Ethical Models of Doctor-Patient Relationship

Patient Involvement In Therapeutic Process On Clinical PharmacologySetyo PurwonoDepartment of Pharmacology & Therapy , Faculty of Medicine , Universitas Gadjah Mada1Ethical concerns over doctor-patient relationshipAutonomy and patient choicePatient right Vs patient interestIntegrity of the medical professionShared decision-making in medical intervention

2What constitutes a persons autonomy?Three aspects of autonomyFreedom of thoughtFreedom of willFreedom of action3Principles of medical ethicsRespect for patient autonomyBeneficenceNon-malficenceJustice4Autonomy and patient rightsWhich of the following are derived from the value of patient autonomy?Right to treatmentRight to informationRight to choicesRight to privacyRight to compliant5Conflicting ValuesPaternalism:The doctor should act in a way that protects or advances the patients best interests, even if it is against the patients will.Patient autonomy:The doctor should help the patient to make real choice, and provide intervention under the constraints of (a) informed consent and (b) confidentiality.

6Difficult cases for doctors: some examplesActive and passive euthanasiaRight to refuse treatmentDNS (Do-not-resuscitate) order AbortionExperimental/risky interventions

Ethical models at a glancePaternalistic modelInformative modelInterpretive modelDeliberative modelEvaluating the four modelsPaternalistic modelPrinciple

Assumptions

Sources

Problems

Objection and modificationThe doctor should make all the decisions for a patient.

People are not always rational/mature.Experts know better about the needs of patients.Qualified doctors have good will.

Hippocratic Oath; Plato.

Are the needs of patients objective? How can we be sure that doctors have good will?

John Stuart Mills liberal principle

PaternalismIs widely regarded as the traditional form of doctor-patient relationshipA passive patient and a dominant doctor

11Informative modelPrinciple

Assumptions

Problems

The doctor should provide all the relevant information for the patient to make a decision, and provide the selected intervention on this basis.

A fact/value division of labor yields the best medical result.What is good for a patient depends on what his/her personal values. Consumerism.

What if the patient is unconscious, incompetent, and making choices totally unacceptable by our ethical standards?The interpretive modelPrinciple

Assumptions

Sources

LimitationThe doctor should help the patient to articulate his/her values through interpretation, and provide intervention which is truly wanted.

Patients have unconscious and inconsistent desires.Their conscious decisions may not reflect their deepest values.

Sigmund Freud; hermeneutics.

All that a doctor can do is to help the patient see his/her own desires/values more clearly, but not to criticize them.

The deliberative modelPrinciple

Assumptions

Source

ProblemsThe doctor should help the patient to deliberate well through dialogue and discussion, and so develop values which are objective and truly worthy.

The objectivity of values.The patients good life consists not in the satisfaction of desires, but maturity and rationality.

Aristotelian ethics

Is the model different from the paternalistic model? What is the difference between dialogue and persuasion?Prototypes of doctor-patient relationshipPhysician control (Low)Physician control (High)Patient control (Low)DefaultPaternalismPatient control (High)ConsumerismMutuality15Consumerism The patients challenge to unilateral decision making by physicians in reaching closure on diagnoses and working out treatment plansReversing the very basic nature of the power relationship

16Patients roleHealth shoppers

Indications of consumer behaviorCost-consciousnessInformation seekingExercising independent judgmentConsumer knowledge

17Doctors roleHealth care providersTechnical consultantTo convince the necessity of medical servicesA tendency for the consumer to be right

18AdvantagesPatients can have their own choicesMedicine is not an accomplished science. There are tremendous gaps in knowledge. Indeed, it has been estimated that the effectiveness of treatment is unknown for about 90% of the medical condition seen in routine practice19DisadvantagesPatients are being more selective in the acceptance of provider advice, based on its costWhen things seem to go wrong, when satisfaction is low, or when a patient suspect less than optimal care or outcome, patients are more likely to question physician authority20DiscussionThe doctor-patient relationship of consumerism seems easily to be adopted, we can simplify the complicated relationship with buyer and seller relationship, is it good or bad? What is your opinion?21MutualityThe optimal doctor-patient relationship modelThis model views neither the patient nor the physician as standing asideEach of participants brings strengths and resources to the relationshipBased on the communication between doctors and patients

22Patients rolePatients need to define their problems in an open and full mannerThe patients right to seek care elsewhere when demands are not satisfactorily met

23Doctors rolePhysicians need to work with the patient to articulate the problem and refine the requestThe physicians right to withdraw services formally from a patient if he or she feels it is impossible to satisfy the patients demand

24AdvantagesPatients can fully understand what problem they are coping with through physicians helpPhysicians can entirely know patients valueDecisions can easily be made from a mutual and collaborative relationship25DisadvantagesPhysicians do not know what certain degree should they reach in communicationIf the communication is fake, both physicians and patients do not have mutual understanding, making decision is overwhelming to a patient

26Discussion Is the patient capable of making the important therapeutic decision even though they have good communication of the physician?27DefaultWhen patient and physician expectation are at odds, or when the need for change in the relationship cannot be negotiated, the relationship may come to a dysfunction standstill.

DiscussionHow to resolve this kind of embarrassed situation?

