Expand on the doctor-patient relationship: what is it? What variables involved in it? What are the four models we have discussed?
The doctor–patient relationship is a fundamental part of health care. It forms one of the basics of contemporary medical ethics. Patient is always a subject of a therapeutic relationship. Patients are responsible for their wellbeing. It is their obligation to protect their life and take care of their health. Physicians are specialists who aid in preventing or treating an ailment or to re-establish the patients’ strength and abilities. “It is always necessary for a medical act carried out on another’s body to occur in the context of a morally qualified relationship in order to prevent it from becoming an act of violence.”
The patient is the primary agent when it comes to maintaining a healthy life and the physician acts with this primary agent for a determined goal. They establish a relationship between two individuals that is based on trust and conscience. The patient trusts in the doctors ability to aid in the treatment of the illness he/she suffered. The conscience of the doctor pushes them to achieve the mutual goal with the patient which is curing the ailment. A patient should have belief in the capability of their physician and must believe that they can trust in them. For most physicians, the formation of good bond with a patient is significant. Some medical specialties, such as psychiatry and family medicine, underline the physician–patient relationship more than others, such as pathology or radiology, which have very little contact with patients. The ethical basis of the medical performance must take into account 3 components. Firstly, the medical act must be in the good of the patient in every situation. Secondly, the act will proceed only under the consent of both the patient and the physician for it to be ethically acceptable. Thirdly, it has to be legal and abides all the laws for it to be legitimately ethical.
In 1992, two authors (E. J. Emmanuel and L.L. Emmanuel) claimed that there are actually four models of the doctor-patient relationship. In this claim, they took into consideration four variables:
The numerous objectives assigned to the physician-patient relationship.
The physician’s obligations to the patient
The role of the patient’s values
The significance attributed to the concept of patient autonomy
The four models are:
THE PATERNALISTIC MODEL
The paternalistic model, sometimes named the parental or priestly model. In this model, the physician-patient relationship guarantees that patients receive the treatment that best promote their health and well-being. To this end, doctors use their ability to figure out the patient’s medical condition and his or her phase in the illness process and to recognize the medical tests and actions most likely to re-establish the patient’s health or amend pain. Afterward the physician offers the patient with selected information that will encourage the patient to accept the intervention the physician views superlative. At the extreme, the physician commandingly notifies the patient when the medical act will be initiated. The paternalistic model supposes that there are shared objective criteria for defining what is mostly suitable. Therefore, the physician can determine what is in the patient’s best interest with restricted patient contribution. Finally, it is presumed that the patient will be appreciative for decisions carried out by the doctor even though he or she would not approve of them at the time. In the tension between the patient’s independence and well-being, between preference and fitness, the paternalistic physician’s chief emphasis is concerning the latter. In the paternalistic model, the physician represents the patient’s guardian, pronouncing and applying what is suitable for the patient. Per se, the medical doctor has responsibilities, counting that of putting the patient’s gain above his or her own and seeking the opinions of others when lacking sufficient knowledge. The concept of patient autonomy is patient agreement, either at the time or later, to the physician’s decisions of what is suitable.
INFORMATIVE (SCIENTIFIC/ENGINEERING/CONSUMER) MODEL:
The informative model, sometimes called the scientific, engineering, or consumer model. In this representation, the intention of the physician-patient interaction is for the medical doctor to deliver the patient all applicable information, for the patient to judge and choose the medical actions he or she prefers, and for the medical doctor to perform the chosen actions. To this end, the physician enlightens the patient of his or her illness state, the type of possible diagnostic and therapeutic actions, the nature and probability of hazards and benefits linked with the interferences, and any doubts of knowledge. At the end, patients might happen to know all medical data related to their illness and possible interventions and pick the interventions that best grasp their values. The informative model adopts a fairly clear difference between facts and values. The patient’s standards are well defined and known; what the patient lacks is evidences. It is the physician’s duty to deliver all the accessible details, and the patient’s values then conclude what treatments are to be provided. There is no part for the physician’s ideals, the physician’s perception of the patient’s values, or his or her verdict of the significance of the patient’s values. In the informative model, the physician is a source of practical expertise, offering the patient with the methods to exercise jurisdiction. As technical professionals, medical doctors have significant requirements to present honest information, to sustain capability in their part of expertise, and to refer to other physicians when their information or skills are deficient.
