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LVLLABY

Each morning I finish rny coffcc,


And climb thc stairs lo the charts.
l-ioping yours will be filcd away.
Bu! you can't hcar me,
You can'l Sr1: yourself clarnpcd
.Bctwecn Ihis hard plastic bindcr:
Lab rcporís and nurscs' notes. a sernplc
In a test lubc. I kccp rcading
Thesc terse cornmcnts. stablc as bclorc.
Vrinc output slill poor. rc:spiration normal.
And you kccp on poisoning
Yourscll, your kidncys more usclcss
Than scewings dren chcd in an oil spill.
I find my way lo your room
. " And lean ovcr Ihe bcdrails
As though I can undcrstand
Your wheczcd-out "fragments.
\tVhal ca nido bu! check
Your tubes. Iccl yOlJr pulse, lisien, ,\

T o your hcartbcat insisten! "., "\(,


., .
As a spoiled child who gocs on bc~~ing? : ." ,,',i. !

Old rnan. lisien lo me:


Lel me takc you in a whcclchair
To rhe back room of thc records officc.
Le! me liff you in rny arms
And ley yoú down in íhc cradle
OC a clean manila felder.

, JON M\.IKJ\ND

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Lthícal Aspects of the


Physlci.an-Patíent Relationship
Howard 13rody

\"rny should ~ JlwJYS be lold Ih.31 Ihe so cornmonplace a n insrrurnenr of diagnosis 3S che st cth-
ahcrnativc is bc+wccn a docttrr who rcally oscopc is missing from this scene. Ir appcars rhar ;¡lJ rhc
kn""", wh.ll he is doi~!<- cvcn if hc docsnl physician has ro ofícr is his prcscnce arid the artirudc oí
havc muen lime lo be wi!h paticnts. to lalk warchful \\':licing thar indicares both a n intimare knowl-
wilh Ihcm and be úndcr>!andin~ of thcrn. and edge of che natural coursc of such illrie sscs and che per-
a doctor "",ha has .11 thc lime in the world (or sonal comrnitmc nt ro srick wirh me paticnr and f:J1l1il~' til]
hi~ pcticrus. bul h~'s J hrst-rl.ns idict. ,)n¿
thc bi rt cr cnd, wharcvcr thc out come 11l;¡~'be. T'hc r cac-
e"uld cnd up lx,n~ J loreal lo your {dvoril~
tions of the parents in thc back;;ound sUf;gesl t ha t rhc
rclallvt's hcalth. cvcn Idcl 1'11answer Ihal. frs
physiciari's cornrnirrcd rresence is nor an inconsidcrab!c
nol a qvcstion: its a rhctorical statcrncnt lo
bcnefit, howcvcr much wc with our mocJem tcchnologv
r aticna liz c (Jllousnm and c-¡:otism,
1m:, be inclincd ro deride or discounr ir.
\--..1W/'\.I\.."\ 0"J:.L~ \,,1W/Vv\~
The sccond painring, by Pablo PiClSSO, a n cxnrnplc of
lnl~~' ~Ih ~tx-rt Celes
the artisr's work bcforc his bcrrcr-known abstraer srvlc of
the ear ly rwcnricth cenrury, anticipares rwcnric th ccnrJr:'
medicine, At firse gbnce: Picassos physician looks rnuch
lile Fildcss, hut the p:lintin~'s compos iricn is rot allv dif-
Thi~ chaprer Iocuses on crhical di- fcr cm. Hcr c. ;¡S thc titl c SU~~CStS, thc physici.ms ~;jlt: is
rne nsrons oí thc ph:'sici:ln-pJciclH" rclnrionship. Two disrracrcd fr orn che: paticnt and insrcnd is rurncd lO SOn1e-
rnodels that plav a complcmc nrart role in guidin~ erhical thing- objccrivc an d mcasurnblc. "The pariem has ro look
pracricc-c-an ~uronol11:' modcl and :J po\\'eí model-;¡n: clscwhcrc for support nnd finds ir in thc fi~'llre of a nUI1
cornpa r e d using :J case cva m p!c chJds rvpical of primarv on che opposicc si de of che hcd. chus ~ug-ses'(in; J Lldic;)l

c:Jre medicine, . divis ion bcrwccn chosc \\'ho devore rhcir livcs ro scicncc
and thosc who brin; hope and comfort thr ;)\lg-h t hc ir per- ,
MEDICAL ETHICSAND THE PHY$ICIAN- sonal pr cscncc a nd comminncnr. .vl n nv c 'iries \\'ould ~;l\"
PATIENT RELATIONSHIP t hat t his picrurc represcnrs prcciscly \\'h:ll is \\'roll; wit h
1111ldef!1 rncdicin c. l l owcvcr. \\'e 11\;1:'he l1lissill~ t hv 111t:~-
Sorne 01' t hc pr olilcrn« thnt 111:1:'hl: cncounrcrcd in ¡he ~:l~e jI \\'C [ump lOO qllickly 10 thc coriclusiun rhnt rhc
phvs iciun-parienr r clauonsb ip a r c su~~esred In' cl;¡ssic de- o ncnrivcncss ro Seiel1Cl' anc] t hc ina n c n t ivc nc ss ro t hc P;l-
picrioris in art, For cx.unplc, thc [\1'0 works of ar: on p;lges ricn t ax a person are rypicul o( medicine onl:' in rhc rwcn-
202 arid 20:; wcr c cornplct cd with in a dccndc of cuch (il'th ccnrurv.
oth e r. T'lic !irsr, h:' Sir Luke Fildcs, was \\'ide:I~' rcpro- :\ third r:liminf' (p. 204) b~' ;1 Durch a rrj sr of thc scv-
duced in che cnrlv and middlc rwcnricth c<.:nrury and \\':15 cntccnth ccnrurv sho\\'s ;1 sccne thar in 50l11e \\,;¡\'S is sim-
adoprcd as 3 S~'J1lh()1 h:' tht: American .vlcdicnl Associn- ilar ro thn t depi~[ed J¡~ Picasso. Evcn though st:¡ring ar n
rion, In i mporra nt \\';'1:', this p;lintin~ caprure:s thc ideal f1~sk of urinc SCel!1S hopclcsslv antiqun rcd roday, ir does
physician-paricnr rclnrionship that was rvpical ofthe ninc- accurnrcly repn:sel1e rhc scicncc of that pcriod. Once
rccnth ccnrury. T'hc physi cian porrrnycd is a lrnost :lg:lill th e phvs icia rr's f:':lze is dirccred 3\\':1)' frorn rhc P:1-
hopclcssly inadcquarc in rhc flce of thc scr ious illncss t h.u ticnr and rowar d somcthj ng obiccrive and mcasur.ihlc. 111-
thrcnrcns thc child. Thc disC:lse: he confronts is pr()lJ:l111~' !leed. Eric Cassell has traccd this habir of mcclicj nc \':1Cl
infccrious, bu¡ he h;¡s no h;¡qennl()r;ic;1ll11ethods ro use :1S far as l-Iippocr a ccs. 13)' c1aiming thru medicine is ;11\;11·
in di:¡¡;nosil1~ ir.arid no antibinrics (o-tre;]r ir. l ndccd. cvcn ural scicncc and by cffectivelv climin3ring n.:li!!iolls 01 ~\I-

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pcrnarur.il cxplunarion-, frcllll"ol1\l'dic:lI scicncc. J Jippu- rrcnrmcnt tl1e~' ,hould :lCCCJ1L In ~cit.:n¡ilic I;nll"ol-
erares bid rhc !_..'T()und\\"ork [or :1 physician who did not cdge P3Ut.:rHS runk bclow physicinns: :JS mor.il
nccd lO spcnk ro thl' p~ril'nt lO di:1~no~t.: :lJld trc.u di~C::1SC, agents °ablc 10 choosc frccly, p.uicnr-, ru n k :l~ t lu,
Thus, ihcr c i~ :1 r<'::l,OIi tu [cur th:l:i lh..: p)l\'siciaI1-p:¡- o.phvsicia n 's °cqll;iL o'f¡,; .o
ricnt rc.:l:1tiuIlShill iO~l:lhjl":¡olh-'íirj)bl~i)~:lli¿¡f¡-lJl;l thc start. 1 Tradiricnal medicine, :1S \\"<.:11SUli1l11:1ri7~ccl°In t hc
Alihougb ¡ln~'dhic:lI f'Uidt.:ii;i~5: f()¡';;th¡~'Jnbli()nship re- o:n.h (~r Hippocr.u cs. p:1íd vj rrua llv hCi ;¡t't~riciún (1
quirc ,h:H rlit.: ph~'sici;1f1 re~:1f(i {h~'Ji:1iicht scriollSJ~o as ¡¡ paticnt Juronoll1y and- ~111phJsizedoil:lticntohcricti(
pcrson, trcnds ,,'irhin ·i1it.:diciii<: ifi~d\cr ch~ physician
o ;J11110S1 cxclusivclv. ,\ lodcm medicine h~~ not ~\Ocn
frorn rhis ol>Ji~:¡ii(Jno ',o,: :: o 1IJ1 t his mor»] couuniuucru ro ti)' tu do. wh.u cvcr is
':. c,!~;~
in t hc pa ticrus hendít n ncl. li:Jr¡it'lll:trl~'. tu :1\'uid
: .. : ::
.,
AVTONOMY MODEL );:¡rllling thc pnt icru unlcss rhc ultiman, hc ncfit ius-
r¡fi~~ rhc inirin l hn rru.
To dcal wirh thc d:1n!-!~rs inhcr cnr i'~ a n uncqual rcla- 3, T'hcs« rwr: l11or:11 vn lues. che traditionn l value uf P:l-
riorrship=-wirl. thc phvsici.in h:1\'inS rhc monopoly of ticnt bendit und thc nc\i'ly discovcrcd valuc of P:1-
mcdical kJio\\"lcdg<.: and thc pnricnt \JCjn~ pa r ricul arlv vul- ticnt Juronol11~', sct up rhc 111:1iormoral dilcrnma in
ncrublc bccnuse of ihc t hr cnt of illncss-:1l1 :1urO!1ol11\' thc physician-paticnt r clnrionship. This is t hc pr oh-
modcl has IJCC0J11l'popular in medica] cthics over thc past lcrn of patc malisrn, dcfincd as the porcn tia l con-
20 ycars. The Icarurcs of iliis model l11ay be summarizcd Hict bcrwccn :111 individual doing whnt he or shc
as follows: fr cclv chooscs a nd doinc wha c anothcr pcrscn LH.:-
1, The 1110r:11 vnluc thm 11105r clcarly defines thc phv- lit.:\'e~ wil] bencfit hirn ;r her. To act °j):ltcrn:1lisri-
sician-paticnt rclarionship is that of rcspect for P:l- o callv is to elevare che value of bcncfirover che vnluc
ticnt auronomy This, in rurn, l11e:1I15thar paticnts of autonorny and to r efusc ro follow rhe wishcs or
are to be rcspccrcd as individuals with thc iright ro dcsircs of thc pntient, cither by ourright coerción
choose freclv. whni thcv..,should do and \vhac .
son of or , more subtly, by dcccption or manipularion. An

