal: it suffers from a lack of skills and abilities in professional ethics. Human behaviour is more intuitive than reflective. Faults of omission are all too frequent.
4. Patients' rights as a humanising project
In order to remedy the status, to humanise hospitals, the Charter of Hospital Patients' Rights was enacted 15 years ago, which was incorporated two years later in article 10 and 11 of the General Health Act 14/1986 of 25 April 1986. These Articles state that patients are persons, not things, persons who enjoy certain rights and who assume certain responsibilities. What B is that, in saying something so transcendental, these articles are little known by patients, except for a tiny minority of activists, and also by doctors. There is even reason to believe that they are deliberately ignored or concealed by hospital administrators.
How, through knowledge and internship of patients' rights, can we take a first step towards consolidating the character staff of doctor-patient relations?
To show my students in a graphic way what patients' rights are and what they are for, and how they are put into practice, I tell my students in great detail what André Frossard, in one of his books on John Paul II, tells of the Pope's meeting with his doctors in the summer of 1981, meeting . The Holy Father had just overcome the cytomegalovirus infection that had complicated his convalescence after the attack of 13 May that year. The doctors were in favour of allowing a couple of months to pass before proceeding, once the Pope was fully recovered, to close the colostomy they had had to perform on him in October. The Pope, who had been informed in detail about his status clinic and the nature of the operation, and who subjectively felt healthy and strong, wanted, as a patient, to speak to his doctors. He summoned them to a meeting and spoke to them at length about the ethics of the doctor-patient relationship as a relationship between people. He added: "Don't forget that, if you are the doctors, I am the sick person, and I must inform you of my problems as a sick person. And the main thing is this: that I would not want to go back to the Vatican without being completely cured. I don't know what you may think, but for my part I am meeting very well [...]. I feel absolutely able to withstand a new operation". He asked the doctors to consider, in the light of what he had told them, whether it was necessary to postpone the operation for two months. In conclusion, the Holy Father said: "All my life I have been defending the rights of man. Today, I am the man". As we all know, the operation was carried out immediately.
I believe that the anecdote highlights the human dignity of the patient, his condition as a man capable of personal, face-to-face dialogue, not on a colloquial level, but on an anthropological level. The story of the Pope and his doctors highlights in a unique way how the relationship between patient and doctor is bidirectional and egalitarian, in which one and the other exchange information, recognise each other as persons of sound mind and adult years, negotiate agreements: in other words, mutually elevate each other to the status of ethically mature and responsible beings, of moral agents.
When André Frossard asked the Pope what he remembered of that meeting with his doctors, he commented, among other things, that he had given them information to help them find the best solution for their case, but that he had done so, above all, to explain to them that the patient, in the process of losing his subjectivity, must constantly fight to regain it and become the "subject of his illness", instead of resigning himself to being the "object of treatment". He added that doctors are not responsible for this state of affairs, because it is a question of the inner life, of the patient's personhood. But he thought that doctors should be much more aware of this danger and should actively help the patient in his efforts to re-appropriate his or her personality threatened by the disease. This is one more aspect, John Paul II concluded, of the reification of the individual that is everywhere to be found in the field of social relations, one of the greatest problems of the Philosophy and one of the most serious problems of the modern world.
Patients' rights are an antidote to objectification. They are a moral, rather than a legal, stimulus that encourages the patient to be and behave as a person; and the doctor to respect, despite all appearances, the human dignity of his patients.
Only by respecting patients as persons, only by treating the physician as a person with a special vocation can the physician find meaning and satisfaction in his or her sometimes strenuous work. The physician is an important therapeutic agent (or counter-agent). His or her personality, it is well established, can sometimes be as beneficial as the medicines he or she administers; at other times, it can be as destructive, if not more so, than the disease itself.
5. To err is human. Humanising medical error
Nothing is more demonstrative of the importance of staff in doctor/patient relations than the mistakes that occur in our hospitals. It would be foolish to hide it: in hospitals, as in any other place where human beings live together, mistakes are made. The vast majority of them, fortunately, we do not even hear about, because their consequences lack substance. But a small issue of medical errors can have serious effects for the patients who fall victim to them. And also for the doctors and the institutions to which they are attributed, when the matter is brought to court or is aired in the media on speech.
And yet it is inevitable that mistakes will be made in a hospital. There will always be unforeseeable accidents, unintentional oversights, mistakes at speech, minor negligence. Tens of thousands of medical and nursing acts are performed in the course of a day, acts that require the attentive cooperation of hundreds or thousands of people involved in patient care. The continuous and densely interwoven structure of this teamwork makes it difficult and complex to prevent all errors, as this would be tantamount to working with suicidal slowness and lack of initiative.
But one thing is clear: if you study the significant errors, you discover several things: that many of them could have been prevented and can be avoided in the future; that a small issue of them are due to negligence and culpable carelessness and must be corrected; that errors are not randomly distributed: certain hospitals have fees up to ten times higher adverse events than others.
