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Thenature of the Doctor-Patient Relaticfrtship Health Care Principles Through the Phenomenology of Relationships with Patients----~ TheNature of the Doctor-Patient Relaticfrtship Health Care Principles Through the Phenomenology of Relationships with Patients----~---. SpringerBriefs in Ethics For further volumes: http://www.springer.com/series/l 0 184 Pierre Mallia The Nature of the Doctor-Patient Relationship Health Care Principles Through the Phenomenology of Relationships with Patients ~ Springer Pierre Mallia Medical School University of Malta Msida Malta ISSN 2211-8101 ISSN 2211-811X (electronic) ISBN 978-94-007-4938-2 ISBN 978-94-007-4939-9 (eBook) DOl 10.1007/978-94-007-4939-9 Springer Dordrecht Heidelberg New York London Library of Congress Control Number: 2012941418 © The Author(s) 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (www.springer.com) Contents 1 Introduction................................. ...... 2 Critical Overview of PrincipIist Theories . 7 2.1 The 'Four-Principles' Approach . 7 2.1.1 Theoretical Basis . 9 2.1.2 The Paradigm Case. 13 2.1.3 The Doctor-Patient Relationship. 15 2.2 Robert Veatch's Model of Lexical Ordering. 18 2.3 The Principle of Permission. 21 3 Phenomenological Roots of Principles. 27 3.1 The Nature of the Physician-Patient Relationship. 29 3.1.1 Communication.............................. 29 3.1.2 Goals of Medicine. 31 3.1.3 The 'Care' in Health Care. 32 3.1.4 The Special Bond. 34 3.2 The Principle of Beneficence and Virtue . 35 3.3 Nonmaleficence................................... 37 3.3.1 Patient Authority or Trust . 38 3.3.2 Epistemology............................... 40 3.4 Respect for Autonomy. 42 3.4.1 A Historical and Epistemological Perspective of Autonomy . 43 . 3.4.2 A Cultural Appraisal. 46 3.5 The Dual Nature of Justice. 50 3.5.1 The Justice of Society. 50 3.5.2 Justice in Health-Care. 52 v vi Contents 4 Principles as a Consequence of the Relationship . 55 4.1 Need for Grounding Principles in the Relationship . 55 4.2 Defining the Ontological Entities. 57 4.3 The Physician as an Entity. 59 4.3.1 Levelling-Down of Medical Relationships. 60 4.3.2 Being as Understanding. 62 4.4 The Patient as Entity: Potential for being Truly-Autonomous. 65 4.4.1 Dimensions of the Illness Experience . 66 4.4.2 True Autonomy and the "Authenticity" of the Relationship . 68 4.5 Hermeneutics of the Relationship . 71 4.6 Phenomenology of the Clinical Encounter . 73 5 Conclusion.......................................... 79 Chapter 1 Introduction A warmth filled the room, a trust, a plea to help, a promise to try. It was what medicine might be ... And I realised that the reason the House Slurpers tolerated the Fat Man's bizarre ways was that he was a terrific doc. The mirror image of Putze!.' Economic, social, legal, and political factors have combined in recent years to effect major changes in medical practice and health care policy.2 Concern for patient rights and patient autonomy have transfonued the practice of medicine which is rooted in the doctor-patient relationship.3 A change took place between 1965 and 1970 which put into question what this relationship is supposed to accomplish. Prior to this date medical ethics was generally thought of do's and don'ts for the physician and the primary principle was to benefit the patient, giving authority to the physician to coerce, deceive and 'do things impermissible' in other human relationships. After that date the patient's benefit was not the only moral principle but of special importance was the principle of autonomy, often thought of as the right to self-determination.4 Medical ethics was no longer the field of physicians but also of philosophers, theologians, people involved in health care and the layman. Robert Veatch considers it a mistake to consider medical ethics to be the same as ethics of the physician.s He suggests that the term patient is not a good one6 as it implies suffering and passivity within the relationship. Many patients, he says, can I Shem S., The House of God, Black Swan Books, 1992, p. 89. Brody B.A., Holleman W.L., "Ethics in Family Practice", in Textbook of Family Practice, 5th edition, ed. Rake!., Saunders, 1995, p. 153. Veatch R.M. The Patiel1l-Physician Relation-The Patient as Partner, Part 2, Indiana 1991, p. I Pellegrino E.D., "The Four Principles and the Doctor-Patient Relationship.: the Need for a Better Linkage", in Principles (!f Health Care Ethics, ed. Oillon, Wiley 1994, p. 362 Cassell E.J., The Nature of Sl(/fering and the Goals of Medicine, Oxford 1991, p. 66. 