The professional-patient relationship is a bond of trust between the patient and the medical professional who is performing treatment.
The relationship established between patients and health care providers is fiduciary in nature, which means that it is based on trust. In this respect it is similar to the relationships between lawyers and clients or between clergy and their congregations. The professional trusts the patient or client to disclose all the information that may be relevant to his or her condition or illness, and to be truthful while disclosing it. In return, the patient or client trusts the health care professional to maintain high standards of competence; to protect the confidentiality of private information; and to carry out his or her work in the best interests of the patient rather than taking advantage of the patient's vulnerability.
Health care professionals are obligated to act according to ethical and legal standards. Ethical guidelines refer to the moral standards that are considered to govern health care. The fundamental ethical principles underlying Western medical practice have not changed since they were first enunciated by Hippocrates (460–377 bc). These principles include:
- Honesty: The professional does not withhold necessary information from the patient or lie to the patient about the nature or seriousness of his or her condition.
- Beneficence (doing good): The professional uses his or her knowledge and skills to balance good results and potential harms, and act in the patient's best interests.
- Justice. The professional does not refuse treatment on the basis of a patient's race, religion, nationality, income, or other personal characteristic.
- Avoiding conflicts of interest. This principle means that the professional must not benefit personally from his or her professional actions or influence. For example, a physician should prescribe a particular medication because it is the best choice for the patient, not because the professional owns stock in the company that manufactures the drug.
- Pledging to do no harm. This principle means that the professional must avoid actions detrimental to the patient.
All major organizations of health care providers, including the American Hospital Association, the American Medical Association, the American Dental Association, and the American Nurses Association have formal ethical guidelines for professional-patient relationships. These ethical policy statements are based on the ancient Hippocratic oath.
In the United States and Canada, the legal obligations of health care providers are based on and presuppose the traditional ethical standards of good medical practice. These legal obligations include accepting federal and state examination and licensure standards; government regulation of medical records; court orders regarding reporting or disclosure of a patient's medical records; and a number of other obligations.
The legal obligations and liabilities of health care professionals have become increasingly complex over the last 30 years. This development is partly the result of technological advances that pose new questions to the legal system. For example, the safe operation of medical lasers depends on proper engineering and maintenance procedures as well as on the surgeon's skill and training in using the laser. A patient injured by a malfunctioning laser might decide to sue the manufacturer and the hospital administration as well as the surgeon. In addition, however, the growing complexity of health care legislation is part of a larger trend toward resolving social issues through litigation rather than through public debate or other means.
Prior to the second half of the twentieth century, the patient-physician relationship was strictly hierarchical. The physician was assumed to know what was best for the patient, and the patient was expected to follow "doctor's orders." After World War II, however, patients in the developed countries began to take a more active role in their health care. This change was related to the larger proportion of high-school students going on to college, and to the rapid spread of medical information via television and health care books written for the general public. Patients who were employed in other fields requiring specialized training, or who read widely, were less impressed by the physician's educational credentials and more likely to question his or her advice.
The social context of contemporary health care
In addition to the rise in education level among the general population in Europe and North America, several other factors have helped to reshape patient-professional relationships. The most important factors are the following:
- The loss of a social consensus regarding moral issues. At one time, health care professionals could be fairly sure that they and their patients agreed on the major moral issues that were likely to arise in health care situations. Today, however, there is widespread disagreement within the professions as well as in the general population about such questions as abortion, euthanasia, organ donation, limitations on medical research, and others. A patient who disagrees with his or her health care provider on the moral implications of a procedure is now generally allowed to refuse the procedure.
- The high-pressure education of health care professionals. Over the past thirty years, the training of physicians, nurses, dentists, pharmacists, and other health care professionals has become much more demanding. One factor is the sheer accumulation of scientific knowledge; today's medical, dental, or nursing student must master a much larger body of information than students of previous generations. Another factor is the increased tendency toward professional specialization, which makes it more difficult for health care providers to see patients as whole human beings.
- Managed care. Managed care has changed physician-patient relationships by requiring patients to choose their doctor from a list of providers approved by the managed care organization. In many instances patients have left physicians who were trusted and who had cared for them for years. In other instances managed care organizations have terminated physicians on short notice, thus disrupting continuity of patient care. Some observers have remarked that patients' attitudes toward physicians have become increasingly adversarial because they think doctors are more concerned with pleasing insurance companies than to provide good care.
- Changes in communications technology. The widespread use of computers in managed care and health insurance organizations to store databases of patient information has raised questions about preserving confidentiality. In addition, the increasing popularity of e-mail for communication between patients and professionals opens up concerns about the security and privacy of electronic files.
