The ethical issue which this paper wants to address is the normative set up in the patient doctor relationship. This is a highly paternalistic model. In this set up, doctors are the experts in medicine. Most patients have only scant and dependable medical knowledge. Hence, the overall trust in one’s medical practitioner is focal to the medical process and doctors carry the main responsibility for the patient’s wellness. The sole duty to decide on every crucial medical evaluations and decisions relies on them.
The patient-doctor patient relations must be a two-way street between the patient and the doctor because medical information does not exclusively depend on the physicians alone. Even when a plain housewife does not know how to treat a basic ailment, she can diagnose her child or husband by just inquiring through books or through online sources. She research on the vital symptoms and manifestations and see the choices she may consider in treating her patient. Hence, she may apply first aid or buy the necessary medicines which will cure her patient. She may get the idea of administering home care or medicines or even herbal treatment, depending on her preferences and judgment. With her newfound knowledge and decision-making, she may not even consult a doctor. Conversely, when she cannot really determine the ailment, she may urgently pursue going to the clinic or hospital for medical help.
The paternalistic approach is illustrated by a doctor-centered approach to medical treatment. It depends mostly on closed questions made to elicit a simple yes or no answer. The doctor’s diagnosis is modeled out of the symptoms and signs of a particular illness. However, this is not centered on the patient’s unique experience of the said illness. This must not be an absolute case in each patient-doctor encounter. (Ibid.)
The main argument in this paper is that the exclusivity of medical information does not rely on the physician. Hence, a father-child relationship between a patient and a doctor is not the most effective set up in this field. At these very knowledge-laden times, a mutual or two-way relationship is more ideal and must be promoted. The faith we render to these medical practitioners does not straightforwardly lead to successful treatment and cure. It must also be noted that the concept of health, wellness today is not solely linked to medical interventions. Traditional and less interventionist methods of medical practice are very much appreciated nowadays. Many people recognize that the individual healing comes as a component of total wellness and not just scientific treatment and cure.
Doctors are not all knowing and omnipotent. They also err and they could make mistakes to the point of sacrificing the lives of their patients. (O’Connor, et. al., 1999) Even when the patients have fully and precisely described their symptoms and their ailments, these doctors are also human beings. They are not gods. To illustrate, a doctor may have a wrong prognosis and he/she may prescribe the weaker medical treatment, or if worst, the detrimental one. Hence, he/she may apply medical cure that will not effectively treat the patient. In all instances, the patient also share in the responsibility of initiating individual efforts to diagnose their conditions, completely express what they are feeling, indicate the exact signs or symptoms, its frequency, among others. (Ibid.)
In a different scenario, an informed and economically independent patient may be diagnosed by the same doctor the same case but the patient may have various options. He may opt for a second opinion. He may instantly request his doctor for another medical procedure. For instance, a patient diagnosed with a lump may rule that if the lump is not cancerous, he may also resort to nuclear treatment. He may resort to natural healing and go to a naturopathic doctor to dissolve the lump without any surgery or any interventionist approach. In these instances, the patient with greater knowledge and more resources has more options. All his options lead to his general well being. This is well outside the bounds of an all knowing doctor.
Another strong contention about the paternalistic nature of the patient-doctor relations is the element of trust and confidence which patients inherently regard to their physicians. A father-child system may be effective when the doctor has been the family’s physician for a long period of time. (Kluge, 1999) Another aspect of this inherent trust is when the doctor is also close to the family (i.e. relative or family friend). This is also applicable when the doctor has stayed in one community and he knows every community member well. In this special condition, an instant sickness warrants the attention of this very familiar doctor who acts as a surrogate physician, taking into his utmost consideration and prognosis the care of the patient. Usually, this doctor is also akin to the medical history of the patient, he knows the patient’s genetic and medical history, congenital conditions, etc.
However, this is not the common practice in everyday living. Because of the current mobilization, people are not permanently living in one community alone. They may constantly travel or may live from one city to another, in their own state or country. People are also moving from one country to another at these times. (Cooper, 1990) With this mobility comes the more emergent nature of commercialist transactions, even in medical treatment and care. Usually, the foundation of trust is reduced by this reality. Doctors are also venturing into a more global outlook and they are urged to treat people at a certain condition and fees. Their reliability is now independent of whether the patient trusts them or not.
Economic and social background ground paternalism. With the emergence of the global economy and/or global village, this type of a feudal system seems to be out of date. We may take it as an archaic concept because it refers to the historic parent (father) and son (child) relationship, where the interests and desires and the command of the father is followed. (Kluge, 1999) In other similar relationships such as mentor and learner, businessman and client, this type of a relationship can be considered as the more powerful stakeholder taking charge of the more subservient one. This is not the case in present times.
