The expectations about the promise and accomplishments of healthcare have led to a distortion of the basic relationship which permeates the clinical situation. Because much of the recent drama in improving healthcare has centered on developing medical technology, both diagnostic and therapeutic, it seems as though the fundamental relationship in healthcare has become the relationship between the patient and the technology. The intimacy of the physician-patient relationship has often been replaced by the romance with medical technology.⁽¹⁾ It is important that this primary relationship between the physician and the patient be reaffirmed if the difficult issues facing patients in the clinical setting are going to be properly addressed.⁽²⁾

    The relationship between patients and their physicians has generally been characterized as a fiduciary one. This means that its primary characteristic is one of virtuous practice grounded in fidelity and motivated by beneficence.⁽³⁾ The nature of this relationship is traceable to the origins of the Hippocratic tradition.⁽⁴⁾

    In a fiduciary relationship the "fiduciary," in this case the physician, assumes an obligation to act on the patient's behalf and in the patient's interest. On this understanding the physician takes on the role of the patient's advocate.⁽⁵⁾ The physician as advocate functions very much like the lawyer as advocate. She stands by the patient who is facing a disease or infirmity. The clinician and the patient confront the disease or infirmity as a shared problem. The physician utilizes her expert knowledge on behalf of the patient and defends the patient against the disease or infirmity. The physician acts as a guide and support for the patient in the situation. The physician is in a position to compensate for factors which might diminish the patient's autonomy, e.g., ignorance, confusion, fear, and isolation. In many ways, the physician is in a position to promote the patient's autonomy.

    The defining characteristic of the Hippocratic Oath was beneficence. The physician was required to act in such a way that the patient would not be harmed but rather would be benefitted as a result of the physician's direction of the patient's care. Beneficence derives from two Latin words, "bene" and "facere," meaning to "do good." In the Hippocratic tradition the obligation of the physician to act in such a way that the patient benefitted was unconditional. But because of the relatively primitive state of medical practice in the Hippocratic school, the doing of good was relatively easy to identify. First of all, the physician was not supposed to kill the patient. Death was seen as an evil. Secondly, the physician was supposed to attempt to cure the patient when possible because health was considered to be a benefit. Finally, beneficence took the form of comforting the patient when curing was impossible.

    Unfortunately, in the contemporary world it is not as easy to identify was counts as "doing good." The "good" is not limited to physical goods. There are psychological goods and even moral goods. In thinking that she is keeping the patient from physical harms, the clinician may be imposing on the patient psychological or moral harms which far outweigh the physical good which is being produced. Unlike the Greek society which had a univocal assessment of what counted as a good, contemporary society is pluralistic and does not have universal agreement on what should count as a good. Thus, death is not always a harm.⁽⁶⁾ Many times it is a release from an extraordinarily troublesome existence.

    Attempting to cure may not always be the most desirable avenue of intervention. Even if a cure is possible, the means needed to achieve it may impose more burdens on the patient than she is willing to endure. Nor does alleviating pain always enjoy universal acceptance as a good. Some patients may view pain as bearing religious significance, perhaps as an act of atonement.⁽⁷⁾

    In addition to beneficence the element of trust is an integral part of the traditional notion of the fiduciary relationship. One of the expectations of the patient is that she will trust the physician; listen carefully to the physician and act on her advice. Sometimes this trust might even take the form of accepting the physician's notion of the good with little questioning. She will minimize noncompliance with the physician and follow orders because the physician, as the expert, is better equipped to know what is in the patient's best interest.

    However, this traditional characterization of the patient's role in the relationship is no longer an accurate portrayal. The one-sided view of agency, and the trust which accompanies it, works in a relationship of radical inequality. It works when the only element at stake is that of expert knowledge versus ignorance. However, in contemporary healthcare, the relationship between the patient and the physician is no longer radically asymmetrical. While the physician is the one who continues to have the knowledge of the expert, the patient has access to considerable information either through the physician or other sources. The requirements of informed consent are designed to insure that the disparity of knowledge between the parties in the clinical relationship is diminished.

