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MEDICAL ETHICS--THERE ARE NO DILEMMAS
The clinician is always right to enhance the autonomy of the patient.

An acceptable standard for the clinical relationship is that an autonomous patient makes his own decisions in consultation with a clinician who offers loyalty, objectivity and understanding.  This simple model is seemingly perverted when any of the factors seems deficient:  the patient's  autonomy, the  patient's action, the clinician's loyalty, et cetera.

It seems to some this model doesn't fit acknowledged difficult cases (the comatose patient, limited resources, involvement of family rights and obligations, et cetera), but it does fit, and to use it consistently will help us to see patient autonomy where it has not seemed apparent.  There are central and substantive reasons to give up the "tin-god" model of the clinician, that somehow the clinician should untie ethical Gordian knots.  I say let’s just stop nervously creating such pretzels.

I am overwhelmed and astounded at the kinds of questions which are treated as medical ethical dilemmas.  There is only one question, after all, which is, "Does it make any sense?"  The key to the confusion currently reveled in by doctors, patients and clergymen is also simple:  They subscribe to the outmoded thesis that the doctor is God.  (Chutzpah!)

A physician is only a person who properly does certain things (which I will detail), and the supposedly difficult ethical questions are, in fact, in the hands of God.  (If you happen to be allergic to the G-word, which I use in its generic sense, then use any idea you wish.  The main thing is to know it ain’t in your own hands.  Now aren’t you relieved?)

The cliché is that the tin-god doctor tells the patient he has only six weeks to live...and he survives seven!  What doctors say was meant only to be a good guess about what seems to be happening,  not  a death-sentence.  Patients seem too ready to respond to what a doctor says with the acquiescence,  "You're the doctor."  All the doctor ever meant was, "It seems this is so..."

A doctor is merely a consultant.  He gathers and integrates data, and makes  likely and risky projections--he says what is likely, and he says what unlikely but dire  events may occur in a person's life.  It is for that person to decide what to do about it.  It is his own life.

I am surprised at the apparent complexity of medical ethics as written and discussed, compared with the usual simplicity of successful clinical behavior as seen from this experienced clinician's perspective.  I really enjoy big words, but polysyllabic approaches to how to act right are usually misleading—“beneficence”, “non-maleficence”, and a whole rainbow of “deontologies”.  I have come to feel confidently that if I behave toward each patient in certain ways, I will not be sued (and I have not been sued).  I believe what I do as a clinician can be outlined.  I believe I see other clinicians using the same principles.  I believe seemingly complex ethical questions can be radically simplified.

We glibly refer to the autonomy of the patient as if we doctors had granted the patient the right to make choices, and could again withdraw it.  Without humility we face the psychologic, biologic and eschatalogic truths as if we had granted them existence.

I am a clinician, I am  here by the bedside when you are down.  You ask me what you may expect, what you might do.  I have come to know you, how you are who you are (not someone else).  When you ask me what you may expect, what you should do, I tell you what seems so,  having thought of things you did not anticipate, having thought with you for your sake, and for no one else's.  You can count on my loyalty.

What you will do I will help you do.  You can be so dramatic as to allow your insides be opened, subject yourself to electronic regulation, radiation, poisons, other powerful and painful agencies--but if you have chosen to use them for some plausible reason or no plausible reason and you are the one who bears the risk, I will not obstruct you, and I will likely help you.  I will advise you as to what makes sense with regard to the health of your whole self, what is likely to help, what is likely to be harmful.

I simplistically identify the patient as an autonomous person who is pursuing his own health and welfare (even if his interest is represented by another person, parent, child, medical decision-maker).  I simplistically identify the clinician as the patient's consultant who relates to the patient  with  loyalty,  objectivity and understanding.

I identify all seeming medical ethical dilemmas as situations in which the simplistic definitions  of patient and clinician seem to be in some way deficient, and I look to resolve each dilemma by finding the simple elements present in an unexpected or previously unidentified form.

I give you a list, not at all exhaustive, of types of apparent deficiencies which characterize many kinds of clinical ethical dilemmas, and propose that there is always a proper course of behavior for the clinician to follow.