4 Brody, H. "The Physician/Patient Relationship.", in Medical Ethics, ed. Veatch R.M., Jones and Bartlett 1989, p. 67. 5 Veatch R.M. The Patient-Physician Relation, p. I. 6 Ibid., p. 2. P. Mallia, The Nature of the Doctor-Patient Relationship, SpringerBriefs in Ethics, DOl: 10.1007/978-94-007-4939-9_1, © The Author(s) 2013 2 Introduction no longer be passive especially in present times when most are healthy and visit the medical profession for check-ups, immunisations and other services. Other patients have chronic illnesses such as heart disease and cancer. But none are really sick so as not to be able to participate in their treatment.7 He views the relationship as a contract between the two in which both are partners. 8 In contrast Edmund Pellegrino, advocate for virtue ethics, argues that the fact of illness and the fact that the physician has the knowledge and the trust of the patient who has come to him for help puts the physician in a superior position.9 He thus affirms that some form of reconciliation between virtues and principles is in order. IO Central to the arguments of the physician-patient relationship and to moral choices in health care in general are the four principles put into a theoretical framework by Tom Beauchamp and James ChildresslI: Beneficence (the obliga­ tion to provide benefits and balance benefits against risks), Non-Maleficence (the obligation to avoid the causation of harm), Respect for autonomy (the obligation to respect the decision-making capacities of autonomous persons), and Justice (obligations of fairness in the distribution of benefits and riskS).I2 Rules for health care ethics can be formulated by reference to these principles together with other moral considerations, although these rules cannot be straightforwardly deduced from such principles because additional specification and interpretation would be neededY Examples of such rules are truth-telling, confidentiality, privacy and fidelity, as well as more specific guidelines to current moral problems in bioethics as physician-assisted suicide, withdrawal of life support systems etc. 14 Clouser and Gert first referred to these four principles as 'Principlism' in a critique they gave of Beauchamp and Childress' theory. IS Although acknowledging that it was used in a pejorative way the authors continue to use it when referring to various principle­ oriented approaches. I6 Albert Jonson, in the forward to a book of essays criticising principlism 17 notes that "The Oxford English Dictionary gives us one more definition: "ism," it states, "forms the name of a system of theory or practice" as in Protestantism, Buddhism, Platonism, and Toryism" suggesting that principlism in bioethics is somehow a Idem. 8 Ibid., p. 3. 9 Pellegrino E.D., "Toward a Virtue Based Normative Ethics for the Health Profession", in Kenn. Inst. of Ethics J., Vol.S, No.3, p. 267. 10 Ibid., p. 274. II Beauchamp. T.L., Childress I.F., Principles of Biomedical Ethics, Oxford 1979. 12 Beauchamp. T.L., "The 'Four-principles' Approach", in Principles ofHealth Care Ethics, p. 3. 13 Idem. 14 Idem. IS Clouser K.D., Gert B., "A Critique of Principlism", in J. of Medicine and Philosophy 15, p.219-236. 16 Childress I.F.,"Principles-Oriented Bioethics. An Analysis and Assessment from within", in A Matter of Principles?, ed. DuBose et ai., Trinity Press International 1994, p. 73. 17 Ionsen A.R., A Matter of Principles? p. XV. Introduction 3 system of theory and practice with principles as its creed and having devoted adherents. Many, he continues, arcastically refer to the "Georgetown mantra".
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