:202'"0 o o AsSC5SmCnt uf PJticnl~


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Sricncc and Cheríty Pablo P'C.lSSO (lH97J. MU5<"u Picasso, Barcelcna.

ethic based on autonornv condcrnns almos: :¡]I such ticnt autonomy cannot be rcspccrcd. Sorne paticnts.
CJSC:S uf patcrnalism and acccpts che decisión ro whilc pr eviously auronornous. wrotc li\"ing wi lls or
ovcrride ihc naticms \\"isht:s'bnh' when str onc and lcft spccific insrructions about ihc CHC thcy wishc.:d
me
o

. cornpcllinp e~;dt:ncc indj~rF's tl';:ír paticnr \\"ill ro r cccivc in the fururc. Othcrs chosc another in-
sufícr sorne grcat harm unlcss his or hcr wishcs are dividua] specificnlly ro makc thcse dccisioris whcn ,
ignorcd. ¡hey no long cr had me mental capaciry ro do so, Or
4. Bccausc ¡he.: tUnd;lmc:nt:d moral dilcrnrna of p:lter~ pcr haps social cusrorn has designarcd an appropr i-
11:11i5111 h:l~ tu do "'ilh lhe.: conflict hcrwccn llC.:ndit :H L' SP()kc~Jll'rS()n such .:l~ :1 close r el.uiv« oflhe P:1-
and autonomy. pnrcrnalism CC.::1St:~°w be a pn:ssil1f! ticnt as thc surrojr.n e decisionrnakcr. In rhcse cir-
moral conccrn whcn :1UIOnOl11\' is abscnr. thnt is. cumS(:1nCC5 me
phvsicia n has an ohligntion ro gct
whcn tbc p.uicnt. for ene rcascn or anothcr. is in.- thc ccnscnt uf ihc surruf!Jll: dccision muker or ro
capahlc of rende.:rin!! a free or rational choice. In rry ro Iollow thc cxplicit insrrucrions !!,iq:n pr evi-
such instanccs physicians mif!hl be justificd in pur- ously by (he patient and cannot simply substirure
osuine: paticnr bcncfit without conccrninc tlicm- his or hcr own juclf!11H:nr uf me
paticnr's probable
sc.:"'~s \\'ilh lhe.: pnticnr's cxprcsscd \\'ish~s. This benc fi (.
rncans thar the nccururc asscssrncnt of ;;¡ paticnr's Considerable artcntion has bcen dcvorcd tu dcciding
capacirv of autonoruous choice and an accurnrc whcn a paticnt is sufficicnilv auronomous to dcrnand that
mcthod for dercrrnininp this in cl in ica l prnctice a rc t hc ph:'sici:m r cspcci h is or h c r d ec is io n on hcnlcl1 ca r e
esscntial [carurcs of ihc auroriomv modcl of medica] rnartcrs. Onc prncticnl appronch has bccn providcd by a
crhia, ' cornmin cc of thc Hastings Ccntcr. who pr epare d guide-
S, Thc paticnts in;¡bilii:' to cxcr cisc auronomy JI a lincs [or thc terminación of Iifc-sustaining rreatment. Ac-
givcn morncnt docs no! ncccssarily irnply thar p;¡- cording ro this comruirtce ji is meph)'sician's dury tO

Eihicc l Aspecrs of thc Pbvsician-Paticnt Relationship 203


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'Thc Drop sical Woman (jodrd Dov (1663). Mvs<-c:s NJt,ondvX·rJns,

LOUVfC Ors.Jy el C.O.L


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decide whcn a paticnt IS capahlc of choosinc arnonc mensures unri] d'll: p.uicnt appca r cd :1t (he hrink of de.uh:
ht::ilth carc nlrcrnativcs. "Cnpablc of ch(l(lsil)~" t:'nLlib th~' :!n~' <.::\'H:nsi;)¡') c;r Jirl: and unv bnrt lc :1!!;\iilSl rhc coursc (J(
follo\\'ing thr cc [carur cs: ' th~ dise:ls~!\\'!.:r:.~iJ11ph- :Jss'ul\lt:d ro -I\cndil thc paticrit.
l. The parient rnusr be capnblc 'of undcrstanding thc 1 l o \\'C\'Cr , p;lti~!;e,. ¡::i~'en" rhc opP¡¡Jth;nir:.:. i:(iil;n~(illJ~'
choice rhat must be 1l1~dC' :lnif thc alrcrnnrivcs. choose lu :1\'oid' h!.:in~ kcp! alivc hv t:.xrré.'Hli.::ill\i~s:i\'¿ ;);)(1
') Thc pnticnr rnust be :t[¡lc' rc{\\'e.:ie:h and rcflcct 011 somct imcs llr1dil..r¡liti~d .mcnns. E~(;1nli~~ill'~ d-i~ r:Úll (l(
thosc alternativos. ',' " pnricn: :1ur<inon,l-~' was.crucial.in r<:(om1ins ;!H:dic:¡l-use of
3. ihc paticnt rnust be :J[¡Ji.:,t(i':~()ll1ll1uniclte this pro- rhcsc Jife~su.sr:linin~ Icchl1olcr;ics.
cess ro the carccivcr. Thc ':1I1l()n()'\l~' IlHHkl is :lhel lISL:f\lJ {or lInde.:rsr:mdil1!-,
CIc':1d)', gcod be.:h~\·i~rdJ skills are I)!.:~(kd t() mnkc such ~ t hc CCJlll:epl of informed co n s c n t , PIl\'sici:lI1s \\'!Jo suh-
dcrcrininariun In diflicuJt C:1~Ó die tre:ltinf! ph~·sici.lf\ ~LTihc {t' 'lhL' ul.lcr model {l(.'nledic:d l'IJlÍl'~ lilld illl'orllll:d'
may need ro consult :J psycholojrist or :1 p'ychi:lrrist, conscru lO I,e.: :111 ill:\PJlr()p~i:ltL' illtíllsi(),i int o 11lL'diC:l,l','
pr.icrjcc. Thr.:s!.: ph~'sicj:\I)S ,;lIso {C:1r th.u p:lli!.:llts 111:1~'l'l:
" .. hnrmcd h~' thcir fL'Fus:J! t o .icccpr possihl~' be.:lldiei:ll rrL':I'l'-"
J3cncfHs -:i ~.
.:.' mcnts hccnusc thc~' are Jrisht<:llccI h~' the ph~'sici:lll \ rcc- '
Thcauronomv 11l6Jd of rhc crhical plivxician-pat icut re- itnrion ()f ;¡JI possihlc risk s involvcd \\'Í'lh' ti\!.:' proccdur cs.
lorionshiphas bccn cxtrcmcly influcnrial ovcr rhe 'Ji;lSl 20 111coutr.ist. flh~'sici:!IlS \\'ho, :¡doJlI i hc ":1ll(()110'11~' murlcl ,
ye:JrS and has brciughi abour somc SU[¡Sl:ll11i;li rcforms in IWjll' t o ;\\'oid ;¡ tot;¡JI\,difCcít:nl' kind (lf'-h;lri1i: h;l\'il)~ :111,
medical cthics.i l n particular, ir hns radie\II)' (,"h~n~!.:d che illdi\'iJlI:il':;'J1UI~l:1n di¡rni~'.yiol:Hed h~'nOl'IH:illg ~11()\\Td
approach tu lifc-sustainiric rr curmcnt in thi.: scriouslv il! {() choosc .in ni.m crs t!1;ll dií,t:Cl'h: ,'O[1l'CrIl his Oí hcr Jife
or dying paticm. t'hc oldcr :lJlpro:lch, W mcdical n'hies .uul I)(l(h- illl~·l!'rit\'. E;'~'1l in th(l~~' C1SUSin whic]: tJ¡v ¡¡id
lefrall such dccisioris r<:~;1r(Jille: :l{!¡;ressiv<l: trcnrmcnt. iil- dccisio!1' t hc J~:l'li,~I1't''ll:\k!.:~ is prcciscly drc: onc ¡he ph~'-
c1uding, dccisions about ~~spir:;to;s' and orhcr mcchanica] sici~ln "\\'u'uld h;l\'t: choscn.uhc nuronrunv tll(Hh:'¡ sh(j\\'~ rv- ,.
rncans ro susrain liíe, srrictlv ro rhc ph):si.ci:ln, Thc ph~'- SjlCCl f()r thc 1;1:lii<':[11
,:)S :¡ pcrsonhy' ;)¡I~\\'ill~ p.iticn: jl:lI::_
sician, in rurn, wás c.":p<':cted to use almosr :JII uf rhcsc ricipntion. In contrnst, ihc physicinnwh« Ill;lke.:s d!.:cisioli<

204 Assessmenr of Pariems


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Tomoko Vcmura in hcr')<'Jlh 1972. from the Series Minomoia. J~pJn. 197~- 1975.,~ 19l11:¡hc H"rl 01
\,\'. tU'1Cnr ~mi!hlBlacl: 5!aró'·'
n« ~ass poisoning fro/~"~dhyl tncrcury 'tbes oavricd in tvtinemet», Japan rc>vJIr:d:I~om
inorpanic westcs discharfi'Cd lrom a plastics [sctoty. Physir:ians bevc a ~pr:ciai;~ponsibi/ity io
documcnt end proles! ibis typc of cnvironmcntsl abuse.