In each case, the clinician's ethical behavior is clear, but there is no definition of  what the patient should do.  This is a direct result of the simple assumption that it is the patient who chooses and acts (and delegates), that the clinician merely sees, formulates and recommends (and does as the patient chooses).

The most general confusion I see in the discussion of medical ethics comes from a single error which is shared all the time by most of us  (patients and clinicians) and sometimes by each of us.  Our error is that we perceive the clinician as we wish him, as a "tin-god."

It is the autonomy and self-interest of the patient which is essential to ethical clinical relationship.  If the clinician merely acknowledges this it will be much easier for him to follow a primary Hippocratic aphorism, "to help, or at least to do no harm" (wfelein h mh blaptein ”ofelayn hay may blaptayn”)1.  But the clinician’s main task is not merely to do no harm (even though that might be an improvement over some current clinical behaviors).

The realities of clinical relationship easily are obscured by some current deeply ingrained shared cultural prejudices, but they also always must be obscured by the nature of being a patient.  It is essential to the ethical relationship that the patient be seen as autonomous, but it is usual in being a patient to be blind and irrational to a great degree.  So a patient (even if he is I), will not accurately perceive his autonomy, not only because the power of choosing has been jealously withheld by the medical guild (a mere superficial historic fact), but the patient cannot easily experience his autonomy since to become a patient he must be frightened and in need of help  (dependent).  A frightened and dependent person does not seem autonomous.

The clinician, because his training and experience relieve him of the necessity of being terrified,  can perceive the clinical  relationship for what it is, and it is exactly in this ability to see what the patient cannot see that he finds  his  singular  responsibility and the key to his participation in his patient's life.  The clinician is first of all responsible ethically to help the patient to become autonomous.

The characteristics I have named for the clinician--loyalty, objectivity and understanding--follow  simply  from  the clinician's basic ethical responsibility to lead the patient from his frightened, irrational, dependent state to a state of autonomy.  Loyalty to the patient enhances the patient's self-interest (and implies acceptance of the patient as a person).  Objectivity balances the patient's subjectivity, his willingness to deny illness as if denial would lessen his pain or loss.  Understanding means especially understanding the experience of being a patient, but also implies the technical   understanding   (knowledge) which is called expertise.

Each of the characteristics of the clinician in the clinical relationship implies honesty and openness.  In being loyal, objective and understanding the clinician  will  give  high  priority  to informing the patient of what seems to be so, but the choosing of idioms can be tricky, and can be done well only with careful attention to each patient at all times.

Here  are  some  general  practical safeguards for the clinician to care not to distort the truth:

1.  There is no need to confuse the patient with non-pertinent, pseudo-information.  The truth is in the meaning, not in the meaningless details.  To share with the patient observations of the clinical process is always pertinent (e.g., interpreting fears, identifying clear risks, identifying  diagnostic procedures, et cetera).  It is usually appropriate to share lines of thinking with the patient, even where confirmation of facts is not complete, always in accord with the patient's capacity to think and understand (i.e., in the patient's language and in response to the patient's questions, explicit or implied).  It is not appropriate to share the clinician's feelings with the  patient merely for  the clinician's sake, especially fears and frustrations.  The patient's own fears and frustrations (and hopes) are very important, should be identified and acknowledged (but not always analyzed).

2.  If the truth is intolerable, the patient's internal defenses will guard against its destructive potential.  These defenses can be identified and reinforced by the clinician.  There is no need to withhold pertinent information; if the patient can't stand it he will repress it, and both clinician and patient will come to learn more.

3.  If something is important the patient will say so repeatedly and in many ways.  As long as the clinician erects no barrier to understanding (out of fear, as if it were himself subject to pain and disease, for example, or out of selfishness or callousness not wishing to waste time on this patient)), important facts and questions will surface.  The patient cannot be dishonest even if he wishes to, as long as the clinician is looking for information at all levels, in all dimensions, for the experienced clinician can see beyond the lie.

To summarize what are practical realities to me, but may seem abstract dicta to you:  The ethical goal is the autonomy of the patient, and the process for achieving it lies mainly in the clinician's leading the patient to understanding what's what, in a manner characterized by open-minded calm observation and full and honest communication.