It is worth noting the existence of this institutional factor: it is not only individual doctors who cause harm, but also hospitals as institutions. For this reason, they distinguish between iatrogenic and comiogenic harm, a neologism which has the same Greek word(komein) as the word nosocomium. It is not only certain bacterial strains that can make the hospital a high-risk place: low ethical tone, deteriorated human relations, lack of institutional pride can also make it an agent of comiogenic harm. Incidentally, a recent study has shown that doctors are vectors of infectious diseases because they do not wash their hands frequently and thoroughly enough when treating their patients.
Comiogenic is not limited to harming patients. The institution itself can be a victim of itself. The leave quality of care in some hospitals stems from factors of varying importance, among which some have been identified, such as the hospital's poor collective self-image, lack of corporate moral energy, poor speech among its members, lack of clarity about institutional goals, recurring periods of crisis triggered by chronic problems, which are never solved. There are hospitals with high morale leave.
Does the commission of errors have anything to do with the staff or reified nature of the doctor/patient relationship? Obviously, yes. Only when patients are seen as persons invested with full dignity, is it possible to step forward and face up to mistakes with the necessary moral impetus.
You hear people say to neutralise mistakes: "We all make mistakes. What can we do?"; or "It's all very well: you think I made a mistake, that I should have done what you say I should have done. But I still think I should have done what I did. You might be right and I might be wrong. But I think things are the other way around. What are you going to do? Saying such things can be either an elegant demonstration of tolerance or a paralysing confession of relativism. Only if we add "It may be that we are both wrong. It would be good to study the matter further. Maybe then we can prevent and learn to correct our mistakes". This overcoming of clinical and ethical relativism is not only a matter, as McIntyre and Popper suppose, of correct professional relations between doctors, but above all of appreciation for the sacredness staff of patients. McIntyre and Popper believe that only physicians are capable of acting as arbiters of what their colleagues do. And in this context, they make some very attractive proposals. They tell us that tolerance is essential for the proper detection of medical errors, and that, in analysing them, any gesture of condemnation or denigration of those who have committed them should be eliminated. The purpose of research of errors should be educational and internship, aimed at improving everyone, not at punishing the guilty. An ethical atmosphere should prevail in hospitals that creates a new subject of trust: that criticism of one another is neither pejorative nor punitive, but a manifestation of mutual appreciation and a desire by all to improve.
All this is plausible and highly desirable. The atmosphere of relations between the doctors working in the hospital would be much healthier and infinitely more humane. It would even be advisable for each hospital to set up a specific written request to analyse ethically the accidents and errors that occur there, especially those that tend to recur. This could reduce the incidence of iatrogenic harm, as I am convinced that, in order to correct its errors, it is not enough for the hospital to use the technical Structures , the subject of the mortality committees or the audits of results. It needs to mobilise its ethical reserves, and set in motion the desirable committee of errors.
But would McIntyre and Popper's proposal solve the problems of patients actually affected by medical error? I think not, at least as far as those errors for which doctors are taken to court are concerned.
We now have enough data to show that two traumatic phenomena coexist at the origin of a very high proportion of lawsuits against doctors for malpractice internship . The first, which is a prerequisite for going to court to claim compensation, is to have suffered serious, goal and measurable bodily or psychological harm. And yet the majority of patients who leave hospital with serious iatrogenic damage do not even entertain the idea of filing a liability claim. The second factor, which acts as a trigger for a legal complaint against the doctor, is the fact that the patient has suffered some form of mistreatment staff: the patient has felt offended, scorned, insulted, neglected, abandoned by the doctor. And, not having obtained a satisfactory explanation for the humiliation suffered, not having received any manifestation of repentance or apology from the doctor, the patient takes revenge for his or her wounded dignity and claims justice in court.
Had the doctor sincerely acknowledged his mistake, the patient would, in all likelihood, have forgiven. There are few things more humanly noble and touching to witness than a doctor's sincere request for forgiveness from his patient: a request that need be no more than a disclosure of the truth of what happened and the truth of the sincere pain felt for it, an offer to make himself available to the patient to help minimise the consequences of the error. In the face of the doctor's sincere humility, the patient softens and forgives, because he feels recognised as a person in an ethical and humane way, who enjoys the privilege of forgiveness.
What I am saying is not result of a voluntarist reflection. It is supported by programs of study conceptual and empirical evidence.