    Moreover, the consideration of the patient's values has assumed great importance in healthcare decision-making.⁽⁸⁾ It is in this area that the patient's expertise takes priority. Physicians can only assume that they know what their patient's values are. When clinicians and surrogate's make careful inquiries about their patient's values they often find that their assumptions are wrong.⁽⁹⁾ Ideally, the patient is the one who can best identify her values but, admittedly, assistance in clarifying and articulating her values is often needed.

    The structure of the physician-patient relationship in contemporary medical practice now possesses a greater balance of power and authority in the decision-making process. The physician has the power given by expert knowledge and the authority to make recommendations grounded in a wide range of experiences in scientific explanations and clinical judgments. The patient has the expertise in the area of her values. She is the authoritative interpreter of her "value life" as it applies to the clinical setting.⁽¹⁰⁾ Because of this balance of expertise the clinical relationship, as expressed in the dynamics of informed consent, is really an exchange of power. The physician empowers the patient by giving information while the patient empowers the physician by giving consent. Thus, the physician and the patient encounter each other as moral equals whose various assets complement those of the other.

    Because of new interpretations in understanding the dynamics of power in the contemporary physician-patient relationship, the understanding of the concept of trust must also be reinterpreted. Whereas, in the traditional view trust was one-sided, in the contemporary view, trust must be seen as a mutual opportunity allowing physicians and patients to reach out to each other as moral friends rather than as moral strangers.⁽¹¹⁾ The patient must continue to trust the physician. But the physician now must understand that she must trust the patient. She must trust that the patient has an active interest in what is happening to her in the clinical setting and that she has some knowledge of what is appropriate to her. She must also trust that the patient is ordinarily capable of actively participating in decisions about her healthcare and that she is willing to assume risks in those decisions and their consequences.⁽¹²⁾ While the grounds for trusting patients may often be deficient in actuality, the physician must begin the relationship assuming that the grounds are there.⁽¹³⁾

    The nature of the physician-patient relationship and the goals of medicine are most effectively identified in the first edition of the American College of Physicians Ethics Manual.⁽¹⁴⁾ In this document the role of the physician as patient advocate is clearly stated as is the role of the patient as the one holding final decision-making authority. In addition, the Ethics Manual states the goals of medicine in clear and precise terms. The physician is to promote health, relieve suffering, and prevent untimely death while maintaining the dignity of the patient.⁽¹⁵⁾ The first two stipulations are not new for they have been a constant in the traditions of the healing arts. The prevention of untimely death is an additional element which is given a new dimension because of the way contemporary medicine has advanced the delivery of healthcare. We will discuss this matter shortly.

    The explicit articulation of and commitment to maintaining the dignity of the patient is an element of particular interest in discussing the physician-patient relationship. The richness of the concept of dignity will be explored in chapter 4. For now it should be noted that a clinician cannot maintain the patient's dignity by ignoring the patient's values and wishes. Nor can the patient's dignity be maintained only in some selective area of medical practice. It must be maintained in all areas. Furthermore, the commitment to patient dignity requires an affirmation of the ability of the patient to take risks and accept responsibility for her decisions and this will be peculiar to each patient, further individualizing the dignity of each patient. In other words, trust in the patient in spite of decisions with which the clinician might not agree is a pivotal way of maintaining patient dignity.

    There is an element of the traditional configuration of the physician-patient relationship which has commanded an extraordinary amount of attention in the past twenty-five years. This is the matter of the exercise of parentalism (formerly known in more sexist vocabularies as "paternalism") on the part of physicians versus the exercise of autonomy on the part of the patient. Parentalism occurs as a function of the belief that one individual is in a more privileged position relative to another individual. The privilege of this position is based upon either a wider range of experience, as in the case of a parent or guardian, or expert knowledge, as in the case of a physician. The one in the privileged position is presumed to know what is in the best interest of the "subordinate" better than the "subordinate" herself.⁽¹⁶⁾