OUTLINE OF CLINICAL ETHICAL "DILEMMAS"
(not comprehensive--for stimulation of questions only)

I. Patient's autonomy deficient
A.  Always true because of fear, irrationality*, dependence and denial
B.  When there is incompetence to make decisions
 1.  Minors
 2.  Mentally  or  psychologically disturbed
 3.  Comatose
C.  When third parties intervene
 1.  Children accompanied by parents
 2.  Spouses
 3.  Parents accompanied by children
 4.  Prisoners
 5.  Insurers
 6.  Regulatory agencies (e.g., the state health department discussed in the chapter “Bureaucracy is Ubiquitous”)
D.  When resources limit choice
 1.  The poor
 2.  Dialysis and other "high-tech" treatment (cf, II.E.)
E. When the clinician must usurp autonomy (i.e., emergencies--very rare)

II.  Patient's self-interest deficient
A.  The patient declines care
B.  The patient is contrary in care (the myth of "non-compliance")
C.  The patient is suicidal
D.  The patient has ulterior motives (e.g., to get drugs)
E.  The patient has badly distorted expectations

III.  The clinical relationship is deficient
A.  Quantitative
 1.  No one in the clinician role
 2.  No one in the patient role
 3.  Too many clinicians (disharmony of opinion or communication)
 4. Too many patients (too little time, conflict with family,et c.)
B.  Qualitative
 1.  Dependency cannot be overcome (e.g. Quinlan)
 2.  Death threatens to end relationship
 3 . Ideas and feelings not shared (no communicative interaction)

IV.  The clinician is deficient
A.  In loyalty (e.g., greater loyalty to family than to patient)
B.  In objectivity (e.g., "overidentifies" with patient)
C. In understanding (e.g. incompetent)
D.  In honesty (e.g., withholds information)

V. The setting  (cultural, economic or institutional) is deficient
A. Ignores the clinical relationship (e.g., fragmentation)
B.  Assumes autonomy where there is dependence (e.g. "consumerism")
C.  Opposes the clinical relationship (e.g., "mills")
D.  Holds non-clinical values higher (e.g., bureaucratic stability or the commercial interests of the institution)
E.  There is scarcity of resources (as in I, D)

* By “irrationality" I mean nothing pejorative, only that the patient's perspective cannot (and should not) be strictly logical or "objective."

EXAMPLES OF SUCH CLINICAL ETHICAL “DILEMMAS”
and a bit of commentary about them

I.  When the Patient's Autonomy Seems Deficient

A.  At the beginning of any clinical encounter or series of encounters the patient is subject to some deficit of autonomy.  He is in need of some help; if he were not in need he would not come.  He is unable to completely help himself, or he would.  In meeting a new clinician or presenting a new situation to a known and even trusted clinician the patient must initially be involved in evaluating the clinician as well as in formulating his problems.  He may suppress much of his internal mental and emotional processes about his dependency, but they will be rapidly progressing, in chaotic ferment, or (if the clinician is receptive and responsive) take a calmer and more constructive direction.  Because each patient must, at least initially, be preoccupied by various tasks of his own (much of which will be unconscious), and because he must depend on someone else to understand, judge and even act, I say each patient is to a significant degree afraid, irrational, dependent, and (despite his acknowledgement of  need) ambivalent and subject to much denial of fact.2

B.  When the patient seems unable to make reliable decisions clinicians sometimes unthinkingly  alter their behaviors toward them, lapsing in respect, communication or confidentiality, discounting the patient’s ability to understand or to make and express decisions.  In keeping with the idiom of absolutes I have come to, I say there is never a situation in which the patient cannot be addressed directly.  If the patient is an infant he may respond to the attitude and tone with which he is approached.  If the patient is a child his understanding and the coherence of his emotional responses will always be greater than we are tempted to assume.  If the patient seems divorced from reality, mad, uncommunicative, unreceptive, we may find dialogue difficult, but we know the apparent barriers are incomplete, and until some confirmation is received from the patient we can take the data of the situation as complex and serious messages from the patient.