privarely, convinccd that he or sheknows exactlywhat me are obvious. First,' me informarion rcvcalcd to orhers.
paticnt would want, displavs disrespecr that is harrnful te such as rhc f:lIilily. fricnds. or crnplovcr of thc paticnr. can
the paticnr's moral integ-;-iry. Sccn mis way, inforrncd cause dirccr harm by ch:i1nf;Ínf: thc \\':l~' those pcople relate
consent is an important inpredicnt of me ethical physi- ro thc paricrn. Second. paricnts C3n be: harmed indircct lv
cian-paricnt r elarionship. Informed conscnt rnav also be i( mey fcar mar thcir phvsicians will r cve al inforrnat ion
an importarn pan of trcatrnent, parriéula~ly in behavioral from me physician-paricnr cncount cr and the)' mif!hr he
medicine . .l\1any behavioral techniqucs work only iJ me r cluctant ro sharc sc~sio\'(: iníormation.
parienr is wcll educarcd about thc nsrur e of rrea 011 cnr arid Ahhough harrn avoidance is imporrant. ir is ()nl~' p:ln
are effecrive ro me exrerit thar ufc
patienr is an active of confidentialirv. For exarnplc. im:lf'inc thnt a phvsician
parricipant in me trcatrnent process. Adcquarc arrcnrion learns about the unusual sexual pracriccs of:l paricnt and
ro informed consent in thc physician-patient rclationship rcvcals-this inforrnation ro thc paricnts emplovcr. Fur- '
helps ensure this will occur. thcr imaf;ÍN: thar thc cmplover is an cxrr e mclv lihcral and
rolcr arupcrson, so that th c paticnt :md his car ccr ",ill in
no wa,:. bc harmcd 11\'
. thc disclosure. ::lIld circumstnnccs
Confidcntiality
havc bccn arr:mgcd so thar no furrhcr spr c.id of in íor-
The practico of medicine' m:ly f;Í\'c thc physician acccss marion about this lcnk will occur: thcrcfor c. tllL' incidcnt
ro inforrnation that the paticnt wishcs ro rcrnain confi- cannot possibly hove an cfícct on pulilic arrirudes about
dential. For cxainplc, thcr c has becn incrcasing concern physiciari-paticnt pr ivacy. \\'ould \\T S;l~' unclcr thcsc cir-
over privacv and anonvrnirv in human immullodcficienC\' cumsranccs that thc moral pr oblcm of C'onliclcllti;lliry has
virus t(:stin'~ and cou~seli;l!!. The rnost obvious \I';1\' l¡l disappcarcd? .\ lost of us would insist rh.u lhe physici:lll
undcrsrand -!he physicicu's duty ro rnainrain privacy-c-onc srill did somcthinc \\'ron!:;. \\1\\' is this so:
of thc ver)' fe\\' mora I dutics rccognizcd by thc modcrn A dccper explanation ;f
thc ¡;npon:1J1CC of pr iva cv lin k.~
physicia» tha t can be direcrly traccd back ro thc Hippo- th c flo\\' o( in íor-mo tio» \\'ith th e \\'ay th;'ll ;'111"rus Or¡p1l1-,
cratic onth-c-rcsults (mm lh.e irnportancc of avoidinc izc our lives, particular ly wirh personal rclationships we
haml ro thc paricnt. Th« physician musr conccal in(or~ havc with othcrs. This rnodcl describes thc individual as
mauon thar thc pntient providcs priva rclv 10 thc ph~'si- surr oundcd by orhcrs in ~r:ldll:1lly incrcasing conccnrric ,
cian, assurning thar it will rernain confidcnrial within thc circlcs, In thc closcst circlc are our most intimare ac-
rela¡:jons'hip. Two risks fr orn br eaking this confidcnrialiry quaintanccs, whom wc allow ro know almosr cverything

Ethir.:;¡J Asp<:t't~ of ilu- Physician-Patiern Rr.:brioIlship 205


abollé us, allhough wc srill withhold SOll1(: sccr cts. On rhc
ncxr circlc out are Cl05C Iricnds, ro whcrn wc srill rcvcal
;1 grcac clc:d UUl ((0111 whomwc kccp rclativcly more pcr-
sonn] 111:1lTCrsconccalcd. \Ve pr.occcd throuah 3 varicrv

of circlcs \IIHil \\'C 'gct ro. thc .bl;gcst, ourcrmosr circlc,


which consists of chorree acquninranccs, such JS thc su-
pcr mar kcr check-out clcrk, ro whom wc fcd no nccd (Q
disclosc ;In)' inform.irior, about oursclvcs whatsocvcr.
MOSl of US' would likc , te> havc rC1S0113bi<.: control ovcr '

thcsc conccntric circlcs, nnd wcdonot wa nt othcrs dc:fin-


il1g Ior us rhc limits of intill1:lcy nnd acquninrancc. How-
cvcr, \\'C determine \\"ho f:llls on which of thosc circlcs
pr imar ilv by ihc cx¡enc ro ~~'hicll'<\'e '~e\'ca( infor mation
about oursclvcs ro tha;¡ pcrson, \Ve can rn akc a wórk col-
le3g1J(! inro a personal fricnd, for cxamplc, h)' choosing ro
sharc pcrsonal.informarion, ..An.d,::\\'c:c;J.n cool off a for-
rncr ly \'e))' clase' j-dao~~nip_:l.ij;gr;¡dually.~~~:ith.holding
imporranr personal informarion [rorn .c}IU individual.
Our scnsc of autohom~~-acpc'rids-'on thc 2biliry ro con- .
rrol chis fiow of information. \Vllen sorncbody violares
our privacy or confidcnrialiry, ir is precisely mis control
mar is lost. 1f sornebody rcvcnls privare jnfor~'1l2oon abour
our inncrrnosr thought5 to a supcrrnarkct check-out clcrk,
ir is alrnost as ir thar clcrk has bccn pushcd into our cirele
of rnost intirnarc acquainranccs.without our conscnt. It is
mis sense of personal violation and thc corrcsponding 1055
of control that g-1\-es rise ro 'me moral indignarion that Hippocratcs E.x..aminin¡¡ a Pat icnt \,\'clkomc Imtilulc Libr áry,
London.
artaches ro me violation of confidenrialiry,
The poinr of chis brief discussion is ro illustratc me Touch is an csscntiel patt of hCd/inR'
irnporrance of rhc auronomy modcl by sho\\lng chal mJn~-
actions in me phvsician-paticnr rc larionship thnt appC:Jr
ro violare moral righcs or moral ,rules CJn ultirnatclv be
analyzcd in tcrrns of thc pa tierit's auronorny and sclf-dc- me wishcs and destres of the pmicnt. Fr om anothcr vicw-
rcrrmnanon. poinr, chis bchavior is nccessary. bi.:c'J:u~c:i¡.-;rppcJrs thar
some paricnrs drv out and are capable of rnaking trul~'
auronornous choiccs onlv.." aftcr thcv rcceive rrcnrmcm.. . .
..:\n .
wcekncsscs iridividual's position on this issuc is dctcrmincd by his or
The autonorny rnodcl is not adcquarc as me: onl)' f:Uidc: her modcl of alcoholism. To 50111e. alcobolism mávbc a
te che physician-parient relarionship, Firsrarid most ob- srraightfo¡-.>.\'ard cxamplc of 10$$ of auronom)' bccause
.viouslv, thc rnodcl gi\'es short shr if: ro paticnt bcncfir. whilc irtthc thr oes of addicoon.:m indi\ldrd h3S no co n-. ."

Dcspirc our concem for thc rights of patie nts. r.hc rnajor- rrol or (rec'\\'illlronicJlly, t.his modclalso rcndcrs nlrnost
, irv of paticnrs pr obably go ro physicians hcca usc rhcv ~II alcohol 1:rC:l:¡I11'cn¡ ;¡ hopclcss qUl:st h<':C3USl' j(:111 indi-
hope ro be hclped: vcrv fc«: paricnts go ro pn)'sici:¡ns I"": \'iJu~1 wt:1II)"bcb thc capaciry Ior tTl:i.: 'choiet, :ind i( :JI:
7JI!l7'i~\' ro hnvc thcir Jutonoll1~' respccied. l t is import.mt coholisrn iS"indced::l lifc:lcin!! discnsc ns most thcr;lpisL\
mar U1C phvsician '5 Iocus un paricru aU¡On0111Y 'nO! oh- C!Ji111' a n individual ourrht r~ 1;1Ck t hc frt'C choice in t hc
scurc a \'itall)' imporranr in~rcdienr of me task of medi- furur~ ro rcrnain drv ::lIlJ not tu t:1k~ ~h;¡llirst drink :1!!:lin,
cine itsel f. " . Altcrnatively. othcrs vie«: alcoholism 'JS a \'.UI)JIlt;U0'·, be- .",
Othcr specific problcrns with thc nuronomy rnodcl havior dcsigned tu hclp an individual cope \i-it.h stress. '"
arise in bchavioral nicdicinc. Pt:rh:¡ps rhe H:1rK<:S¡ cxamplt: Thcsc critics note that alcoholics COJllIlHH1)Y displ:l~':1 "'-

is me alcoholic paricnt who rcsisrs cm cring inpnricnt ¡:;re:Jt dcal ofcontrol ovcr thc serrina and ,th:C:1H10Ullt of
trearmcnr: Anumber of alcohol counsclors currcnt!v rcc- ~eir drinking nnd occasionallv e\'(':;l choosc ro ,gi\'e vp
ornmend the us~ of cocrcion ormanipulntion ro gc; such drinkinc; and cnrcr thcrapy.
J parienr ro "cntcr thcrnpv, somctimcs inc!uding \\·h:ll Thc -COllcCpt of autorH;I1l~- is difficuh ro ::lpply to :1<1-
nmounts ro a conspiracv ~ll1on~ ihc physician, thc P:l- dictivc beh::1\·ior. Thc S:1I11C rll:ly be rrue, '::1ltholl!!h te!:1 !;:,'
tient's [¡¡mil)', 2nd r.he p::1'cicnr's cI11Jllo~'cr. This hl.:h:1\'ior lcsscr cxtcnt , in 111:111\' lifc-srvlc issucs U1:1t Cf\:.:lll' .hc:dtJ¡ ,,',
sccm5 un;¡ccept.1bly p3ternnlistÍc.:, UCC:1usc: it (()tally rcjl.:L"ts prolJléms, su eh ::1Ss1l1~kin~ :\;1(J o\'C.:rcaripg, Likt.:wist.:: P:I-

