Health Science

Consent and Patient Relationships Consent and patient relationships are complicated. There are various models. For example:

The Paternalistic Model The oldest physician/patient relationship is based on the paternalistic model, according to which the physician (father) acts for the good of the patient (child). In many cases, the physician overrules the patient's "immature" wishes. Refer to the lesson on the codes of ethics, particularly that covering the Hippocratic Oath, generally a paternalistic ideal. Paternalism in medicine can be justified if it meets at least two conditions: The judgments and decisions must be for the patient's own good. There must be a reason that the patient him/herself cannot make the decision for themselves -- he/she is not qualified to make a judgment. Mature adults should be allowed to make their own choices, and bear the consequences for their decisions. Normally, people make choices because they have the most information (knowledge) about their lives and they generally care about the outcome. Occasionally this is not true, but still, paternalistic decision making is not the best relationship. A patient who has been treated paternalistically will feel like an object, as if they have no ability to make a decision or they don't care about the outcome. Occasionally patients would like someone else to make the decision. We all feel a lack of power when we become ill; particularly when we enter the hospital. The trick is in choosing a physician or medical care provider who understands what we want, as well as what we need. The Business Model In this model, the physician sees himself as rendering a purely neutral, nonmoral service to his/her clients. The client is seeking these services like he purchases any other service in the community. He/she expects to receive a good service with good results and a warranty! Outside of extreme requests, for example, for the death or disfigurement of a healthy person, physicians in this model have no right to refuse any request. They must abide by the law, of course, but other than that, their role is not to judge requests from their patients, simply to do what is asked to the best of their ability. Physicians are businesspersons, free to pursue pure profits with minimal morality issues. Conversely, patients must be informed that they cannot assume protection from their physicians. Think about the business rule of "caveat emptor" -- let the buyer beware; a principle utilized in free market relationships. No person seriously proposes this model as an ideal relationship. I think it sets up an adversarial relationship, which runs counter to healing and health in general. Some persons, however, want physicians to be both wise and compassionate as well as open to anything the patient wants at any time. It seems we choose how we see our physician, colored by our needs and wants at the time. The Contractual Model This model assumes moral equality between the physician and the patient in making moral decisions. The contract is a moral agreement between the two, outlining general obligations and rights on each side. It is determined in the first meeting between the "sides." In a contractual relationship, certain conditions or assumptions are made: Physicians must allow the patients to make all important moral decisions. Physicians cannot omit information which would assist the patient in making a decision. He/she cannot omit relevant information to the decision. Physicians must make all technical, medical judgments. Physicians are not obligated to enter into contractual relationships which are against their own moral principles. They are not required to perform all functions the patient desires, if these decisions violate the physician's personal morals or ethics. There are similarities between a contractual model and the business model. If we take the contractual model as it is without assuming any good intentions on the physician's part, patient and physician rights are simply conditions of a contract. At the lowest level of this arrangement, the physician may become a technical adviser only. Few important decisions in medicine and health are purely technical only. The contractual model requires physicians to educate patients who have trouble making their own decisions. Patients, who want physicians to make decisions for them should be taught to assume responsibility for their own lives. Many physicians believe this education is impossible, or at best, difficult. Education requires motivation to learn, time to digest, and skills to change behavior. Physicians in many cases do not have the time to devote to the task. Most patients fall into the traditional paternalistic pattern in times of crisis; they don't want the responsibility for choice at a stressful time of their life. They want the physician to make the "correct" choice for them, expecting they will be treated well. They don't want a lesson on critical decision making and medical facts. Sometimes patients make "bad" choices. We are irrational at times; should a physician guard us against these times of irrationality? People who subscribe to contractualism believe paternalism is never justified when a patient is conscious and not psychotic. This cannot be correct, because few of us have scientific, medical knowledge to apply to our decisions. Some paternalistic judgments are always necessary. Is Contractualism the Best Situation? Contractualism works best for articulate, middle-class patients who are knowledgeable about medicine and medical services. Some patients actually know more about their conditions and treatments than does the average physician. Faced with such patients, a physician can actually feel relieved that he/she can perform his function with an educated, interested patient. Contractualism is not ideal. It was borne out of a fear of physicians and of losing control. It also came about with dissatisfaction about medicine. Contractualism does seem to foster an adversarial relationship between the physician and patient. It implies that one must win and the other lose. Contractualism also seems to favor the patient in the relationship. It may see failure as one or the other dropping the ball, rather than a failure of the limitations of medicine. What do Patients Want? Patients and physicians want the following characteristics in each other. What could be better? courage temperance justice compassion competence honesty