The doctor-patient relationship: toward a conceptual re-examination
Discusses the ethical obligations involved with the physician-patient relationship, including tips for communication and student concerns. Faculty experts: Farr Curlin, MD, Clarissa Diamantidis, MD, Peter Ubel, MD, Rebekah Wu, MD. Patient empowerment is a simple guide the provider–patient relationship.
From a psychological point of view, the five concepts of "communication behavior patterns" including submissiveness, dominance, aggression, and assertiveness"psychic distance", "emotional quotient", "conflict between pain relief and truth-telling", and "body language" have received specific emphasis. Lastly, from the sociological perspective, the three notions of "instrumental action", "communicative action", and "reaching agreement in the light of communicative action" are the most significant concepts to reconsider in the doctor-patient relationship.
It should be added, however, that from the sociological point of view, the doctor-patient relationship goes beyond a two-person interaction, as the moral principles of doctors and patients depend on medical and patient ethics respectively.
The theoretical foundations of the doctor-patient relationship will finally help establish the different dimensions of medical interactions.
This can contribute to the development of principles and multidisciplinary bases for establishing practical ethical codes and will eventually result in a more effective doctor-patient relationship.
Doctor-patient relationship, Philosophy, Psychology, Sociology, Orbital parameters Introduction The doctor-patient relationship plays an essential role in ordering the health care system and medical ethics, and since it is a form of communication, it necessitates ethical, philosophical, psychological, and sociological considerations.
The present paper aims to evaluate the essence of the doctor-patient relationship in order to re-examine its conceptual framework. In the first part, the philosophical, psychological and sociological significance of this relationship is explored, and in the final section, the theoretical implications will be discussed.
Simultaneous consideration of sociological, psychological and philosophical dimensions of the doctor-patient relationship can contribute to developing theoretical foundations and multidisciplinary bases for establishing practical ethical codes. The result will eventually be a more effective interaction between the two.
A The Philosophical Essence of the Doctor-Patient Relationship In investigating the philosophical essence of the doctor-patient relationship, three points should be taken into consideration. First, ethical demands in doctor-patient interactions must have distinct definitions and terms; second, the phenomenological ethical debates on this issue need to be explored; and third, modern topics in the philosophy of the relationship should be considered, and relationships with the others should be analyzed from different perspectives.
Ethical Demands Various organizations and professions differ in their attitudes towards ethical demands, recommendations, norms, values and judgments.
Physician-Patient Relationship: Ethical Topic in Medicine
The three components of inclusion, priority and severity are presented below as the criteria for judgment in ethical issues. The main questions to answer in regard to this component are: This important matter is embedded within the principles of beneficence and non-maleficence. The component of priority relies on the answers to the following questions: Should we always take the ethical side and forget about our personal interests?
Or personal interests could have priority over moral obligations? The main questions here are: Can ethics press extreme and costly demands from us? Or are the obligations of morality lighter and easier in the way that most people could overcome? Based on the above-mentioned considerations and classifications, three macro-positions emerge in the ethical relationship, including: Maximal ethics include all the three components discussed above.
In this type of ethics, ethical inclusion does not have any limits and covers all human actions. Extremist moralities consider ethical inclusion to be an absolute matter that covers all life styles and signify that no human action should be outside of this infinite circle.
Are Physician-Patient Relationships Ethical? Ethicists Say No, But Some Docs Disagree
Here what ethics demands from us are boundaries. In other words, moderate ethics often state that after performing our obligations and moral duties, in a relatively wild range of personal interests we can start selecting. Thus, our actions are not always subject to moral judgment.
This type of ethics is contradicted with maximal ethics. According to minimalists, the only forbidden action is intentional harassment. Followers of minimal ethics believe in a wide range of choices and selection areas; they recognize only a limited range of constraints and are in favor of acting upon personal interests 3.
It is a growing concern in medical ethics that the doctor-patient relationship is not approached in a sufficiently broad way and that this overly narrow medical perspective leaves doctors, nurses and other health care professionals badly equipped to deal with ethical dilemmas 4.
Phenomenology could broaden this perspective and serve as a strong basis to understand moral sensitivity. Two notions in phenomenology have a central role in understanding the concept of the doctor-patient relationship: Intentionality and first-person point of view One of the basic concepts of phenomenology is attainment of phenomenal intentionality, which occurs when a person recognizes earlier assumptions and adopts a perspective 5.
Some thinkers like Franz Brentano believe that intentionality and the phenomenological approach can be applied to the first-person point of view 6. For instance the first sighting of a beautiful landscape elevates us in a way that may not happen in later encounters.
The reason is that later encounters are accompanied by presuppositions of the observer, who will be more used to the landscape. It seems that the phenomenological approach can be applied to the doctor-patient relationship. Doctors must reexamine and restrict assumptions toward patients, and at the same time value intentionality in order not to fall into habits.
Moral Sensitivity Moral sensitivity may be enhanced in two ways. First, through reinforcing the phenomenological approach by renewing the first sight experience, that is, in each re-identification of the patient for instancepriorities should be observed.Legal and Ethical Aspects of Medicine – Confidentiality: By Nelson Chan M.D.
