In my last column, I had discussed how the relationship between physician and patient is slowly moving from an ethereal and mystical plane to a more rational and predictable one. What this paradigm shift has done is to facilitate Medical Ethics being viewed slightly differently. In general conversation, a discussion on medical ethics is usually confined to unscrupulous practices by a section of the medical community to exhort as much financial gain as possible from the hapless patient community. Physicians rationalise this by pointing accusing fingers at the astronomically increased cost of medical education, corporate bottom-line pressures, imbalanced distribution of healthcare resources and so on. And patients' arguments centre around the ‘nobility' of the healing profession, the need to de-emphasise the profit motive, and the intrinsic potential for self-actualisation that the healing process provides the healer. While this is certainly an important debate, I believe the focus must shift from ethics being perceived only as a watchdog concept (to ensure that the physician does no ‘wrong') to one that is also concerned with defining parameters for an ethical doctor-patient relationship.
Reinventing the relationship
Of course, watch-dogging must and will continue to remain part of the ethicist's job description in order to prevent abuse, which as fallible human beings, physicians are likely to fall prey to every now and again. But laws and their enforcement alone are not enough. To ensure that unethical practices are more a breach than the norm, we need to reinvent the doctor-patient relationship itself on more ethical lines. When I use the term ‘ethical relationship', I do not do so from a moral or a preachy sort of position. As I see it, ethics exist to simplify our relationships by giving us practical and tangible anchor points around which we can build them. If properly implemented, these anchor-points ensure that we experience far fewer dilemmas than before, thereby enhancing our own quality of wellbeing. I believe that the bedrocks of the ethical doctor-patient relationship are formed by three related parameters: transparency, confidentiality, and boundary definition.
When I talk of transparency, I refer to transparency in the consultation and intervention process. This can be difficult to achieve if the physician continues to perceive his location in the doctor-patient relationship from a one-up position (the demigod syndrome). For, if one does this, one ends up talking down to the patient and not treating the latter as an equal partner in the intervention process. However, if the physician is able to make this transition, an open consultation with the patient becomes possible, where diagnoses are discussed, treatment options are evaluated and interventions are initiated. If the patient has a full understanding of what is being done, what side-effects to anticipate and how to manage these (remember, the patient already has half-knowledge of this from the Internet), treatment compliance as well as outcome tends to be better.
Allied to the concept of transparency is the issue of confidentiality. The relationship between body, mind and the sense of self is unique to each individual and is frankly, the individual's own business and no concern of anybody else, even those who are considered ‘loved' ones. Since the doctor-patient relationship is a consultative one, the primary line of confidentiality that the doctor has is with the patient and no one else. However, if the patient permits or indeed so desires, expanding the line of confidentiality to include designated others is perfectly acceptable. When a patient realises that the doctor is serious about keeping personal information confidential, even if the information is not particularly damaging, it engenders a feeling of trust in the doctor and immediately creates an excellent platform for healing to begin.
Defining limits
Transparency creates emotional comfort and confidentiality engenders trust, but nothing creates more respect in the mind of the patient than when the physician has a definitive awareness of his own limitations and limits, thereby strengthening the possibility of defining boundaries in the relationship. Learning how to say ‘I don't know', referring a patient to a senior associate for a second opinion, limiting the consulting hours to physically manageable proportions, determining the level of telephonic accessibility to be provided to patients, clarifying how emotionally close one gets to a patient etc, are issues that require conscious attention and discussion. An important aspect of defining boundaries is the consultation fee, for, this ensures that the relationship remains on a consultative platform. I have found that often fees are charged on the basis of perceived affordability of the patient. While this may be an apparently egalitarian approach to the issue, it immediately creates a potentially discordant class division in the patient population (“Will those who pay more get better care?”). Application of mind to defining the fee structure has the added advantage of ensuring that the physician need not supplement his income by resorting to dodgy alternatives.
Ethical doctor-patient relationships create a win-win situation for both sides of the equation. And achieving these are not as difficult as one would imagine. Creating trust, respect and emotional comfort should be an important focus of the physician's responsibility and this, I believe, goes a long way towards enhancing the quality of health care services. Then, medical professionals need no longer be considered hypocrites and the good Hippocrates need no longer watch over them.
Email the writer at vijay.nagaswami@gmail.com.
