1. Rels 300 / Nurs 330 1 October 2014 THE HEALTH CARE PROFESSIONAL / PATIENT RELATIONSHIP

2. Models of Illness & Medicine ALLOPATHIC MEDICINE = diseases are treated by producing effects that are different from those produced by the illness; the disease is fought HOMEOPATHIC MEDICINE = diseases are treated by inducing effects that are similar to those produced by the illness; substances that produce similar symptoms in healthy people are used 300/330 - appleby2

3. Western Medicine is Allopathic Diseases are seen as invaders or enemies of the person and his or her well-being Medical profession seeks to eliminate disease from the person Persons “have a disease” that is separate from their normal well-being Physicians treat the disease to erase its effects Patients themselves may be expected to be fairly passive in the healing process 300/330 - appleby3

4. Exploring models of the physician-patient relationship Robert Veatch (1972 article); May (1975 article); Childress & Siegler (1984 article); Emanuel & Emanuel (1992 article) Many possible models discussed, including Engineering, Informative or Consumer model Priestly, Paternalistic or Parental model Collegial or Interpretive model Contractual model Covenantal model 300/330 - appleby4

5. Collier & Haliburton’s terms: 1. Engineering model 2. Paternalistic model 3. Contractual model 4. Covenantal model 300/330 - appleby5

6. 1. The Engineering Model Physician is a medical engineer or technician Has particular training and expertise Offers medical services to patients When medical decisions must be made, the physician presents all of the relevant clinical facts and options  Patient then considers his or her own values and comes to a decision  Physician carries out the procedure 300/330 - appleby6

7. 2. The Paternalistic Model Physicians are like a parent or priest who knows what is best for another person Physicians have superior education and clinical judgement; patients have limited medical knowledge and capacity for complex understanding  Patient should not be presented with alternatives that are not in his or her best interests  Patient should be guided in making decisions by the physician who knows best 300/330 - appleby7

8. 3. The Contractual Model Physicians and patients each have responsibilities to the other that simulate a 2-party contract Both parties have obligations to share information and work together towards medical decisions  When there is agreement, a mutual decision can be reached  When there is disagreement, then either party can opt out of the therapeutic contract 300/330 - appleby8

9. 4. The Covenantal Model Physicians and patients have reciprocal and enduring relationships Physicians benefit from educational opportunities, social esteem and regard Patients benefit from the experience and medical expertise of their physicians  Mutual & reciprocal relationships have the potential for long-term benefits in promoting health and minimizing the effects of disease  Covenantal fidelity provides mutual benefits 300/330 - appleby9

10. Results for patient autonomy 1. Engineering 2. Paternalistic 3. Contractual 4. Covenantal Patient autonomy is absolute Physician value judgements are masked, not absent; patients may be vulnerable and might benefit from deeper considerations of potential values and risks Potentially harmful patient choices need to be discussed in depth; physicians should not be required to provide therapies or procedures that are requested, but likely to be harmful 300/330 - appleby10

11. Results for patient autonomy 1. Engineering 2. Paternalistic 3. Contractual 4. Covenantal Patient autonomy is disregarded Physician expertise so outweighs patient understanding that the physician will always know what is best for the patient Full disclosure of truthful information does not serve the patient’s best interests; withholding accurate information may be needed in order to persuade the patient of the doctor’s recommendation Patients are regarded as interchangeable: familiar diagnoses, prognoses and treatments work for all 300/330 - appleby11

12. Results for patient autonomy 1. Engineering 2. Paternalistic 3. Contractual 4. Covenantal Patient autonomy and physician autonomy are equally protected Patients are free to seek care elsewhere if agreement cannot be reached Disregards effects of illness and patient vulnerability Minimizes the role of compassionate caring by the health care professional Information sharing by patients, facilitated by fidelity and compassion, may be eroded 300/330 - appleby12

13. Results for patient autonomy 1. Engineering 2. Paternalistic 3. Contractual 4. Covenantal Patient autonomy is promoted in a long-term and reciprocal physician/patient relationship Both partners see the mutual benefits each owes to the other Ongoing relationships provide a richer understanding of health, illness and medical goals Both physician and patient are challenged to be the best persons they can be 300/330 - appleby13