In educational systems, teachers are already taken as mentors, facilitators or gurus and not a sole authority. They assist the students in the learning process but the learning style and the pacing still depends on the learners themselves. In business and trading, it is the buyers’ leadership which is followed and not the suppliers’ commands nor the entrepreneurs or the businessmen. Commercial activities are also more market-led. They patiently heed their clients’ feedback since they are the ones who rule. With the availability of many suppliers around the world, they have no choice but to heed their preferences and needs. If their important clients will be irate, they will surely look for other suppliers. With the onset of knowledge and information online, the experts are now reduced to what people know at one instant and how far they can digest their acquired knowledge. Hence, a professional can be knowledgeable to a specific level, but they may also be missing on certain aspects. Thus, it is better to heed and allow the stakeholders decide, certainly because they will make their own decisions according to their own terms, beliefs and gut feeling or simply their basic instincts and inherent will. (Cooper, 1990)
In the medical field, the system of patriarchy has gone down. Doctors must not have this surrogate father and child relationship with their patients nowadays since the modern time renders it unethical and disenfranchising, at worst, even detrimental to the patients. Even when the medical customers are very progressive in the way they choose their doctors and health care or treatments, others are still in the archaic situation of the under supply of doctors. Hence, they do not enjoy quality medical attention and access to medical care. Evidently, in poor countries, the people do not have ready access to excellent healthcare because none is available or if there is, they could not afford it. These poor patients still look up to the doctors as their father and they rely on their every word about their health. At this juncture, the paternalistic relationship between the patient and the doctor is sustained.
An enduring environment warranting the paternalistic set up of the patient-doctor relation is when the medical professional assumes the complete responsibility and commitment to his patient. By compelling the patient to do as he told, this type of doctor deduces his liability by the virtue of his medical authority and professional practice. Hence, if something alters as to the expected outcomes along the way, the doctor is not challenged or questioned. (O’Connor, et. al., 1999) Often, when the diagnosis calls for immediate medical attention, patients do not question the strong authority and direct decisions which the doctor makes. The patient accepts the process as it is.
Cooper (1990) considers “responsibility” as a modern term. According to him, ethics is very important for public officials because they have multiple roles (and obligations that go with them) and they have discretion. Ethics guides them in their responsible use of their discretion. (Ibid.) In application, doctors are also public officials who are “citizens with special responsibilities.” They are professionals and they have fiduciary obligations.
It may be assumed that the physicians also fear for the absolute responsibility or decision making that they exhibit. They also take into account the fact that they may be blamed if something bad happens to the patient. Hence, when they are authorize to proceed with a viable medical procedure, they also instantly confer the said process to the patient and they also resort to their personal authority by the mere rendition of a form of a signed waiver or form to be able to proceed what they have already initiated. This general practice, especially during critical medical conditions or situations, is usually assumed under a doctor’s well meaning intentions. People and institution assume that by the virtue of their sworn occupation, the doctors are only working to the best interest of the patient. However, the problem arises when the doctor commits an oversight or when he falls short of the right faculty in thinking and decision making. (O’Connor, et. al., 1999)
There is little knowledge on the readiness of patients to manage their decision making responsibility. Evidences show that many patients have defined treatment preferences; however, these are not often instantly evident. It should also be considered that doctors sometimes fail to understand the patients, but some patients may not wish to have a strong hold on the situation.
Younger people often have the tendency to be more critical of professional paternalism and more likely to expect active participation in decisions about their medical care. However, some older patients and some with grave illnesses prefer to defer decision making to the doctor. This may be because it gives them an escape to avoid the responsibility attached to the consequences of “wrong” decisions. (O’Connor, et. al., 1999) In hindsight, it may be important to find ways of sharing the involvement which do not place an unnecessary burden on the patients. (Ibid.)
The dichotomy between individualism and pluralism, or self-interest and the common good, puts a natural tension in individuals or organizations, depending on the systems or institutions set up to manage the tension.
The doctors should develop skill in thinking about ethical problems, toward the end of creating their own working professional ethic. Another significant point is that ethical thinking does not only make doctors better at decision making, more fair and compassionate. Ethical thinking also gives them more freedom and allow them to anticipate more problems and challenges in the future. (Gawthrop, 1998)
There are advantages and disadvantages to the paternalistic relations between patients and physicians. The major responsibility does not depend on the medical experts alone. The patient should also be responsible for his health. He/she must be the one to manage it. He may heed the prognosis and the advice of the doctor but he may also consult other important people. The general assumption that the doctors alone are the authority discounts the fact that they may have also short sighted diagnoses. In applying Cooper’s principles and ideas, members of the medical organizations must apply both tacit and explicit knowledge to better grasp the situation. It is in fact the interaction of explicit and tacit knowledge that enables organizations to make sense of their environment. They appeal to both types of knowledge. They exercise moderation, control and manage explicit knowledge, their intuition, and organizational memory, to the best of their experience and judgment. (Cooper, 1990)
In a more organizational level, there is also a middle ground and a better alternative to this ethical situation. This is through “collaborative participatory model.” (Kluge, 1999) The present dynamics in medical organizations warrant the potent synergy of medical knowledge and information which do not only com efrom the doctors or the experts but also from the patients and other important resources (these may include other individuals like another doctor, nurse/s, the patients’ relatives, community health workers, among others). (Cooper, 1990) If this kind of a relationship is reinforced, the outcome may be a more integrated health and wellness for the patient. It may even guarantee a more improved medical diagnosis and treatment.