THE INTERPRETIVE MODEL:
The aim of the interpretive model’s physician-patient interaction is to clarify the patient’s standards and what he or she really wishes, and to assist the patient in selecting the existing medical interventions that grasp these principles. Similar to the informative physician, the interpretive physician offers the patient the information on the type of condition and the risks and benefits of possible medical actions. After this, however, the interpretive physician helps the patient in explaining and articulating his or her values and in choosing what medical actions most show the specified values, thus helping to understand the patient’s values for the patient. According to the interpretive model, the patient’s values are not certainly set and known to the patient. They are sometimes immature, and the patient may only partially comprehend them; they may conflict when applied to specific situations. Therefore, the medical doctors working with the patient must explain and make these values clear. To do this, the physician acts with the patient to rebuild the patient’s ambitions and goals, commitments and character. At the end, the physician should consider the patient’s life as a narrative whole, and from this specify the patient’s values and their priority. Then the medical doctor chooses which tests and treatments meet these values the most. Notably, the physician does not command the patient; it is the patient who in the end selects which values and way of action fits who he or she is. The physician will not be judging the patient’s values; he or she assists the patient to comprehend and use them in the medical situation. The physician’s obligations include those enumerated in the informative model but also require engaging the patient in a joint process of understanding. Accordingly, the conception of patient autonomy is self-understanding; the patient comes to know more clearly who he or she is and how the various medical options bear on his or her identity.
THE DELIBERATIVE MODEL
Fourth is the deliberative model. The aim of the physician-patient relationship is to assist the patient in choosing the most suitable health-related standards that can be comprehended in the clinical situation. To this end, the physician should define information on the patient’s medical situation and then explain the types of morals personified in the available choices. The physician’s objectives include suggesting why certain health related values are more worthy and should be aspired to. At the extreme, the physician and patient engage in deliberation about what kind of health related values the patient could and ultimately should pursue. The physician discusses only health-related values, that is, values that affect or are affected by the patient’s disease and treatments; he or she recognizes that many elements of morality are unrelated to the patient’s disease or treatment and beyond the scope of their professional relationship. Further, the physician aims at no more than moral persuasion; ultimately, coercion is avoided, and the patient must define his or her life and select the ordering of values to be espoused. By engaging in moral deliberation, the physician and patient judge the worthiness and importance of the health-related values. In the deliberative model, the physician acts as a teacher or friend, engaging the patient in dialogue on what course of action would be best. Not only does the physician indicate what the patient could do, but, knowing the patient and wishing what is best, the physician indicates what the patient should do, what decision regarding medical therapy would be admirable. The conception of patient autonomy is moral self-development; the patient is empowered not simply to follow unexamined preferences or examined values, but to consider, through dialogue, alternative health-related values, their worthiness, and their implications for treatment.
The authors maintain that the last model should be privileged over the others, despites its limits. Why?
It calls for a methodologically guided reflection on the decision – which is the most helpful thing for the patient and his autonomy
Doctor: not limited to ‘information and health care provider’ but also human person with his own value and his own take (i.e., his own humanity to share with his patients)
Guidance and support does not necessarily mean or lead to imposition!
At times, the values of a physicians are precisely what makes patients make a choice about the physician (or the hospital overall)
Poor preparation for physicians? Could be overcome by appropriately structured university programs.
To conclude, the doctor–patient relationship continues to be more in the realm of art rather than science. No measurement tool can capture every nuance of this complex relationship. Good doctor–patient concordance (agreement) leads to better trust in the physician, which in turn leads to better patient enablement, irrespective of the sociocultural determinants.
Done by: Omar Al Droubi