:206 A$~CSSlllcnt of PJtjcnc~

.. _---------
ricrus Wilh psychoscs or orhcr scriol\,s ps),chi;1Jric disor- pronch is unsnrisfnctorv, bccausc ir f;1ils \O cOl1(1'ont
dcrs, sllch :15 mosr of those \\:))0 arrcmpt suicide, clcnrly squarcly rhc problcm' oí rhc physici:ll1 's ])o\\'c1' arid indccd
del110nSU:He abscncc of subsranrinl autonorny; this ex- suggcsts thnt tlic physician-paricnt r clarionship is Iacili-
plains why we may be justified in trcating thcsc paticnts tatcd wlicn that po\\'cr is erascd. A much more sophisti-
contrary to ihcir cxprcsscd wishcs, carcd analysis of thc role of powcr in U1Cphysicia n-pnticnr
SOIne critics mainrain that the auronorny rnodcl lcads rclationship arid che cthical implicatioris oí thnt power is
to an unforrunatc rninimalism in rhe ph)'sician::'¡ntíclH necded. fu1 alrcrnarivc modcl, Iocusing 011 po\\'cr ;TS che
r claricnship. Accordjng ro ihis argumenr, me physician central cthical issue in thc phvsician-paticnt r clationship,
who is motiva red by paricnt bcncfit is always trying ro "go has thc íollowinp clcmcnts (Brody, 1992):
thc extra 111ile" to .hclp t;he patient. In contrast, thc phv- J, Phvsicians ha ve cOl1sidc:r:;¡blc powcr t o observe ;¡ncl
sician n1Oti\':ned primarily hy rcspcct for autonorny is tO alter rhc coursc oí discnsc, ro prO\'iclc cornpnssion
concerncd primarily.about \'i()hting pnticnts' righi:S, This :1I1dcomfort, and tO r ccommcnd liíc-srylc chnngcs
physiti:lÍ'1 I}1ny of{er options bur thcn sir back p~ssi\'el)' rhnt have irnporrant irnplicaricns [or furur e hcalrh.
and lcr the.patient make irnportant choiccs, stili main- Paticnts go 10 physicians prcciscly bccnusc rhcy
tairung.:a rninirnal role whcn me paricnr picks what thc want mar po\\'er ro be uscd on thc ir bchalf
physiciar. pcrccives ro be me wrong choice, In so me \\'a~'S 2. The sarnc power that can be used on me si de of thc
the :¡,útonomy model allows me physician-co abdicare re- patie nr ag:linsr me discase can also be uscd ngaillS1
sponsibiliry
.
for health
..•. .
dccisions
.
and their consequences.
_-_ ,.
thc pa tienr. Arme sarne time patierits scck [he phys-
iciari's power to trear disease, me)' oftcn rernain ap-
prehensive mar mis will be used 2g;¡insr thcrn.
Tbe lou_chtog was thc real proíessicnal sccrcl, nrvcr J. The phvsician's power is cornplcx and consists oí a
acknowlcdpcd as thcccnrral: esscntial skill, alweys nurnbcr oí components such as scicntific kÍ1Q\\'I-
obsrurcd by íhc dancins and thc chdnlins, bu! e dge, rcchnical skill, and the force oí me physician 's
. always busily therc. the layin~ on oí hends.
0\\11 personalirv. The physician also has po\\'cr be-
Uh1> THOMl'\.~ ckocnb,n~",""""n.
cause oí his .or her.social starus and me respect P2-
H<>v« e.JI>
ricnts have for pbysician authoriry. (A discussion oí
how the physician's personal pr esence and social
aurhoriry cari promete healing is providcd in Chap-
PO\AJER: A COMPLEMENTARY MODEL ter 23).Jusr as the scalpcl that cancut out 2 malig-
nant rumor C:1l1also nick a viral arrcry or ncrvc,
Becausc me autonomy rnodel has such importanr irnpli- .everv ene of mese components oí power could be:
cations for informed consent, me 'riE:h¡ to r efuse trcat- used ::lgainst me parient. as we ll as for the parient.
memo confidcnrialiry. and other mtdíc:lI decisions. it is The line berween use and abuse of powcr may be
unwise ro abandon it sirnply bccause of incomplctcness. unclcar in particular cases.
Insread, the modcl can he supplcmcnrcd or cxpanded ro 4, The central ethical issue in thc phvsicio n-paticm
retain its importan: insights \\'hí1~ filli~g in thc missinr; rclationship is the rcsponsiblr use .of pO\l'cr. 1'0 use
g2pS. po\\'er rcasonably mcarrs tu use ir for thc paticnr's
Some authors have suzucstcd that thc auronornv bcncfir and ro avoid using ir ag:¡insl rhe paricnt or ,
model :be supplemcnred \\'í~rh a cornmunitarian mod~J iD \\'a)'s that fulfill thc physiciari's selfish nccds. This
mar would remind us of thc moral value of comrnunirv problcm C:1nnOI be solvcd sim plv liv raking pO\\'t:r
cooper arion. This model would rnaintain that. free choice ~\\':!:-' frorn t hc physician and f!i\'ing it ro t hc paricnr
rnust be assesscd wiihin thc conrcxr of comrnunirv idcn- hccnusc the paticnt continucs 10 look ro (he: ph~'si-
riry ra thcr than be vicwe d :;¡sa thrcst ro cornrnunirv and ci.m's po\\'e:r:1s his or hcr mnin dcfcnsc :1S:1ins¡ dis-
social cooperarion. Othcrs hove suzcesrcd rhnt rhc auron- case and ¡II hcalth.
om~' rnodcl ncnlccrs virruous bchavior and fails ro inform 5. ]¡ is possiblc ro cre:1rt' a ph:-'sicjan-p:Hient rc}:¡tion-
us 3bom wh:1t ~char;lcterisrics \l'Quld gO\'crn [he beh:l\'ior ship in which rhe responsibk use: o( po\\'cr is pro-
of the.: ideall~, \'irruou$ ph~·sici:m. ~ tt:Cted. One particubrl:-' appc:1linf:: notíon i$ rhar of
J :\rgue for a slif!'htly díf(c:n:n¡ :1ppro:lch, \\'hich ]¡c:!!'ins .r!,lnrer/ flO::'fl', 1'0 take: jlo\\'cr :l\\':l~' frul11 (h(' ph:'si-
wim the rt:aliz.:¡tion that po\\'cr iS:ll1 impon:;¡nt il1c:rc:die.:nt cian is ro rob thc p:;¡rienr of ;¡ prim:J.ry rcsource,
in me physici:m-pnicnr rcbrionship, ir p:J.tienrs· dicl not Ho\\'c\'cr, if po\\'cr is monopoli:t.cd h:' one person,
percci"c ph~'sici:lns:1s pO\\'t:rful indi\'idua1s \\'ho could do rh:!t pcrson is suongl:-' tcmprccl ro use che po\\'cr
>, something abou! discast: :ll1d the: thrc:n oí disc:1se:. rht:\' selfishl:' ur irrcsponsilJly. Thc bCSI rcsulutiol1 is ro
"

\\'ould probably nOI f!o lO thcll1 at :111.The: :JllronOI11~' lT1:1kcsurc th:1t the patient h;¡s :)11:lprropri:1te: sharc
modcl O'c:ltS rh~'sici:ln ]lo\\'cr :l~ sOll1e:thinS unío,run;'ir~ (l( the ph~'sici:;¡n's po\\'cr, '\\'ithm1t \\'c:lkcning che
char muse be coume:rb:danccd by ¡;i\'in¡; chc pnicnr more allilir:' o( thc ph:-'sici;¡n ro r:lke: ;¡CDOn:1S:1inst disC:lSC
po\\'er, ancl rcspl'ctin¡':'!lis or her :llltOnOI11~·.I3U! rhis ;¡p- and illncss.