- Multicultural issues. Hospitals and medical or dental offices have been increasingly confronted with the complications that can arise in cross-cultural professional-patient relationships. Different ethnic and racial groups in the United States have widely varying customs and attitudes toward such matters as expressing physical pain or grief; undressing in front of a professional of the opposite sex; asking questions about their diagnosis and treatment; and other issues that arise in medical settings.
Now, at the beginning of the twenty-first century, the major emphasis of the professional-patient relationship is on the medical professional and the patient as partners making a a joint decision about the patient's treatment. Patients have requested and been given more rights concerning their medical treatment. Medical professionals should encourage patients to learn about their medical problems, weigh the benefits of different treatments, and make choices based on their own beliefs and values.
Some specific issues
Recent changes in professional-patient relationships have tended to cluster around several specific issues.
INVOLVEMENT OF FAMILY MEMBERS IN PROFESSIONAL/PATIENT RELATIONSHIPS. Although discussions of professional-patient relationships often proceed as if the relationship concerns only two people, the care provider and the patient, in many cases family members are also involved. In the cases of children and elderly patients, family members may be needed to describe the patient's symptoms or provide care at home. With regard to the elderly, different family members may have sharp disagreements about the level of health care that is necessary, which can complicate the professional's work.
CONFIDENTIALITY. The computerization of patient information, combined with the increasing involvement of federal and state governments in health care, has led some observers to ask whether present security measures are adequate. Both trends—the use of computers and the expansion of government regulation—increase the number of people who have access to patient records and private information.
In the United States and Canada, the courts generally recognize two limitations on the professional's obligation to preserve confidentiality. The first is a court order that requires the physician to deliver confidential information about a patient. The second limitation concerns situations in which a patient is endangering his or her own life or the lives of others.
SEXUAL MISCONDUCT. The most explosive issue in recent years has been the rise in the number of reported incidents of sexual harassment or abuse of patients on the part of health professionals. The two specialties that have studied the issue most carefully are psychiatry and obstetrics-gynecology. Most such incidents (about 85%) involve male professionals and female patients; another 12% involve male professionals and male patients. The remaining 3% involve female professionals.
Boundaries— The limits that define a human being's personal space. Boundaries may be physical, psychological, emotional, or spiritual.
Confidentiality— The protection and maintenance of strict privacy and secrecy in relationships between professionals and their patients or clients.
Ethics— The rules of conduct recognized as governing a particular group, as medical professionals.
Hippocratic Oath— The ethical pledge attributed to Hippocrates that is used as a standard for care by physicians worldwide.
Rapport— The relation between professional and patient, particularly one that is harmonious and empathic.
Studies of sexual misconduct on the part of professionals have reported the following findings:
- The greater degree of patient participation in medical decision-making does not do away with a basic inequality in professional-patient relationships. The patient is dependent on the professional's knowledge and authority, and the professional is obligated not to exploit that advantage.
- People who are seriously ill are emotionally vulnerable. They are less able to protect themselves against violation of their physical or psychological boundaries. Thus they cannot be regarded as "consenting" to a sexual relationship with a health care provider.
- Many adult patients were abused as children and find it difficult to protect themselves in adult life even apart from health crises. In particular, many women have been trained in childhood to be passive and compliant in the face of aggressive or exploitative behavior from men. These patients should not be accused of inviting or "asking for" sexual abuse.
- Some medical procedures appear to be fertile ground for poor communication or misunderstanding between the professional and patient.
Most medical, dental, and nursing schools in the United States and Canada now include courses in professional ethics, communication skills, and understanding of the social context of professional-patient relationships. Students are taught that mutual respect and clear communication between professionals and patients are the most effective safeguards against abuse.
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American Hospital Association. One North Franklin, Chicago, IL 60606-3421. 〈http://www.aha.org〉.
American Nurses Association. 600 Maryland Avenue, SW, Suite 100 West, Washington, DC 20024. (202) 651-7000. 〈http://www.ana.org〉.
Canadian Medical Association. 1867 Alta Vista Drive, Ottawa ON K1G 3Y6. (613) 731-8610x2307 or (888) 855-2555. Fax (613) 236-8864. [email protected]
American Academy of Pediatrics, Committee on Bioethics. Appropriate Boundaries in the Pediatrician-Family-Patient Relationship. Policy Statement, adopted August 1999.
Canadian Medical Association. The patient-physician relationship and the sexual abuse of patients. Policy summary approved by the CMA Board of Directors, June 1, 1994.