2.  A patient in a drug treatment program suffers severe high blood pressure, seizures of  increasing frequency and uncontrolled and erratic intoxications.  After several attempts to get him to appear in neurology clinic, with the expectation he will be admitted to the hospital, he calls me to announce he will keep his appointment this day.  On coming to the hospital I find him crawling across the parking  lot (for he cannot stand or walk), slowly making his way toward the busy intersection.
"I thought you were going to see Doctor Jones."
"I did.  Now I am going to work."
"You won't make it.  Come into the hospital with me."
(Beaten by his own symptoms) "Okay."

3.  A patient is comatose.  The clinician immediately proceeds to assess breathing, heartbeat, blood pressure, respiration, skin color and temperature, papillary responses, wounds, movement,  et cetera, then quantifies blood sugar level, blood alcohol level, sodium, hematocrit, et cetera...The patient has somehow become comatose and has somehow presented to the clinician.  It is as if he had said dramatically, "Look, Doc, I am unconscious and threatened with death.  Help me!"

C.  Often third parties intervene in the  clinician-patient relationship.  The simplest  practical rule is to treat third parties as extensions of the patient, or if there is no valid relationship or  responsibility between that third party and the patient, politely to exclude them.  We retain a two-person model of the clinical relationship.

1.  A child is being treated by a nurse practitioner, her parents present in the examining room.  The nurse practitioner, who used to speak more directly to the mother, kindly and simply reviews his findings and recommendations with the child.  The parents are doubly gratified:  that their child is not severely ill, and that the  nurse practitioner relates to her so well.  Also, they have received the interpretation thoroughly, perhaps more emotionally and intellectually well than if the nurse practitioner had addressed them directly in more technical language.

Those parents certainly have a valid relationship to the child-patient.  They have real responsibility for the outcome, real data for the clinician to make use of, so they belong there.  By addressing the child (at this age, having known her before) the clinician more successfully includes the parents, as if they were aspects of the patient.  (Family practitioners  know this  well:  the family of persons, rather than the naked individual, is their “unit" in the clinical relationship.)  If the patient were less receptive or responsive, however, or an infant rather than an older child, to address the child might serve to exclude the parents.

2. The wife of a 45-year old man is a nurse.  She complains to a doctor-colleague that her husband is sick and won't admit it, is too "macho".  The doctor calls the husband, bluntly says, "She's putting pressure on me, too.  It sounds like you're scared to be sick, to miss work and all, but I'll bet you’re as afraid of her as you are of doctors.  You can feel exactly what is wrong.  Let me help you make sense of it."

3.  A medical student reports and discusses in detail at a conference the following occurrence:  A baby is  seen who is generally well.  Later an older sibling is seen with respiratory symptoms.  It is observed at these two encounters that their mother seems harried and depressed.  She expresses a desire for permanent sterilization, and would prefer her husband have a vasectomy.  She makes a subsequent appointment for him, and he comes on schedule, but with another woman.  He does not mention vasectomy, but indirectly expresses concern about his long hours of work managing a bar and restaurant, his dependence on cocaine and alcohol.  The other woman is present in the interview.  It is agreed in the conference afterwards that the behaviors of these five persons seen in three appointments reflect some complex relationships, and that the status of the other woman might well have been more actively inquired into by the Family Practice resident.

5.  A patient has had measures of mild elevation of blood pressure which may represent no significant pathology.  An inquiry comes from an insurance company.  The clinician calls the patient to ascertain whether the patient is making a claim or applying for new insurance, and to confirm that the patient wants information to be forwarded.  The relationship of the patient to the third party must be checked with the patient.  The clinician cannot properly answer questions unless he knows their meanings.  Who is asking?  What is the question?  Then the proper response can be  formulated without distorting the truth or abrupting confidentiality.

D.  It is difficult to dissolve away the ethical dilemmas presented by limitation of resources.  They cannot well be resolved within the clinical relationship, but require resolution at the level of public policy, where the clinician has little input and the patient little visibility.  But at least limitations of resources need not be complicated further by clinical misbehavior.  Once a clinical relationship has been established there is never a necessity that the clinician to terminate it; and  limitation of resources is only relative, not absolute.  At least the patient can get some attention of a proper sort, a valid orientation to the nature of the problem and the nature of resources which may be available to help some, or at least proper referral for further care.  It is when time and space are too limited to allow access to a clinician, or when bureaucratic barriers have been erected (purposely or inadvertently) that the clinical work cannot take place at all.