Ethit~¡J :\SI't:t'ts {)( {hc Physici3n.P:nicll{ ReI:¡¡iollship 207


',O_, ,'o
. (,: Í'("Wtr can t:fÚ:cli\"l:I)' lic ~h;lr..:d in i hc physicial1- :tI!y, t hc physician also h:1S speril"ic t licr.rpcu t ic icchniqucs
¡i:llicl1t rcl:ltiol1Ship in ;¡ numhcr of wavs. Scicruific nvnilnhlc to hr.:lp lhe smokur quir, illeludillg- ;l g-()od 1111-
knowlcclf!c ~nd skills '(;:1n he shnrcd h~" paricnt cd- clcrsranding, horh physiological nnd hchaviornl, of I\"h~'
\lotiol1,l't:fsol):ll¡l.<)I\·c!' ell) he Sh:lf'l:d hv cmorional pcoplc, knol\"ing irs d:lI1!;l!rs, srno]«, a!Hi wh.u pJ~(llilplS
. counscling lh;¡t fCIl10l'CS bnrricrs \O free cxcrcisc uf thcrn ro kccp smoking. The physii::i:1n ulso h:ls :1 consid-
rhc p:Hiellt's own will :1I1d mnkcs ihc paricn: fe.:d crahlc personal .md social powcr th:1t can he llscd 'to con-
more in control o( lifc and his 01' her illncss. Meo- fr0J11 rhc paricnt and ro rcquirc an cxplicit dccision at this
icinc :lS'~ wholc C1Jl he more opcn with sociery rime. Srudics of nddicrivc hchavior dcmonstrntc thal ph:'-
:II'oUl ies prucriccs so th.u p.uicnrs Iccl morc :thlc tu sician confronuuion of the paticn: is an eXln.:mcl:-: pOIl"-
participare pcrsoll:lll:-' in medica] chniccs, er(·1.I1morivntor to ch:1ng'c Uilhc:llthy lifc-srylcs. Alt crn:»
Thc pOI\'l:r rnodcl irxclf docs nor sucucst an Sil' cr S to rivcly, physicinn rcfusal ro coníronr ihc issuc iildi'rectl~'
di((icult moral pmhkl1~s in medien] prncticc. Ir docs, on slIppons (he hahir hy :llloll"ing. rhc p:lticl1t ro' conrinue ti,
rhc othcr h~IHI, shovv us :t 111':1\'11':1)' ro look nr spccific c.lcn~' thc prohlcr», . .
problcms and idcnri Ií~s :ÍSp<:CL~of th~ physician-p.uicn: Physician pOll"er can nlso be uscd :1g:1insllhc p:ninll,
rclariunship thn: lllighr have bccn prcviously ignoreu, In For cX:llllpk;:1 physicinn who has gre:lt corucmpt Ior P:l-
particular, ir hclps us ;¡pply thc social ano bchavioral sci-. ricnts who ruin thcir hcalth throuch thcir 0\\'11 bchavior
cnccs ro. problcms in: medica] ethics,:f or -cxamplc, thc lll:1y use thc officc visir ro brówbcat or bclinlc ;{ paricnr.
word "pcwcr" is a rcrm cornruonly uscd-bysocial scicn- Thc physician llla)' red bcrtcr aftcr suchan cxcho ngc, hur
tists whcn rhcv describe medica] practicc-The saruc 1I"0ro ir 1S unlikcly thc paticnt will bcncfit. Anothcr physicia»
hJS liccrr-unpopular amongrncdical cthicists.twho have ll1:Jy símply be unskillcd in counscling paticnrs abour
maintaincd rhar nn individual hJS (\1'0 wavs org-crdi'-g pco- habit changc and inrcrfcr c wirh che paricnr's eventual im-
ple t o do what he or shr.: wants: O¡~e is ro l.i5C'po\\'cr 10 pr ovcrncnr, dcspirc thc physician's f!"0od irucnrions. (This
force: rhcrn ro do whn t is dcsircd: thc othcr'i~·f()r ihc in- could rcsult , for cxnmplc, if un rchlisticallv liif:h f:ci:lb are
.dividunl. ro pcrxu.idc «ihcrs rarionullv th:1·r·his or hcr sct [or rhc paricnr roo cnrlv in rrcauncnt.) Fiú:111:', 'lhe
coursc of action is the ris-ht ching tu Jo:)( rhc lartcr js physician m:1y manipulare the paticnt int o l11;¡lin~':1
done, thc individual is Jppc:;¡ling to crhical principies 'or . cha ng c that che paricnt docs not \\·:lTÚ.]{ rhis occurs, [ht
crhical rules, But chis \\"J~' of thinking ;¡ppears tornllv un- phvsician will havc succccdcd in illlp()sin~ his or hcr 0\\"11
.rcalistic to the socia! scicntists for wlrorn dispnritics of valuc s~'stem on thc paticnr without thc paricru 's coriscnt
pu\\"e:r are a hasic rcalirv in human rclationships. Rcrurn- or p:l rnci pauon.
inf! thc conccpt of powcr ro J' Có1u;¡1 place in mcdicil \ \ n:n would constirurc :J sh a rc d power :lpprCl:lch t o
crhics :1110\\"$thc use: of insighrs from thc social scicnccs lhis problcm? As :1 ¡¡IOn: ~t:ner:Ji rulc.' a shared 1)()lI"I.:r
without ;¡banuol1ing cthica l conccrns. nppr onch ro :1n~' physician-pnricm cricuurucr. p.rrticular lv
Thcsc issucs can bes: he cxnrnincd in che COnteXI (Jf:1 in prilll:lry cm':' mcdicnl pracricc. h:1~ thc f()llo\\'il1~: ~'e:l-
cununonplacc medical pr ohlcm. For cxarnp!c. J "¡~-\'e3r- rurcs:
~Id mun shows Up:lS:l ncw paticnt in thc physician's ~ftíel' l. Thc ph,,'siei:1n's powcr tú Jc.:al ~\'ith t hc lll~di(::lJ
se<.:kill~:l complete hisrory and physica] cxarnination. He problcms at hand is undirnin ishcd. lx n h in rcalirv
admirs sl11ükins- rwo packs o{ <:ÍS-:lre:rH,:~d:1il~' for lhe.: pJ~¡ :1I1d ill ¡he pnicn¡'s eStill\:ltiol1,
20 ~'e~rs. \\ll:lt should thc ph~'Si~'i:1n::do: :\.no mure.: spc~ :\t lhe end of tht.: cllcount..:( the p:ltir.:nt {c..:b :111
CitiC:llly, \\'h:¡¡ acoons on rhe p¡':'ysi~j;¡n's p:lrt con>tinltc cnh;¡Jic:cO sensc. of pOll'cr 01' control ü\·t!r hi:-. ur hcr ,
rcsponsiole use of medical po\\"cr? )' s:lnproms :lnd prol>lcms~
The ph:'sic:i:ln h:1s :1 wide r;¡nf:e .of options, :\t O!ll' n- -" 1ncrC:1sr.:s in perc:ei\'eel .pO\\·cr h:' hOlh ph\si(..'i:ll1 :lIld
. ¡reme is lhe possi¡'ilit~· th:1\ lhe.: ph~'sic:i:ln '111:11'IHll L'\'en p:llielll :lre l'(Jlllplr.:l1leJll:lr;.· :llld lll\lll·t:dk :-.1IJ1illlr·.
rnentíoll the Slllolillf!':1S:1 problcl11 ll¡)!t:SS ¡he p:l\ient sp..:- ¡i\'e, For ins¡:lnce, :lS tlit p:llie.:llt h..:,'únió cdUCll..:d
cinc:J!ly asb f()r hdp. (l'hr.: ph:'sici:1n lllif!hl r:¡¡ioJ1:1Iil.l' :1hO'lli ¡hc n:lrurc of thl' illl1l'ss, I!lllh ¡he J1:ltiCnl'~
this b~'lll;¡illt:1inin!! th:11 S0 Illuc:h pul)!ici~":lhoUl lhe l'l'ib p"\\'~r w c:ontrol S~'IIlIH<illls aiid· t1w p()\\,cr \)( lhL'
of cicrarene sl11()lin~ cxists .lh;¡r e\'CrYOnl' in our SOCieIY. ph~'sici:ln lO cnsllre.: \leHer 1l1:ln:1!!l'lllel1t :lrl' CI1-
must\no\\" abOlir il~ or ¡h:1I p;¡riclHs ''''ho d() not n,:quc;r h:¡nced,
help h:1I'c il1dil':H..:d th:1t [he\' do not wish lO 00 :111\'lhil1!! -t. The ph~'sici:111 \ use o( pcill'ef is 0Pl'l1 :111<1e ....pliCit.
:loout thc.:ir sll1ulil1~ :ll1d p:l;icnl< :lllWlltlllly (lu~h; ((l ¡,~ The p:llicllt is :11 all lilllO :11L1rl' of the· 1'1:111:-':ll1d
respccted.) Ar the uthc.:r cxrrenH: is the dOS'111:1ticph~'sici:1n srr:lte~ics t hl: ph~'sici:lIl clllpl():'s_ \ \ 'hel1e\·r.:r possi-
",ho t'ells the )l:1tient thal hc' mllst 'luit sl1)oking illlllll'- hJr.:, the ph~'sic:i:1I1 :1I'oidS (kl'Cplil't: or lll:lllipul:ltil"l'
di;¡tc\)', :lnd if he refllsc~ ro 00 so, he lllusr línd :1nothn tec:hniqlles, el'cn \\'hL!11lheir llse \\"ollld ~'ir.:ld ~h<in"
physici:lll, Mosr physiciaT1s :lre morr.: COlllfort:1l>k ",irh :ln tcrrll ~:lIJlS,
intermediate posi.tion, S, Pbnl;int:" str:l(c~ii.:s for l11unl:1li~, cllh:1I1ced !lCl\\"l'r í~
The ph)'sician has :1 great eleal uf sciL!nti(ic ln(l,dedgl' p:lrt o( thc. phrsici:1Il-P:ltii.:llt rcl:lli()n~hip, amI e\"l:J~'
:1nc! skill. :1nd kJ10\\'S holl' smoking can h:1rtl\ hr.::llth, Ide- ell(.'oulHcr is \'ic\\'ed :IS':1n in\'csüilCIlI in thi'~ IOII'!-!'-

lOR A~~l:ssmenr o( PJtit:ncs


l·'

tCJ"l11lher:'lpetltic rclarionship. Ovcr lime, !loth phy- long hnul. l ronicnlly, this rcsults in :l pn t icnt wlio ir1"lhc
xicinn :'Ind p;¡tierll come ro he cmpowcrcd \\.:irhin ihc [ut ur c is lcss C:1p;¡blc of ;¡utOll0Il10US act ion. On rhc ot hcr
rclnrionship, ]l3nly lhrough ;111 cnhnnccd kllowl- hnncl, ir wc rcjccr ihc aut onomy moclcl c:oJ1lpletcl)' :lJld
cdgi:: o( cnch othcr :ll1d panl)' lhrough a n apprcci- rcly only on thc powcr modcl Ior f:,rtlid:lJlee, wc m;lY UIl-
nrion for hO\I' thcy work togcrhcr as n rcarn ro solvc duly violare thc righrs of thc paricnt in the shorr run in
po ticnt problcrns. hopcs of long-rcrm gain. Ultirnntc ly, rhcse rwo modc ls
Thcse gener;¡1 guidclincs providc a perspectivo [or che must be vicwcd as cornplcmcntary and murunlly beneficia]
problcm u( smoking. por cxarnplc, dircct confronmtion approachcs tu thc cthical practico of IllcJicir1e.
might inirially appcarjto rurn off thc paricnt arid thrcnrcn
thc Ion g~rcrlll rcla ti onsh ip. \Vi eh rh e shar cd pOWCf SVMMARY
modcl, howcvcr, dirccr confronmrion is secn ;15 an obvi-
ous use o( ihe piwsici:¡n's j)o\\'<.:r. /\11 thc issucs are mude . T'hc pbysician-paticnt rclationship mises 1l1:111)'crhicnl is-
cxplicit, and t hc pnticnt can sce prcciscly what thc phy- sucs rha t are central rorncdical practico. T'hc concept of
sician is doing and what choiccs must be madc. Other uses rcspccting paticnts' auronomy h;¡s scrvcd mcdicul crhics
of PO\\'<.:r (c.g., engaging in scarc tacues or rnisrcprcscnt- wcll in thc reccnt rast by scrving as a correctivo t o in-