Some conceptual programs of study have further elaborated on the fact that patients are not things, but people who feel and judge. Harm, iatrogenic or comiogenic, has, like any other human illness, two dimensions: a biological and an experiential one. The first, the biological one, can be measured objectively. But the second, the experiential, is subjective, not in the sense of something capricious or feigned, but of something that, by breaking personal projects and deteriorating the quality of life, only the patient experiences intimately, only he can evaluate with his own yardstick. Iatrogenic and comiogenic damage is related to the quality of medical care. And, like quality of care, it has two dimensions: technical excellence and the experience gained by the patient. And the latter is not measurable with professional parameters: it belongs to the patient's estimation, which is, God willing, reasonable, but inevitably subjective.
programs of study Numerous empirical studies, both in Europe and in the United States, have already shown that internship all patients want to know what is wrong with them and want doctors to recognise and confess any errors, even minor ones, that they may have made in their care. In the case of errors with moderate or serious consequences, far more patients consider going to court or reporting the case to professional bodies when doctors hide the error from them than when they confess it to them. The rate of patients reporting doctors is very high when the error, not confessed by one doctor, is later discovered by another. These programs of study field studies have confirmed that the human quality of the doctor/patient relationship is a factor that decides whether patients' attitudes are vindictive or not.
This is not difficult to understand. Trust and loyalty are essential elements of a truly human doctor/patient relationship staff . But for such trust and loyalty to exist and be affirmed, a frank and honest speech is required between doctor and patient. Moreover, only in a climate of trust is it possible to carry out the difficult process of confessing the truth. Admittedly, it is not easy to confess mistakes to patients. But it is extraordinarily effective. Patients, who may renounce knowing the truth and claim their right to be ignorant, have a right, even a legal right, to know the truth. Withholding it from them, in whole or in part, tends over time to undermine the doctor/patient relationship, for the simple reason that such behaviour is tantamount to denying the patient his quality as a mature person capable of making position himself, it is like reducing him to the status of a moral minor. It is like reducing him to the status of a moral minor. It is to nullify the communitarian sense of the society of the sick. The first reason given by European patients who are victims of medical error or negligence for taking action against doctors and hospitals is not financial compensation for the harm suffered: it is to ensure that this doctor or hospital does not do the same thing to another patient. They seek redress for the conduct.
6. Ethical Respect in Medicine
The first article of the Code of Medical Ethics and Deontology that deals with subject , the first of the chapter on General Principles, states that the medical profession is at the service of man. And it adds, without pausing to give reasons, a conclusion of enormous force. He says that, consequently, the primary duty of the physician, that is, the one from which all others flow, is the duty of respect: respect for human life and respect for the dignity of the person.
In this respect, the Spanish Code is in unison with all those in force throughout the world. The Declaration of Geneva, the founding document of the World Medical Association ( association ), was the founding document of the Declaration of Geneva. The Declaration was conceived in 1948 as a substitute for the Hippocratic Oath, as a new formula containing the basic ethical commitments of the modern physician, the core of professional ideals shared by all.
The Genevan Declaration is no longer an oath before God, but a promise that the doctor makes on his own honour. This secular form seeks to make the new order acceptable to all, believers and non-believers alike. And it imposes on all the basic rule of respect for the patient as the cornerstone of medical ethics. And all accepted it, because ethical respect connects deeply with the Judeo-Christian tradition of love for one's neighbour, as the enlightened attitude of man's civil dignity. Man had always been considered, at least in theory, as endowed with a superior dignity, as worthy of honour and respect, so that the possibility of not respecting the human being, whether in oneself or in the other, as a rational creature, was not admitted. In the Christian tradition this notion is reinforced not only by the creation of man as imago Dei, but also by the fact that the Incarnation of Christ brings to humanity a special stamp: every human being is a child of God. This appreciation staff to which every human being is entitled is part of Christian charity. Blessed Josémaría Escrivá expressed it very forcefully: "Christian charity is not limited to helping those in need of economic goods; it is directed, above all, to respecting and understanding each individual as such, in his intrinsic dignity as a man and as a child of the Creator".
What, then, is the ethical respect of the doctor? I conceive it, over and above the politeness and polite attention that we owe each other, over and above the technical correctness of good clinical practice, as the nervous system of the ethical organism. Ethical respect is, first and foremost, sensitivity. The quality and abundance of moral life depends on the ability to grasp ethical values. Respect sharpens our senses and gives ethical value to the patient: to his time, which must be respected; to his anxieties, which cannot be dismissed as mere sentimentality, irrelevant background noise; to the things he tells us, which must be taken seriously; to his preferences, which, in the broad measure of what is acceptable, must be accepted; to his body, which must be treated with reverence.
Respect, as well as making us sensitive, makes us intelligent, as it leads us to select the ethically significant data , charges them with meaning and integrates them into a balanced and prudent judgement. The capacity to analyse, select and integrate data depends, to a large extent, on the respect with which we face our official document, on the availability to give a rational and ethically satisfactory explanation to the decisions we propose and take.
Finally, respect is also the effector arm of the ethical body. It disposes the doctor to put diligently on internship what he should do, it fills with dignity the service that the doctor renders to his patient.
Respect energises and enriches the practice of medicine, the most humane of sciences. Respect for the patient is one source of many pleasurable moral satisfactions, which are the most valued supplement to our salary. There is a gulf between practising medicine in the enriching context of respect for the person of the patient and practising it in the exasperating boredom of spending the day patching things up.
Thank you very much.