28Doctor-patient relationship in the pastPaternalismBecause physicians in the past are people who have higher social statusdoctor is seen as a sacred occupation which saves peoples livesThe advices given by doctors are seen as paramount mandate 29Doctor-patient relationship at presentConsumerism and mutualityPatients nowadays have higher education and better economic statusThe concept of patients autonomyThe ability to question doctors30Reasons for the changeDoctors conditionPatients conditionEnvironmental factorsRelationship between patients and doctors are often unstated, and they are dynamicAs conditions change, the kind of relationship that works best for a patient may changeDoctors and patients should choose a relationship fit

HOW?31 What is Patient Empowerment?32Patient Empowerment Empowerment is a concept that has recently emerged in the health scene. It embraces the idea that everyone has the right to make their own choices about their health care because patients are the ones who experience the consequences of both having and treating their illnesses, they have the right to be the primary decision makers regarding their medical conditions 33Patient EmpowermentA key part of empowerment is that the patient, personally, must actively search out sufficient information to fully understand their health conditions and their treatment plans Although their physician should be involved in the decision-making process, the final determination of what is best for the patient is both the right and responsibility of the individual patient. 34Why Patient Empowerment?Remember the patient centered clinical methodEvaluating both the disease and the illness experience Understanding the whole personFinding common ground with the patient about the problem and its managementIncorporating prevention and health promotionEnhancing the doctor-patient relationshipBeing realistic3535Why Patient Empowerment?Only 9% of consultations with surgeons and primary care physicians meet full criteria for informed decision making. Braddock JAMA 1999Distinguishing elements of shared decision making occurred in 0-11% of audio taped patient interviews with general practitioners. Elwyn 2001.. Checking of understanding, and the involving of patients in decision making .. are rarely demonstrated [in video taped consultations submitted for MRCGP examination]. Campion BMJ 2002363637What is shared decision making?Two definitions of shared decision making:

The process of interaction of patients with their health care providers in making health care decisions

Involvement of patients with their providers in making health care decisions that are informed by the best available evidence about treatment / screening / illness management options, potential benefits, and harms, and that consider patient preferences.

38What is it?an individual being an active member of his/her disease management team 39Laura E. Santurri. Patient Empowerment: Improving the Outcomes of Chronic Diseases Through Self-Management Education. http://www.case.edu/med/epidbio/mphp439/Patient_Empowerment.htm40Shared decision making combines the measurement of patient preferences with evidence-based practice.41Why is shared decision making important? Interventions have different benefits/ risks that patients value differently There is no single right answer for everyone Ethical principle of patient autonomy and legal requirement of informed consent Evidence-based practice movement Increasing realization that an important piece of evidence is missing without the patients perspective

42Patients cannot be forced to follow a lifestyle dictated by others. Preventive medicine requires patient empowerment for it to be effective. Patients as consumers have the right to make their own choices and the ability to act on them 43Why is the concentration of power in this relationship with physician?Patient is sick, weak, vulnerable, not feeling fully oneselfPatient may be afraidPatient in a state of dependencyLack of medical knowledgeLack of knowledge on the system and how it worksUnfamiliar environment44Why is the concentration of power in this relationship with physician?EducationProfessional status/authorityKnowledgeSkillsExpertiseExperienceOn familiar territoryGATEKEEPER TO HEALTHCARE SYSTEM45Why Patient Empowerment?People whose lives are affected by a decision must be a part of the process of arriving at that decision.John Naisbitt, Megatrends46 Education supporting self care and self-managementOffering a choice of providersSharing treatment decisions47How to empower patients47Key characteristics of shared decision making (PE) in health care At least 2 participants are involved - health care provider and patient Information is shared Participants take steps to build consensus about the preferred treatment / care Agreement is reached on the decision to be implementedBenefits of Patient EmpowermentLearning from our patientsTaking a proactive roleProviding a support & information service to our patients and staffComplaint ResolutionNegotiation & MediationBuilding trust48

4849The old model vs. the newPatient says: Doctor responds (Old model) (New model) "I hate this exercise plan." "Then try walking after dinner every night with your husband for 10 minutes "What do you hate about it? What would help you do better at it?" "I don't think I can quit smoking." "Smoking is the leading cause of preventable death ..." Why do you think that? What has happened in the past when you tried to quit? What concerns you most when you think about trying to quit? I haven't been able to test my blood sugar four times a day." "It's hard at first, but just keep trying. You really need to keep track of it." "What is preventing you from doing that? Do you know what the numbers mean?" 50Some useful hintsThe skilled family physician can spend 10 minute with a patient and the patient feels it was 20 minutesEven the busiest physician can accomplish wonders in a few minutes by indicating that their full attention is on the patientPlease conclude every interview with the statement is their anything else bothering you that we have not discussed?Rather than assuming that the patient have understood the instructions, ask them to repeat as they understoodUse the patients name or ask him what he prefer to be called asUse how can I help you? Rather than what brings you here today? 515152Follow-upManagement / treatmentPresenting concernpatients storyHistory and physical examHypothesisIdentified problem or diagnosisIdentify choices Review pts preference for informationPresent evidenceRespond to pts ideas, concerns and expectations re: managementAssess partnership (review previous steps) DOCTOR - PATIENT COMMUNICATIONEstablish pts role in decision makingAgree on an action planNegotiate a decisionModel forClinical Problem Solving & ISDMStep 1Step 2Step 3Step 4Step 5Step 6Step 7Step 8*ISDM: Informed Shared Decision Making52Common problems that can lead to poor decisions: Relationships and roles are unclear Objective data are inadequate Values, interests and assumptions are unexplored Too few options have been considered Alternatives are unclear Communication is poor

53What is a "good" health care decision? Well informed, supported by the best available evidence, weighs pros and cons, compatible with patient's values and practical (Dow, 1999).

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Empowerment allows our relationships to grow in strength56Coming together is a beginning; keeping together is progress; working together is success.Henry FordFirst, they have to be informed. Specifically, they have to be given an objective, unbiased presentation of reasonable options to consider and the pros and cons of those options.

Second, once informed, patients have to spend some time to consider their goals and concerns and how each option is likely to play out with respect to those goals and concerns.

Third, they have to have an interaction with their providers in which their goals and concerns are shared and incorporated into the decision-making process.11For patients to have a meaningful say in their medical decisions, three essential conditions