ing informarion sueh as prcrcndingthat me paricnr's chcst dcfensible parcrnalistic pracriccs tha t markcd much of [he
ausculraticn rcvcals signs o(C:lrlr crnphyscma whcn in, prcvious hisrory of medicine, Howcvcr, :l\1ronorny is ul-
fact ir is normal) are rnuch more m;nipu];¡ti\'c and . tirnarcly incornple té as an cthical :1genda Ior me physi-
thrcarcn the conccpt of shared powcr.. Recommending cian-patie nt relarionship, and case cxarnplcs drnwn from
cnrollmenr in cornmuniry sclf-hclp groups, such as thosc cvcryday prirnary ore, espccially issucs ar ound liíc-srylcs
cornrnonly sponsorcd hr rhc American Canccr Socicry, thar pose: risks ro hcalth, illustrarc clcarly me lirnits of an
also prometes rhc paricnr's scnsc of powcr b~' bringing . :1uronoJl)~" approach. Bccausc ofits irnportarn srrengths,
thc paricru im o a consrructivc alli;¡nce with othcr paucnts thc ;¡1I10nOm~' concept should no! simpl~' he rosscd asidc;
cxpcricncinc sirnilar problcrns. This gTOUp involvcrncnt howcvcr , orhcr ethiól approachcs a r c nccessary ro {jll in
r crnin ds the paricnr that physicians are not magicians and me gaps that it leaves. This cha ptcr has prcscnred o nc
. carmot solvc al! of me
paricnr's problerns unilarcrally. Fi- such supplcmcntary modcl, :J powcr appr oach, which ar-
nallv, it is use fuI ro schedule multiple visits ro assess me guC5 thar me central cthical questions in medicine involvc
paticru 's progn:ss. This dernonstrarcs-ro me paricnr that wha t ir rncans ro use powcr rcsponsibly. This in rurn sug-
the physician's po\\'er will contiriuc to be availablc and gC5ts a sharcd po\\'er approach ro me phvsiciari-pa ric nr
that thc phvsician is conccrncd and cornmirrcd. It also relarionship thar CJn poirn ro oprima! he:lling actions, as
reinforces rhc 'ph~'siC'i;¡n'!' m~ssdge that thc ccssation of \\'('11 as ro proper rcspect for paricnrs' righrs and valucs.
smoking is a difficulr pr occss and thar progTess is 510\\'.
This hcrtcr prepares thc pnticnr Ior thc rcalirics of thc CASE STVDY 1
rrca trncnt prograrn and will makc che paricnt Iecl more
in control evcn if thinr:~ do nor cósruoothlv. lt also en- R_S. is :1 70-\'ear-old rcrire d divor ccd sccrcrarv wilh
harrees the long-tenn ;d:nionsl;li!).I;erween phvsicinn and chronic lcukcrnia. Her leukcrnia rcce ntlv cnrcrcd an acure
paricnt hv illusrratinc a shnrcd ¿émmi'onenl \\'ith time. phasc. whicb did no! rcspond ro thc 'sland;ud chcrno-
Finallv, i~serves thc purposc of dirccr confrontation l)l'- thcrapy. Evcnruallv she transferrcd hcr car c ro a hornc
cause cvcn though thc pnricnt Jll:¡~' rnakc thc choice 10 hospice prof'r.lnl aftcr hcr oricologists pr cdicrcd th:lt shc ?
cancel fururc visirs and rerurn tu Sn)ol..:ill~, rhis mUSI he ;¡ h;¡d \·cr.,- li[llt- eh:1I1CC of li\-in!:; morc d1;¡n :l fe'\· \I·":cl.:s:"
deliber:lle choic<.:, Thi~ str:1!egy i~quite tii((crent From ;¡;1 She h:l~i pre\'io\lsly li\'Cd :1lon~. bur her d:1ughtt:r ¡(lOI..: :1
inr<.:nsi\·e :¡nÚS!l10killQ !cCrul'l' f(lll()\q~'d li\, lh~' SI:lIell1~'l1l. I..::l\'e (Ir :ih~eJlct: froll1\\'ork \(l CHe i(Jr her !ilOrher durillf!
"C:llllllc lue\.: i( ~'oll'h:l\'l' ;¡n~' pruIJ!cms.· .. [he n:ll1;¡i·ning rimc o( her life,
:\bn\' o( lhes:: str:1t..:r::it:~ :lIso lit :1n :lUtOIH1I11\' lllOtkl. :\s i~ not unusll;¡) in hospicc Clre, I~.S. did hertt:r lh:ln
Ho\\'é\·~r. rdlinf! rhc rh'~'s¡ci:lIl rh:n a prim:l~' oi)liptinn :ln~'one h;¡d cxrecred once she \\':lS r~¡\lrnt:(l ill her O\\'n
is ro t1St: po\\'er rcsponsibl~' on rh<.: p:1tiellt's heh:df pro- home: and :Ippe:lrcd ro be rt:]:¡ti\'l:I~' ~r:lhlt: :2 lll<lIllhs l:llcr.
\-ide~ !llorc ~,i(J:¡nt'c Jnd dirt:ction !h:ln [he injullCtion ¡.j(l\\T\·<.:r, C\'L'1l thou!:;h she \\·;¡S rt!:ltin:h- (rel' of S\'Jllp-
that lhe pril1l:1r.\· IllOr:l1 dury of rhc ph~'sici:111 is .[(1 prCJtect [()Jl1S :11 thi~ tillle. sh~ bCS':ln ro r()Cll~· fnl-;t::l~ill!!I~' 0;1 her
p:1tienr ;¡\lIO!l()(llY. The :1tllOnnnl~' Illodel hc.:lps us ro :1\'oicl \\'ish ro die, Shc kJlc\\' rhal shc h:1d :1 termin'.:!I prú~n(1~i~,
manipubrion (lr dcceprioll of jl:lricnts in rhe short rUIl; it riespirc her tcmpor:lril~' sr:lh!c condition, :lIH! cOl1lphillCcl
is mueh Icss lIst:f1d in est:lhlishillí! a InnQ-refm direcriCl!l o( !lCJth \\'e:lkllcsS ;¡nd !:lck o( an~' hopc or :1hiliry ro ll1:lke
for ¡hc ph)'siei:lll-p3Iiclll rl'I:Hi(l!~~hip (J~ in e:sr:ll>li,)¡ing pl;1n~ rOl' lhe f\lnrrc. "l\'l' :l1\\':l~;s,been· ¡l (utll!'c,oriclltcd
:In apprOpri:1ll' U:1hllce IJe['\\'l'cll ph:-'sici:11l ;ls~eni\'enes~ person, 111:1killt: pl:lIlS :llld lhinl..:i~f; ur proj<.:cts, :mc! rhis
and p:ltic!l! ril!hlS. Exclusi\'L' usc or rhe :1\ItOIlClIll\' l110del jusI ¡SIl'1 a qll:1li~' life: fm me," ~he r<.:115hcr physici;¡n.
rcsulrs in mi~sed oppormnities f()r de\'CI{)pin~':1n <,:1)- "1\'<: I)<.:cll re:1c!iIlQ :lbOlll C:lses ",here rhe: doctOr gi\'cs:the
hanced sense of po\\'er ;¡nri control in rhe p:ltient 0\'<':1'¡he p:1[ic!)[ :1 bordc ü'( rills, enough ro kill them ir they r:1kc

l.".
': .
.: ...
"

,
1,

II
"(

Echo of él Scrc-'a1T1'"David Alrm' Siqociros 1193i¡' bu(~ on wood, HI' by 91 rm, Ccllcrtion. thc
Mux-um of Modrrñ:-I\r1, Nc-w York, (id, 01 Edw~rd M. M, \"'Mbur~, -
Fhysici-ms JIi.Jpr_~ aU(1ul thc cxtcnt 1(1 wbicb tbcv are c:thi(,¡}}y bound 1(1 adJ~r::55$~~icld¡
ptoblcrtts ¡:ue:h di hun!~(r, 1"'vrr1y. M racis! iniustics:

thern all ar once, \\'ould yOIJ 1)(: \\'illinf: ro do th:H [or long ;1S rhc paricnr is dcmonsrr:lbl~' cnpablc. of in;¡lin~
me?" The physician, in this an'd othcr inrcrvicws , f;¡ils ro racional choices. Thosc 0pjJost-d ro physici:ln-Jssistt:d su-
derccr any signs of dcprcssion or ot hcr incapacimring icide rclv on ('\\'0 counrerar gumcnts: rhc likclihood th at :1
mental ilIness (Quill, 1 ()C))), pnlicv of :dlo\\'ing suicide nssisrancc \\:ill It:~d<~o abuses,
, wirh dcnth bcing' forced on vulnc.rnb!c person's:rw,ho did
Ho» sbould tbr pl.~)'¡¡ám, 1'Clp01ln ro tbis 1'('r¡/lC,rt (
not voluntarily conscnt: and ;1[1 argurncnt frorn-phvsician
intcg-riry, sraring thnt aiding (k;ith direcrly is conrrary ca
I Discussion me physicinn's fundamental he:11ing- role,
I Physician-assisred suicide hns bccome n vcrv controvcrsinl A powcr -Ímscr] appronch ,¡'oUld echo this di\'crgencl'
I issue in medicine. Purc rcliuncc on patien'! aut onomv as oC opinión. CIt::1r1y,:15 a rcsult of rhcir hiomcdical
edg-c.: and rhcir legal authoriry ro prescribe drugs, ph)'si-
knowl-
0e primal)' cthical principle would sccm ro suppori thc .
right of the paricnr to rcqucsr this son of assistancc as cians posscss che powcr ro hclp paricnts die in chis fashion,
1