    For much of the history of medicine it was believed that disease or injury automatically leaves one unable to make decisions on her own behalf.⁽¹⁷⁾ Thus, physicians could exercise different forms of parentalism because physicians considered decision-making on behalf of patients to be one of the privileges of their social position. The expert knowledge of the physician was considered to be the foundation for this privilege. However, as was noted earlier, the broadening of the knowledge base of the patient has eroded this social position of the physician. The extension of the notion of expertise to the value life of the patient has further contributed to this erosion. Thus the tendency of physicians to adopt a parentalistic posture toward their patients, while historically understandable, now has become ethically inappropriate.⁽¹⁸⁾

    The autonomy of patients is now assumed from the outset rather than assuming that they lack decisional capacity.⁽¹⁹⁾ The only form of parentalism which is generally considered to be appropriate is that which is exercised when the individual's decisional abilities are permanently compromised or temporarily underdeveloped. Parentalism in this case is ordinarily exercised by the surrogate. When there is a question about a patient's decision-making capacity parental interventions may be appropriate but they should be limited.⁽²⁰⁾ It is generally considered to be inappropriate to override the decision of a functionally autonomous person.⁽²¹⁾ Far from overriding the patient's autonomy, the physician is expected to promote the patient's autonomy and thereby enhance the patient's dignity.⁽²²⁾

    The turn toward patient autonomy in the past twenty-five years, together with all of its accompanying debate, has laid the foundation for the Patient Self-Determination Act. If patients are autonomous, then it is appropriate to translate this moral authority into legal protections. Rather than jeopardize the physician-patient relationship, it strengthens it. For now the patient is viewed as a partner or collaborator with the physician.⁽²³⁾ Each brings her own strength to the relationship and empowers the other through the dynamics of informed consent. Their communication patterns can reflect and enhance the dignity which both enjoy as persons in a difficult situation facing disease or injury. The respect for autonomy and the use of it as the pivotal point for effective communication emphasize in a dramatic way the central role of the Patient Self-Determination Act in the clinical setting.