14. What role does the patient play? 1. Engineering model – patient is seeking a medical technologist to provide a therapy 2. Paternalistic model – patient is like a dependent child seeking guidance and care 3. Contractual model – patient is a consumer of medical services who is free to enter into and break the contract for medical care 4. Covenantal model – patient is a partner working towards mutual well-being 300/330 - appleby14

15. The Nurse/Patient Relationship Historical (and largely ongoing) context of hierarchical relationships among health care providers, especially within a hospital setting Physicians generally have more power than nurses and may discharge their duties by writing orders that nurses fulfill Where it is the nurse who provides ongoing personal care for patients, the nurse does not have the authority to modify care plans independently 300/330 - appleby15

16. Physician/Nurse Relationships Affected by professionalization, licensing  Physicians comprise a group of elite medical professionals  NOT nurses; NOT midwives; NOT homeopaths Also by historical gender differentials and a cultural norm of subordination of women to men Power imbalances exist between physicians and nurses  Physicians ultimately make treatment decisions that nurses are expected to follow and carry out 300/330 - appleby16

17. Moral dimensions of nursing Ethical decision-making revolves around the physician and patient as the central dyad Physicians may consult with other members of their health care team, but if the team is not persuasive in challenging the physician’s decision, he or she has the authority to implement his or her decision patient’s loved ones The patient’s loved ones may also be consulted in reaching decisions, but the authority to implement a decision lies with the physician 300/330 - appleby17

18. Nurses as ADVOCATES Within the health care team, no one is likely to provide greater continuity of care than the nurse If the nurse is witness to patient dissatisfaction with treatment orders, or confusion or disagreement among the patient’s family, the nurse is uniquely positioned to make the decision-making process explicit Where teamwork is valued, the nurse can make valuable contributions to the ethical process by raising alternative paths & voicing the patient’s concerns 300/330 - appleby18

19. Nursing Ethics & Advocacy Care Ethics Feminist Ethics Virtue Ethics 300/330 - appleby19

20. Practise QUIZ Case Study Mrs. MacFarlane makes an appointment with her family doctor to confirm whether or not she is again pregnant. With a family of four girls already, the youngest of whom is now in school full days, Mrs. MacFarlane is unsure of her feelings about having another baby. If she could be sure that the fetus would be male, she would definitely carry through with the pregnancy; however, she really doesn’t want to have another girl. Dr. Connors confirms her patient’s pregnancy. When Mrs. MacFarlane asks about prenatal testing, she is told that ultrasounds are commonly used, but that amniocentesis is only offered for medical concerns. Mrs. MacFarlane indicates that unless she can be assured that the fetus she carries is male, she will abort the pregnancy. At the prenatal testing clinic in Halifax, says Dr. Connors, genetic counselors have established a policy which does not allow the use of amniocentesis for purposes of sex selection unless there is concern about a sex-linked genetic disorder. Mrs. MacFarlane says, “That is so unfair.” Dr. Connors recommends that Mr. and Mrs. MacFarlane request an appointment at the prenatal testing clinic to confer with the Director and their ethics consultant. What decision should they reach, and why? 300/330 - appleby20

21. 300/330 - appleby21 Instructions:  Quickly test out each moral theory to see which one(s) would be useful for each question.  Decide which moral theory you will use for each question. You must use only one moral theory for each question.  Each answer should use a different moral theory. Do NOT use the same moral theory in more than one answer.  Prepare your answers for questions #1, #2 & #3.  For question #4, use the health care principles to reach a decision.

22. Answer these Questions: 1. Imagine that you are the Director of the prenatal testing clinic. Using one moral theory, explain to the MacFarlanes why your clinic has established a policy to refuse amniocentesis for the purposes of sex selection. 2. Imagine that you are Mrs. MacFarlane. Choose one moral theory and use it to outline your argument that the policy is unfair and that the clinic should make an exception for her. 3. Imagine that you are Mr. MacFarlane. Your wife has never expressed sadness at having four girls and no boys before, but you can see how upset she is at the thought of being denied this choice. What will your contribution to the consultation be, and what moral theory will you use? 4. Finally, imagine that you are the consulting ethicist for the clinic. After hearing the moral perspectives of Mrs. MacFarlane, her husband and the Director, you will use the principles of health care ethics to facilitate further discussion and resolve this issue. What will you say? 300/330 - appleby22