I¡ 210 Assessrncnt of Pazienrs

I
I
:, ,:'

..•.-:_ ...
:lnd lhis pO\l't:r could t~~·cirhcr uscd or :lhú~t:d, SOI11t:
would $:1)' ¡h:1l such ;¡ Jl~\\~'t:r,issimpl)' too (bl)g<:rOll~ un-
der :my circumsinnces. Orhcrs woulcl rry ro rlcvclop srric: , Wilh íhc second drink. 'al thc rcstaurent,
crircria ro cssurc that this po\\'er ¡S uscd only in carcfully holding hcnds on íhc barc ta,ble
sclccrcd cases whcrc nb good medica] altcrnativc cxisrs we are al [f again. Tencwing :¡;ur promise
for rclicf of suffcring ;/nd
whcre the paticnt voluntarily lo kili each olhcr. You are di¡~king gin,
:ind consistcnily initinrcs the requcst, nighl-blue [unipcr berry
Thc pocrn Tbc Promisc providcs a cornpclling glimpst: . dissolving In your body, 1 arn drinking Fumé,
into the thoughts of ~omc paticnts who might rcqucst chc:wing ils fraBranl dirt and srnokc, we. are
assisrancc in suicide (which, according ro 111:111)'opinion taking on certh. wc are part soil alrcady.
polls, is thc stnnce of ;¡pprOXilll:ltdy 60% of thc U.S, pop- and always, whcrevcr wc are,..ve are also in our
ulnticn). The pOCJ11o p,tlJ res SOllH': of lhe amhivalcncc that , 'bed: kilcd naked closCly- ", ., .'..•.
crhicists Iccl ovcr lhis: issuc. On rhc onc hand, assistancc along cach othcr, half pam'd.éG,
in d)'ing is portraycd '~'s a !O\'j!lg aci and indeed :l mnrtcr after leve. driñing baek an9/:> .
of marital dury. Thc '\l11;¡gery of sexual inrcrcoursc arid forth across lhc border of cQn~ciousncss, OUT
binh is ,employed ro sUggest thar dcath is a natural pan bodic:s bucyant. clasped. Yo~/hand
of thc life cyclc, and so.sccking ro rakc mere dircct control li.ghlcns on thc lablc.. You·ré~;~.litlle afraid
ovcr onc's d~'jng in ccrrain circurnsranccsis a full)' human l'llchtcken out. What you db"npl wanl
and understandable r,e.~ponse, Orrthc othcr hand, mere '," ís I~ !'te ih il~hospilal bed for ;~;~ar
is an air of inre llcctuat.dctachmcnt about this con\,crs;¡-. ilf1cr ~.~rokc, wílhoul being abk lo
Don berwccn rwo (apparcntly) )'oung pcoplc sharinp a íhink or die, you do nol wanl,
borde of winc in a restaurant. 0.either is now sick or el- lo be ticd lo a chair likc my prim grandmolhtr,
dcr lv, and rhc rC3dc:r'h:l's t o \\'ondc:r whcthcr thc issuc cur>ing,Thc room is dim a~ql!nd uso
\\'ou'ld still sccrn so clcar once ag-ing OT terminal illncss , o
i"v !)! globc:s, pinkrvrtains ..
becornes.part of life 's rcaliry. 't;;u'n'if~t th~waÍ5!,.and outsidc
:'.1 w~iBhi1'c:sibrigh¡; Üftro-up é. .'
In thc case of R,S,,:further cxplorarion by thc phy~icia'h riirri~c[tWi[ighl. J i~lÍyou.YoÜ don',
and me hospice rcarn ~~\'C:lled thatthc reason m.c; paricnr , kn6w rh~
íf.you thínk I W¡il'~nót
is n ow voicinp me wish to:dic; is that hcr daughrer had ,;< kíllyou. Th¡~~,how wc
ha~f¡oa'cd Iogcthcr
bccn absenn:fTom work. 'c~¡-in!! for hcr scveral \\'ccks , Cyc' lo
eyc. nipplc lo nipplc",. .
.longcr than titheT of mCITl had ';:¡nticipatcd, and R,S, in- .:_.~',:"~~'í~'S;;_-iht-hal~ ·o( á singJ~ crcaturc
crcasinclv felt that she \\'JS btcominr: an intolerable hur- . :¿ri~g up lo thcJip oÍ";f!l'~lii:r..'
den (Q h~r dauzhrcr. ,-\ f:;mih'C(m(e~enc:c was convcne d. .,' anJovcr it-yo!J. know f¡;¿fron) thc brighl. blood-
. an d afrcr frank 'discussion, R:S, ;:¡n~rhcr daurrhrcr azrccd '" . ncchd,delivcl)t~;;¡;-m. jf'á bt~
that R,S, would be adrnin cd U;';¡ n~rsinf! car~ f;¡~ilj~, 01'- had you in its j'a~'I wO~¡¡~I1~d< il. il thc ropes
era red in conncction ,,'ilh rhc ~hoirice. whcre she could bindinj; your soul are your 0W11 wrists I will cut thcrn.
conrinue tO rcccive cornfort carc ~'nd whcrc hcr dnughtcr " '", ,.1

SHN:.ONO~
could visir on wcckcnds. R,S, no 'Ionger rcquesrcd 3CU\'e ,':';

assisrance in d~-jng arid livcd anothcr :: rnonths in ;¡ppar- Prom Ole!<5: 'Th<:. pr~mts<, ~ Yorlm bO!l71:80,
1990.
VS«l by ~.u'ion, , -,
e nt pea ce and cornforr.

CASE SrvDY 2

CH" :l 4 ~ -~'C:1r -old houscwi f e, h;JS bccn :l pnri cnt in :'our to 'lhl: '~krnl:lI·()I(¡triSl.·Th(.' mcdi ca l clir cct or O( the plan
family practicc fUT 7 years. Shc and rwo of hcr d:1uf'hlerS caiis \:'óu rillJ \\'~"C'k htcT and S:l\',S thnt shc i~ rcfusing ro.
have a condirion wal h;¡~ hecn diagnoseo ;¡s dyspl:tstic aPIH~\'(': thl,"rd~:fr:J!: "'F~mily ph~'sici;¡ns C:111 look:JI moles
nenlS S\'íldromt:.
,
and sC\'t:r;¡1 moles th:1t the\' h3\'t: dc\,t:!-
,
:and per(orl1l biopsic:~ :1S \\'ell :t~ deml;1(ol0f!"i~IS can," she
opcd o\'(:r the :'cars h:1\'l' ht:t:n C:XCiSl'd :1I1d (ound to he Sr:llt:~, ,,]( \'Oll ti:n'd ~n'il'i-crhinfr .rh:ll's rruly sllspiciou$ and
. precancerou's, J ler dcrl11:nologisl h:ls all lhrl.:l' on ;¡n think i¡ nt:'t:ds t'xr~n c:\';:¡lu;¡oon. il \\'ould ht: di((erent,"
every-ú-month schedule: (or \'isies ro inspt:ct thc:ir skin(or l'ou \\'ondcr wh:iC'(o do. 'You C:ln coll CH, inro your
an~' suspicious moles, Thl.:~' come: to you (or all of ¡heir offict: 10 cli~Cll~~ this. rcmind ht:r o( tht: r¡;strictions placed
ower medical problellls, on ]¡t:r insur:Jlll't' t'()\'t:r:l1!0 (:'Iftt:r :111,1'0/1 diJn't sc:lJ her the
No\\' e,H, h:1s S\\'iICh~d inSllr;JnCC C()l1lp:ú¡it:s :md h:ls ir1~Ur:1nc(.' pl:ln). :1(h-isl.: ¡lt:;r rh3! y(l~ rrul~' think ~'OU can
signed up with :l 10c:1I l11:1n;l!!t:d-on: S\'SIt:ll1 in ",hich \'0\1 h:lJldlc: the: (,-l11Clnlh $kin check~, ;¡ncl also rernind her t.har
p;¡rocip:ltc, Sht: callsy(J~r o((¡c:e.: ;lIlcl ~~byou ro c01l1¡;Ie.:\l' ,Shl' CO\Jld, ir sht: \\'isht:d, st:e tht: oermarolo~ist and pay
the forms ro apprO\'e p:1~'llenl for rht, neXI rOlll1d o( \'isilS out o( her 0\\'11 podet. '¡'ou are afraid t.h;¡r" she ",ill be

hhicd :\'1"'("\' (l( r]H.: J>hysieinn-P:nicnr Rt:I:nionship 211


~'
r. .•..• "".

41".,
~'" .,
,'.-

" qurtc :ll1gT)' \\·jlh )'(lll j( ~'()lI do rlint , hccausc yOlI kno«: director. Thc.:\' cvcnrun llv :ll.:re:cd on n COlllprolllisc.:: C.H.
shc h:1s ;¡ lor 01" (;Ijth in ihc dC!"I11:110Io¡;isrand also lncks :1!1clher rwo C¡":1\lg)¡lcrs\\"~lllid he :IPJlro\"l:d (o'/" \·¡SilS to i hc
thc (und, to he ablc com(on:lhl), ro Jla)' for rhc visits hcr- cJe:r!l1:1tologist e"ef)' J 2 mont hs, :l/ld in hcrwcc n lhe>'
sclf. YO\] n::lli7.e: rh:1t i( vou are jllSI :1 lirtlc J110re drnmntic would scc the (:lmil>, physici:1I1 [or :1 mole inspccrion.
in your dcscriprion of thc moles, rhc medica] director wil]. C.H. bclicvcd that this was :1 suitablc compromiso a ncl
apprrivcthc visits, appr cciatcd [he [nct tha t thc famil)' ph)'s.ici;¡n liad tak cn
1.r ir ctbiral to f7llbc¡jisb yOIIl· 1"CpOl1? r.he time: nnd rroubie 10 pursuc thcmarrcr furthcr.