1. A man is covered for health care at a health maintenance organization through his employment as a security guard.  He suffers increasingly frequent attacks of dizziness because of inner ear  dysfunction called Meniere's Disease.  The otorhinolaryngologist at the H.M.O. is ready to operate, but the man loses his job because he cannot perform it, thereby losing his coverage, thereby losing his clinical relationship and his opportunity for treatment.

Limitation of technical resources (e.g., dialysis machines, expensive drugs) does not prohibit clinical processes, no matter how desirable they may be.  Persons as patients need human resources much more often and intensely than they need technical resources (which may be powerful curses as well as powerful blessings).  As long as we are neither omnipotent as clinicians nor immortal as patients, our batting average at keeping people alive will eventually be zero.  What counts most is the quality of what we do in the meantime.

2.  One of Bruton's first three cases of agammaglobulinemia (severe immune deficiency) was expected to perish of infection by his third year.  At age twenty-nine he had been admitted to a respiratory intensive care unit with another in an innumerable series of pneumonias, this one precipitated by his anti-war demonstration barefoot in the snow.  He had little lung capacity and his bacterial colony were highly  resistant  to  antibiotics.  Realizing he would likely not recover, he pulled out the plug of his respirator several times, activating an alarm so that the staff would simply plug it in again.  My interpretation to him was that when he sought admission to the hospital he had obligated us to treat him, and that discontinuing the respirator was not compatible with that treatment.  He borrowed from me a copy of Hermann Hesse's Siddartha.  He and his mother had struggled through more than a quarter century of hearing doctors say he could not live, neither one of them shedding a tear.  They had learned to disbelieve he could die,  but this time it seemed he could not survive, his lungs severely dysfunctional and his germs ineradicable.  A further alarm for the staff was that the balloon which held the respirator tube in his neck had eroded within a millimeter of his carotid artery.  We predicted he would suddenly  and dramatically exsanguinate, die in a gush of blood.  I shared this likelihood with his mother and with the two of them, which they used to complete their laying aside of denial.   They cried,  as  if to  say goodbye.  He neither bled to death, nor  did  he  again  disconnect  the respirator, but died quietly during the night, the machine stubbornly continuing to ventilate his benignly smiling corpse.

D.  It is the discrepancy between expectations and reality which defines limitation of resources:  the clinician offers too little if the patient expects too much; the clinician and the patient are deprived if they cannot get for the patient what someone else seems to have; where expectations are generally untrue there is limitation of resources, by acculturation (e.g., expectation of third-party payment because it has become a standard, but too expensive to serve its purpose) or political action (e.g., promotion of neighborhood health programs which are subsequently abruptly defunded).

When the patient's expectations are a bit closer to the realm of his own control and understanding the clinical processes are less likely to be abrupted, even where disease, disability and death are not vanquished:
     "I understand my kidneys are  irreversibly damaged; so, as difficult as it may be to do, I must restrict fluids or live less well      and long."
     "Yes, I'll talk to the nurse instead of the doctor…but are you sure she will discuss it with my doctor?"
     "It takes all day, but at least my baby gets seen."

E.  Emergency staffs see emergencies because they are funneled to them.  They see more non-emergencies than emergencies.  In other clinical settings we see few emergencies.  But the patient usually sees his own condition as an emergency.  Rarely is there such an emergency that the clinician should act before communicating and cogitating.  Even in the emergency room, progress is made usually when calm has been established and the patient has been integrated actively into processes of evaluation and decision-making.

II.  When the patient's  Self-Interest Seems Deficient

A.  When a patient declines care it is likely to be because his denial of disease is too strong, that it overpowers the pressure of the pain or disease to force him into the patient role.  When the patient has presented to a clinician "declining care" he has not declined care but is testing to see if his needs can be met.  When a third party has presented the patient's problem in some form, likewise the patient has indirectly expressed his desire to have diagnostic and therapeutic care. The patient has made his approach, no matter how indirectly, and the clinician is obligated to continue the difficult communication carefully and purposefully, avoiding pitfalls and dead-ends, to reach a good result for the patient's sake.