Cooper (1990) takes a different and more practical approach in assuming that “ethical public administration needs a theoretical perspective on the role of the public administrator.” The author’s motivation for a practical approach is the apparent requirement for leadership, as shown by the ethical behavior in public service. This is similar in the medical profession.
As cited by the author, the government has the obligation to set the example in society. In applying ethics in the workplace, people and the organization are empowered. However, there are inconsistencies in the way the persons of authority dispense of their responsibilities and functions. Leadership has a major role in encouraging people to act honorably. (Ibid.)
For doctors to act ethically and honorably, they must be guided by a responsible medical organization. They must have ethical decision-making skills which are developed through theory, skills and experience. Without the presence of theory and experience, their choices are limited and freedom is inherently controlled by the unforeseen consequences of their actions. (Ibid.) In contrast, with their ability to generalize and apply theories based on their experiences, they can overcome the challenges and the demands of their professional work.
Cooper (1990) is convinced that the role and responsibility and the terms have a modern implication. This is an important baseline to practically approach ethical decision-making. As he said, the concept of role then becomes a facilitator to conform the expectations and obligations linked to the modern world. In this respect, the paternal role of the doctors no longer suffices. This is not anymore the most adoptive and effective role for them to play.
However, to further achieve the better role, the doctors must comply with certain role, responsibility, and a comprehensive process within the medical organizations to solve ethical problems associated with their roles and responsibilities. The approach for decision which Cooper suggested is but one effective way to deal with the ethical boundaries associated with the doctor’s role. In considering the collaborative participatory model in the medical profession as a middle ground and a better alternative to their ethical dilemma, it must also be considered that this is not the single best solution. The more appropriate approach, as shown through the process designed by Cooper, is that the problem is handled at the urgent short-term situation but it is also taken in the wider organizational, legal, and social contexts for future and more reliable solutions and/or practices.
In setting up the ethical decision-making model, Cooper designed four categories of deliberation: 1) the “expressive category” which means the “spontaneous, unreflective expressions of emotion”; 2) “the moral rules category,” where issues are assessed against “rules, maxims, and proverbs”; 3) “the ethical analysis category,” when rules seem ineffective or conflicting with each other, “or when the actions they seem to prescribe do not feel right”; and 4) “the post-ethical category,” where the involved personnel struggles “to seek some basis for emphasizing those things that were determined at the ethical analysis category.” (Ibid.)
As Cooper suggests most effective decision-making occurs at the second and third categories of deliberation, we submit the idea of the said collaborative model as a more ethical decision making position against the paternalistic model.
As reinforced by other studies, the integrated system warrants the integration of the medical care. This means that the flexibility must be present along the way. (Kluge, 1999) For example, in a given situation, the medical expert may become more patriarchal as situation requires it. At another time, the expert may heed the patient’s preferences regarding his/her medical care. The excellent feature of this system is that it does not rely on the absolute power and authority to one main interested party in the health or medical organization. Both parties will brainstorm the options and discuss the good and the not so good aspects. It is good to stress that the utmost responsibility for one’s health is divided between the physician and the patient as well as the patient’s family and extended kin. In this set-up, a more wholly integrated healing process happens. This is a good alternative from the old practice that when a doctor diagnoses the patient’s condition and what treatment is required, the patient then willingly submits to the diagnosis. The modern concept of healing and wellness is very parallel to this set up since it presupposes that the patient is actively partaking in his wellness or health. (Ibid.)
For doctors, the best strategy is to determine which patients want to be given choice/s and which prefer a more passive role. The need for informed consent requires some level of patient engagement with decision making. Various medical organizations and councils have put down the stringent information requirements. (O’Connor, et. al., 1999)
Informed consent must not only be taken as a simple gesture of acquiring the involved parties’ signatures of various forms. It means more than this. It means that in more than several minutes of quality patient-doctor consultation, the feasibility of determining the patients’ preferences and sensitivities and the provision of full and unbiased information must be deduced. (Ibid.) This will certainly require for more and better training in communication skills on the part of the medical practitioners and it will also require better access to good, quality information to enhance the decision making. (Ibid.)
Cooper, T. L. (1990). The responsible administrator: An approach to ethics for the administrative role, Third edition. San Francisco, CA: Jossey-Bass, Inc. Publishers.
Gawthrop, Louis. (1998). Public Service and Democracy. Baltimore: CQ Press.
Kluge, Eike-Henner W. (1999). Readings in Biomedical Ethics: A Canadian Focus, 3rd ed. Toronto: Pearson Education Canada.
O’Connor, A. M., Rostom, A., Fiset, V., Tetroe, J., Entwistle, V., & Llewellyn-Thomas, H. (1999). Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ, 9:319, pp. 731–734.