SVMMARY
Discussion
Thc conílict oí thc pri¡113ry ca re phvsician who is ex- Considcr thc acrual rcsolutions achicvcd by rhc Jlh)'$ici:111
pcctcd h)' :1lllall:1¡!cd-c:lrl: S)'St<.:i11ro serve as me financia] in both case srudics. Thcv poiru out a COIllI1Hin criticism
"~:l(c.:kce:pcr," decidin~ whicl: paticnts are approved Ior of thc "principies nppr oach " lO mc dica l cth ics. l( (lile !>t:e,
various high<.:r-cosl proccdur cs and which are nOL, is a case srudy 1 JS :J srrllgglc bcrwccn thc pr inciplc of .un on-
s-roll"ing scurcc of erhi:c;¡I conccrn a nd inrcrcst 35 thcse om)' a nd :1 principie oí prorccting liíe or pr cscrving pro-
fin:mcing rncchanisms assurnc a brgcr role in me U.S. Icssional inrcgriry, and case srudy 2 JS a srrugglc hcrwccn
hcalth care S\'stCl11. Thc conllictin¡; cthical valucs are be- ihc principie of auronorny and me principie oí justice, o nc
ncfoc"Il(( and )"Ilsria-me physicia n ~seeks elJ provide be n- II"jll rcnd ro assurnc that onc principie h;¡s ro win :1nd che
efits tO the individual paricnt, wher·eas juscice r equircs othcr one has ro f;i\"C 1'."2)' and rnay (JillO look íor cr ca tivc
somcone ro allocarc limired mcdical resources fairlv cornpr orniscs o n d middle ground solutions. 13)' corirrast.
among all corncrs. Tradirionally the physician be}ic\'ed me po\\"er rnodcl, along with modcls thar cmphasize \·ir-
that thc oblipation to ~. ro provide a benefit for me p:;r- n.¡CS in ¡;lcdical practico and thc carcful analysis of indi-
ticular paricnr in thc pracrice \\"25 sacrosancr and could vidual oses in cantor, rcnds ro su~;.;esr tlia t approprim c
n ot possilily he ourwciphcd by an_:.-duties owed ro paticnts clinical wisdorn, :Jlun~ wnh thc '3CO\"(: invclvcmcn: of JII
more generall~· or 10 me socierv a¡ large. Bur mis purist conccrncd parrics, more oft en ~h:ll1 not lcads 10 crcarivc
vicw of physician I()yalr:· to thc parient's inrerests can be accommodations that rnaximizc scvcr al impor i a ru moral
challcnjrcd. Afi:er ¡¡II, ir mere are only so man)" placcs in \·3} u es sim U Irarreously.

a particular trcatmcnt progT3m ro go around (based on


me sum of rnoncy thar our sociery ...has clectcd to spcnd SUGGE5TED R.E.·\l)J:--'GS
on hcalth car e), and other phvsicians irrnorc cons'idcr.¡- Bcauchamp TL. ·Chíldrc~$ .1F: I'n"",-;['/r.' </·;01/1(,/':.,.' rtbir). ni .;. :'< eH
tions of justicc and refer mcir parieras f~r tr carrncru sirn- ·York, 1\189, Oxíord LJni\·cr.;i[\".
ply bccause me paticnts dcsir e it, your paticnt, for whorn PerhJ[" tht· mOSI "idcly us e d "nd Cilt·J le:.:tl"",l·o('"l"llicJI ct lucs,

me trcatmcnr may trulv be a rnarter of life 3nd dcath, t.hi~ bC)(,ll.: uses :) "principlcs appr oach ' and b~~ ~'ut ti H'. nn\l -rr:ld¡·
{lonJ) "c ui o nornv rnodcl."
mighr be left out in me cold. Some \\"o_uld arguc that me BTC>Ó~·!-l: Tbr bralrr's [,CT_-"". :-':c\\"Havcn, Conn. I()')~. Ya le L·n"·,,,.,.it:·.
physician 's durv of bencficencc to m'c· individual paticrn Thi, hoo\; elaborares thc '·po"-cr mode l" Jnd "I'pli", it ((1 " n um lx-r
is rcmpcrcd ar lcast in part bv a dur:· of wisc stcwardship (Of í~~ue, in Illcd,c::1 c rhics. On« ·ch"['lcr ,1<:,1, ~l'<.·,·,¡",cdly \l"llh rc-
ovcr me rcsourccs cnrrusrcd to die r.h·siciJn'5 discrcriun ~lIllrp.: allocauon and ihc pr()hkrn~ uf th",· ~Jl(,:b:(pt:r r(llt: (:-oto\," C., 'l'

bv thc socicry :Jr larg-c. . " ~lUÓ~· ~).

Dcceivinn me rnanazed car c svst ern bv ovcrstarinc thc


GUl/ir/iIJrI 011 tbt trrminmion o/ 1~(;·-rJl.r:l1ill¡n.r.. trr armrut 11IIJ lJ:.r ca re o/ll.(
d\·;I/.~. llriorcliff .\1onm, :---¡., I(J~;. J b'lil1::' Ccm cr , (Sul"rqlll·nlh
extcrit of m-e di$C3$e ~a\' seem· lile :l ~ood shor~-~cml di~trihuu_:·n h)' lndi.Jn:J l'ni\'t'r~'r:' J>a·~~. nlonrniil~..,nf1, lnd.)
solutiaD, bUI i¡ compaunds rhe probll·m- \,·ieh thc· elhic:!1 l-hi~ rcp"!"1. 3u\hofL·d h~';¡ rHultidj~c:iplin:lr: ~r1'Up. ~\lllllll;lril~" ("u:·

principlc o( ¡ustin· 1)\·:Jddin[! thl' n.lrther l'lhic:d ,·io!:nilln rl.:nl l:thj.~·.d lhinl.:iof! (11\ tht..· LI:l' 1)( tlll' d~'''':: )l.\!It.·nt ~1!ld 11.1' hl't.·.:\

oídeccption. In Lhe l·()ng ter;n, rhe m()r~ ph~·sici3n~ re~(ln t,.· •.• ¡H:c,·i:.1IJy· u~cfu1 :1:- :l \T:'linin;: TIl:tIHI:tI (or fHl"lJt:t1 Jlld nU:~III:: IHHt\r

(,:!hjf..~ t:tlnllnltt<':l·~.
10 such llle:3ns 10 fi!!hl "the s,·slelll." lhe l110re "d;c s\·.<-
.l""'CIl .-\~. Sit·~kf .\1. ".",,1:.<1<" ".: (."1/1;:",101'1:.'. t"tI .'. :",:" Y"d ..
rem" is forced tu :lJd funht.:r ·[¡urt:3ucr:llic r\.·\·ie\\·s :lnJ· ¡;, I ')I)~. A¡c-<.;r.1\\"·JI dI. )1)112.
micromal1:1f!"e !1H:dical c;¡re. 'rhi~ \'oluIIH: i.' inlt:ndt.:t! =h :\ \\'()rkill~ ~llldl' fuf' :--t'nlflf IlH:diC':d !'[II'

A power approach rnighl .1dopl ;:¡ sill1il:H cunclusiun. dl'l1L'i :lnd hou~(." SI:lf,. :l'nd rdh·(.'1!' ~1 lUCIr!.: C:l~(.:-{)fJL"ntL'd :'l'pro.\c..:h (\1
Ordin:lrily rhe: ph:·sici3!1's obligaLion i~ lO use his or hc.:r Tt·~(I¡"in¡: t·lhit",1 pr"i>¡l·n" \\"hill· ~lilJ Cllrmín!= \)11 ,,">le ¡'"i •. t·lhiol
prjnciplc.:~ :\Ild C:\ll.·~lIril"~.
po\\"er to di;¡gnost: :1I1d :real disc.::1SCon lhe p:1tienl'S bl'-
h:"u ..l: 71( silr,,! ~··ur'" o( ti." O" n /JI/ {'II/ 1(/". :--·l·" \" "rl. II}¡;'¡. he,· l' rt"".
half. \\'hen chis po\\"(:[ c:xp:me!s into :1 po\\"t:r ro C()11l11l:1n- h:.:HL.:t ph:-sici:\n.p~~·ch(J~,n:d~·!,;twh" tt::tcht::<o in ;1 b\\' :-.,t:hotll. prcl\·j,!t·!-
deer an unfair ponion of soci:1lh- fl.lndcJ n:sourCl:S so l]¡;¡r :t uni4\lt: \·ic\\, o( in{nrJ1ll"d l"On~1.·I1\, !-h()\\"ill~ ",.h~·it i •. c:-.:-.cllll:,1 Hl
omer paDents m:l\· hJ\·c 10 (!(J ·\\"iLllOlIt whik (lllt:'s o\'·n IlHH!t:rll 1111'cliC'inr :tnd ~''''1"'h:' h'lth p;l\it,.·nh ;)I\t! ph~·~i(.:i:lll' r\'.'I'\ I\.

.\ lorn.:il11 J J: h'U/JltJrilJ.C. na: '1111' Jlt-':' 7l1nh·,tI oJ.,:( t{ 1JU·.!/,·III,··.c 11.-':' 1',',··
patíent gets extra· bencfits, - ¡hL' ph:·sici:1n·s ex("fcist: of
,,"',,;(.<, ""I"\ITII. ,\ la.". 1'}lll. h:lll\\"ef :\clIlcnllt".
power might be consid·neu :In :1buse:.
.\¡"rrcír>l,:l phil","pher \\"hu \\"",1.:., in:t 1lll"(lrcd t"Clller, t"Xl'l:.ir1' \\"1'.'
. In me case describt:c.J, thc prim;¡ry ph~·sici:l!1 111c.:t:lg:lin ph~'sici:\ll~ h:1\'(.' ,huit::-. lO indl"idu:d p:ltll'n\;\ hUI ;d~(, dtltic.·•...(1) till'
Wlth C.H. 2nd held fun.her c.Jiscussiom \\"ilh ~he: llledic:d brJ!(."f !-ocit·ty lo U"'(.: !-ic:,n-c n.:~()llr('(.:~ \\'i~dy (!'olo,,: <::I!'ol' ~lucly ; ,.

212 Assessrnenr of Paticnts

:.-·:.;.:7····_·· ..:_ 1

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