B.   When a patient is contrary in care, not following the recommendation of the clinician, the patient is said to be “noncompliant".  "Noncompliance” is a myth.  It is not a refusal to comply with clinical recommendations, but a sign that there are major discrepancies between the recommendations as they have been presented and the patient's real situation and needs.  Again it is the clinician's responsibility to clarify such discrepancies.

C.  When a patient is suicidal, which he may sincerely and seriously be, and confronts the clinician with life still in him, he is asking the clinician to do what is possible to preserve his  life.  Similarly, when a patient is not recuperating, and his condition is threatening to do him in, it is for the clinician to find the discrepancy between the patient's having presented for care and his apparent lack of motivation or ability to recuperate.  Each of us will die, and some quite purposely, but before our exits there may be important acts of human living to be performed which a clinician may be able to facilitate.

D.  Sometimes a patient approaches a clinician with ulterior motives, especially to get drugs or documents.  The clinician, understanding the true nature of a valid clinical relationship, can open up for the patient scrutiny of better purposes in the clinical encounter without  imposing on the patient procedures or areas of inquiry for which the patient is not prepared.  The clinician is not obligated to provide drugs or authoritative medical statements which are not true, but the clinician does not have to reject the patient out of hand because of the shallowness of  his presenting purpose.

E.  Sometimes patients' expectations are beyond reality.  Again, the clinician need not reject the patient, but may engage the patient in a process of reassessment of purposes which may lead the patient to satisfactory compromise with reality (e.g., "I don't care what you have to do, Doctor, I'm ready for surgery," when surgery may not at all be the proper treatment for the patient’s condition).

III.   When the Clinical Relationship is Deficient

A.  There is no clinical relationship when there is no clinician or when there is no patient;  nor can a patient be his own clinician, a clinician his own patient.  There may be too many clinicians, that is there may be too many opinions or too many idioms so that the patient is confused and cannot make important decisions in his own care.  In such cases the  communication can be clarified by identifying a primary clinician, or having a team of clinicians present a single communication.  There may be too many patients, as in several of the cases in I.C, where other parties intervene in the clinician-patient relationship,  or in I.D, where resources are too little or time too short.

B.  The clinical relationship may be deficient in quality.  If dependency persists because of pathology or less than ideal progress in recuperation, the clinical relationship may not be allowed to progress to successful "cure “.  This is the case when no progress toward health, perhaps not even physiologic stabilitycan be established (as when a patient is irreversibly comatose on artificial life supports).

The quality of the clinical relationship is threatened when death is imminent, but the clinician who recognizes his own and his patient's mortality may be able gracefully to continue with the patient to the end, and with the patient's family through the process of mourning, on into subsequent living.  As my granddaughter has taught me, “Nor time, nor space, nor even death can separate those who share affinity.”

IV.  When the Clinician is Deficient

A.  A clinician may be deficient in loyalty by paying attention to parties other than  the patient.  If the clinician attends too carefully to other family members, to public agencies, to hospital administrations, et cetera, he may lose contact with the patient's real interests.  It is always justified to maintain conscious priority of loyalty to the patient himself.  The clinician may be more loyal to himself than the patient, "antisocial."  (See "The Myth of the Marketplace.")

B.  A clinician may be deficient in objectivity, especially by over-identifying with the patient and having difficulty managing his own fears, as if he were himself afflicted.  Sensitivity to patients can only be maintained by conscious and careful emotional separation from the patient.  (See "The Accomplished Clinician/The Accomplished Patient.")

C.  The clinician can be deficient in understanding, especially when the entire profession is deficient in understanding a process of disease or a successful approach to reversing that process.  When new knowledge allows us to deal more successfully with a condition, it points out to us the  deficiency which we had previously suffered.  The clinician may be deficient in understanding clinical phenomena, what I call "clinical science," which this book and courses in ethics, patient contact and behavioral science are meant to correct.