1. May WF. The physician's covenant: images of the healer in medical ethics. Philadelphia: The Westminster Press, 1983, page 97.
2. Pellegrino ED. Humanism and the physician. Knoxville: The University of Tennessee Press, 1979, pages 123-124.
3. Pellegrino ED, Thomasma DC. For the patient's good: the restoration of beneficence in health care. New York: Oxford University Press, 1988, page 116.
4. Lloyd GER (ed). Hippocratic writings. London: Penguin Books, 1983, page 9. Some might argue that the Hippocratic characterization of the physician-patient relationship is outdated. In the era of managed care and HMOs it is often considered a mere museum piece which can at best be romanticized in the contemporary practice of medicine. Quite the contrary may be the case. The fiduciary nature of the relationship depends on the character of the physician and the manner in which she practices medicine. (Cf. Drane JF. Becoming a good doctor. Kansas City, MO: Sheed & Ward, 1988, pages 23-28 and 89-90.) Even in a healthcare environment in which the contact between a physician and a patient may be brief and sporadic as often happens with specialty practices and HMOs, the attitude of care and focused attention to patients' needs and wishes can still be present. A patient does not have to be cared for by a physician over a long period of time for the patient to realize that the physician is truly functioning as a patient advocate in every sense of that role. And a physician does not have to spend hours with the patient to communicate her concern and provide help for the patient to participate in sound decision-making. Even in a busy HMO, practice patterns can be designed to reaffirm the Hippocratic view of the physician-patient relationship if the physician and organization are willing to make the effort to do so.
5. American College of Physicians. Ethics manual. 1st edition. Philadelphia: American College of Physicians, 1984 page 13.
6. Thomasma DC, Graber GC. Euthanasia: toward an ethical social policy. New York: Continuum Publishing Co., 1990, page 3.
7. Engelhardt HT. Bioethics and secular humanism: the search for a common morality. London: SCM Press, 1991, page 39.
8. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: The ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, page 51.
9. Layde PM et al. Surrogates' predictions of seriously ill patients' resuscitation preferences. Arch Fam Med 1995;4:518-524.
10. The term "value life" is used to capture the notion of human life as a narrative (Cf. MacIntyre A. After virtue. Notre Dame, IN: University of Notre Dame Press, 1981, pages 202-203.) or history which can be explored on many levels. There can be a comprehensive notion of this narrative by recounting the experience of the individual in its most general sense. Or the examination can focus on the actions of the individual giving rise to a virtue narrative of the person. Since human action is permeated with motivating values, whether consciously or unconsciously, it becomes possible to talk about the value life of the individual as the evolving narrative which unfolds as individuals live out their lives and make their decisions based upon what they consider to be of central importance to them. The notion of a value life assumes particular importance when talking about advance directives. For the ideal advance directive would be one which reflects the value life of the individual as it has evolved from past experience and as it anticipates future matters of importance.
11. Moral friends are those who share common values and commitments, and respect each other as mutual participants in a moral community. Moral strangers, on the other hand, do not share in the same moral community but may still respect and trust each other across the boundaries which separate them. The trust between moral friends may be easier to achieve than that between moral strangers. But the trust is nonetheless important in both cases. (Cf. Engelhardt HT. The physician-patient relationship in a secular, pluralist society. In Shelp EE (ed). The clinical encounter: the moral fabric of the patient-physician relationship. Dordrecht: D. Reidel Publishing Co., 1983, pages 253-266.
12. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, pages 50-51.
13. Ibid., page 62.
14. American College of Physicians. Ethics manual. 1st edition. Philadelphia: American College of Physicians, 1984, pages 7-8.
15. The goals of medicine have recently (1996) been restudied by The international study sponsored by the Hastings Center. (Cf. endnote 81 in this chapter.)
16. Traditionally family relationships placed wives and children in the "subordinate" role relative to husbands and fathers. While many Western societies have moved beyond placing wives and mature children in these roles, it is still considered acceptable to maintain immature children as legitimate objects for parentalistic interventions. There is much disagreement about when children move from one social role to the other. In the situation where expert knowledge gives one parentalistic privilege, there is even greater disagreement. How much knowledge, and of what kind, one must have to be free from parentalistic intervention cannot be clearly defined.
    Parentalism can take three forms. Parentalistic interventions occur when one overrides the decision of another whose decision-making capabilities are permanently compromised or temporarily underdeveloped. This occurs in many cases of mental retardation, advanced dementia (which frequently occurs in the aging process), and young children who temporarily lack the perspective required for sound decisions. In these cases, the party who is the object of the intervention lacks the fundamental characteristics of being autonomous.
    A second form of parentalism is found when the intervention occurs because it is questionable whether the object of the intervention is capable of making decisions about the matter in question. This situation may be found in some cases of mental disorders or when there is suspicion that the individual lacks some key information to make a decision. These interventions are temporary and they end when it becomes clear that the individual is truly capable of making the decision about the situation.
    The final form of parentalism occurs when there is interference with an individual who fulfills the conditions used to describe an autonomous person (cf. chapter 9, sections 1 and 4). This would occur when one adult intervenes in and overrides the decision of another adult merely because she believes that she is in a better position to judge what is in the other's best interest. This becomes the exercise of power which arbitrarily places the other in a "subordinate" position. This last form of parentalism is the only one which is discouraged by various ethical codes governing physicians. Cf., for example, Council on Ethical and Judicial Affairs, AMA. Code of medical ethics; current opinions with annotations. Chicago, IL: American Medical Association, 1996, Opinion 8.08.
17. Pellegrino ED, Thomasma DC. A philosophical basis of medical practice: toward a philosophy and ethic of the healing professions. New York: Oxford University Press, 1981, Pages 200-201.
18. American College of Physicians. Ethics manual. 3rd edition. Philadelphia: American College of Physicians, 1993, page 8.
19. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: U.S. Government Printing Office, 1982, page 61. Cf. also American College of Physicians. Ethics manual. 3rd edition. Philadelphia: American College of Physicians, 1993, page 8.
20. Greenberg DF. Interference with a suicide attempt. New York University Law Review 1974;49:227-269.
21. American College of Physicians. Ethics manual. 3rd edition. Philadelphia: American College of Physicians, 1993, page 8.
22. Ramsey P. The patient as person. New Haven, CT: Yale University Press, 1970, page 116.
23. Council on Ethical and Judicial Affairs, AMA. Code of medical ethics; current opinions with annotations. Chicago, IL: American Medical Association, 1996, Opinion 8.08.