Second, since any situation could come to a fork and ethical conflicts may rise, the adverse impacts should be considered and every situation must be regarded from an ethical perspective.
Although at commencement moral sensitivity appears to overlap with maximal ethics, it is of particular importance especially in heterogeneous communications such as the doctor-patient relationship. It may be added that enhancing moral sensitivity even seems to be the target of the phenomenology of ethics in the doctor-patient relationship 7. B The Psychological Essence of The Doctor-Patient Relationship In terms of psychology, the doctor-patient relationship is imbalanced as the doctor has superiority over the patient.
Such imbalanced relationships may give rise to various patterns of communication behavior. Psychologists 8 have distinguished the following four communication behavior patterns based on components such as honesty, perspicuity, respect and inhibition: They are also afraid of being judged or offending others, so they are incapable of making eye contact while speaking.
Their voices are weak and unsteady, and they speak hesitantly. Submissive people avoid conflict rather than try to resolve it.
Doctor–patient relationship - Wikipedia
They speak indirectly and in general terms because they cannot express themselves openly and may quickly feel depressed and vulnerable. People with this behavioral pattern admittedly let others abuse them and treat them disrespectfully.
These patterns work both for doctors and patients. Accordingly, they try to deceive others and take advantage. Domineering persons do not have the perspicuity and honesty necessary for earning their wishes. They express themselves in general terms and sometimes their voices shake. This behavioral pattern is often seen in doctors and sometimes among patients as well. Doctors who prefer patient satisfaction to authority thus create a false autonomy for the patients and will eventually be dominated by them, and patients with this behavioral pattern impair the healing process by inhibition and deception.
Their difference is that a domineering person achieves this aim by secrecy and cheating, while an aggressive person follows it frankly and openly. Unlike the domineering type, aggressive people are honest and straightforward; they are horrible listeners, always accuse others, get angry soon, get confused by criticism, and are usually grim in appearance.
They have loud voices and look hostile, and in conflicts, they tend to destroy their opponents. This pattern is seen among both physicians and patients. Impatient physicians that do not listen, shout all the time and sometimes make irreparable mistakes during the healing process, or patients with lower anger thresholds who create tension in medical environments belong in the category of aggressive people. Assertive people respect themselves and others, and observe the authority of all sides.
They are both honest and frank, and do not accuse themselves or others. Their approach to matters is problem-oriented, that is, when dealing with a problem, instead of accusing themselves and others, they think of a solution. They listen effectively and speak appropriately and understandably. During conflict they emphasize conversation. Their arguments are clear, specified, objective, fair and respectful, and eventually they are the most successful communicators.
Issues such as breaking bad news, wasted treatments and medical mistakes are easy and solvable with this type of behavioral pattern. Labeling such patients "noncompliant" implicitly supports an attitude of paternalism, in which the physician knows best see: Patients filter physician instructions through their existing belief system and competing demands; they decide whether the recommended actions are possible or desirable in the context of their everyday lives.
Compliance can be improved by using shared decision making. For example, physicians can say, "I know it will be hard to stay in bed for the remainder of your pregnancy. Let's talk about what problems it will create and try to solve them together. Would you prefer to try the medication, or to wait? Would you be willing to take this information and find out when the next support group meets?
What will make it easier for you to take this medication? Dilemmas may arise when a patient refuses medical intervention but does not withdraw from the role of being a patient. For instance, an intrapartum patient, with a complete placenta previa, who refuses to undergo a cesarean delivery, often does not present the option for the physician to withdraw from participation in her care see: In most cases, choices of competent patients must be respected when the patient cannot be persuaded to change them.
What can a physician do with a particularly frustrating patient? Physicians will sometimes encounter a patient whose needs, or demands, strain the therapeutic alliance. Many times, an honest discussion with the patient about the boundaries of the relationship will resolve such misunderstandings.
The physician can initiate a discussion by saying, "I see that you have a long list of health concerns. Unfortunately, our appointment today is only for fifteen minutes. Let's discuss your most urgent problem today and reschedule you for a longer appointment. That way, we can be sure to address everything on your list. What do you think we could do to meet everybody's needs? And yet, physicians may not abandon patients. When the physician-patient relationship must be severed, the physician is obliged to provide the patient with resources to locate ongoing medical care.
When is it appropriate for a physician to recommend a specific course of action or override patient preferences? Under certain conditions, a physician should strongly encourage specific actions.
When there is a high likelihood of harm without therapy, and treatment carries little risk, the physician should attempt, without coercion or manipulation, to persuade the patient of the harmful nature of choosing to avoid treatment. Court orders may be invoked to override a patient's preferences.
However, such disregard for the patient's right to noninterference is rarely indicated. Court orders may have a role in the case of a minor; during pregnancy; if harm is threatened towards oneself or others; in the context of cognitive or psychological impairment; or when the patient is a sole surviving parent of dependent children.