D.  A clinician can be deficient in honesty, especially by withholding information which the patient needs to use.  The result of even inadvertent dishonesty by mere omission reduces the ability of the patient to participate in his own care and abrupts the basic principle of autonomy in the clinical relationship. 

V.  When the Cultural, Economic or Institutional Setting is Deficient

These are our deepest problems because they are out of the control of either clinician or patient.  We are in the midst of cultural, economic, political and institutional chaos in health care which will not soon be reversed in our society as a whole.  Health care reform is just as inevitable for our culture and economy as quitting smoking is for the nicotine addict:  either to go through the agonizing withdrawal energetically now, or quit by default by dying in the near future.  We have not yet perceived how dark it will become before we seek a dawn.  (For an outline of some of the factors of our past and future suffering and for some detailed background and analysis, see "The Myth of the Marketplace” and the chapter on health care reform.)

So we see the clinician's task is very simple:  to attend the patient with unflagging objectivity,  understanding, and honesty, constantly reassessing the clinical process to identify discrepancies and repair deficiencies, each successful step leading to identification of new needs.  The result is the enhancement of the patient's ability to care for himself, i.e., his autonomy.  Each of us is mortal, and cannot succeed in the wish to avoid disease and death, but each of us can make many powerful and important choices in his own life, sometimes with the help of a skillful clinician.

The clinician’s task is indeed simple:  to serve the patient by promoting the patient’s own purposes and the patient’s autonomous strength to fulfill those purposes.  The patient’s task is not so simple, perhaps:  to live his own life in his own skin in his own real world.

***

OUTLINE OF CLINICAL ETHICAL "DILEMMAS"
(not comprehensive--for stimulation of questions only)

I. Patient's autonomy deficient
A.  Always true because of fear, irrationality*, dependence and denial
B.  When there is incompetence to make decisions
 1.  Minors
 2.  Mentally  or  psychologically disturbed
 3.  Comatose
C.  When third parties intervene
 1.  Children accompanied by parents
 2.  Spouses
 3.  Parents accompanied by children
 4.  Prisoners
 5.  Insurers
 6.  Regulatory agencies (e.g., the state health department discussed in the chapter “Bureaucracy is Ubiquitous”)
D.  When resources limit choice
 1.  The poor
 2.  Dialysis and other "high-tech" treatment (cf, II.E.)
E. When the clinician must usurp autonomy (i.e., emergencies--very rare)

II.  Patient's self-interest deficient
A.  The patient declines care
B.  The patient is contrary in care (the myth of "non-compliance")
C.  The patient is suicidal
D.  The patient has ulterior motives (e.g., to get drugs)
E.  The patient has badly distorted expectations

III.  The clinical relationship is deficient
A.  Quantitative
 1.  No one in the clinician role
 2.  No one in the patient role
 3.  Too many clinicians (disharmony of opinion or communication)
 4. Too many patients (too little time, conflict with family,et c.)
B.  Qualitative
 1.  Dependency cannot be overcome (e.g. Quinlan)
 2.  Death threatens to end relationship
 3 . Ideas and feelings not shared (no communicative interaction)

IV.  The clinician is deficient
A.  In loyalty (e.g., greater loyalty to family than to patient)
B.  In objectivity (e.g., "overidentifies" with patient)
C. In understanding (e.g. incompetent)
D.  In honesty (e.g., withholds information)

V. The setting  (cultural, economic or institutional) is deficient
A. Ignores the clinical relationship (e.g., fragmentation)
B.  Assumes autonomy where there is dependence (e.g. "consumerism")
C.  Opposes the clinical relationship (e.g., "mills")
D.  Holds non-clinical values higher (e.g., bureaucratic stability or the commercial interests of the institution)
E.  There is scarcity of resources (as in I, D)

 

___________________________________________________

1 Hippocrates, translated by W. H Jones, Loeb Classical Library, Vol. 1, p. 165, Harvard/Heinemman, 1972.

2 David E. Reiser, in Patient Interviewing:  The Human Dimension (Williams and Wilkins, 1980) emphasizes the ambivalence of the patient.  I have chosen a more extreme characterization in the hope it will more vividly bring to awareness the profound denial patients tend to experience.  Where he says “ambivalent” I say “terrified”.

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