The Good Patient: Responsibilities and Obligations of the Patient-physician Relationship
A Brief History: The Medical Relationship in Focus
The scope, nature and tenor of the interaction of physician and patient have been the source of considerable conjecture since antiquity. Prescriptions and proscriptions of the Hippocratic Oath and Corpus defined particular parameters of physicians and patients in relation,1 and consideration of the medical relationship has been an element of almost all major accounts of medical practice from the middle ages through the twentieth century, as evidenced in the work of Galen, Percival, Holmes, Rush, and Osler.2 In fact, one of the treatises for which William Osler was best known—“Aequanimitas, with Other Addresses”—was essentially a discourse on the responsibilities, obligations and conduct of physicians toward their patients.3 Without doubt, the nature of the physician-patient relationship has been one of the more provocative issues of contemporary bioethics. A number of convergent factors have contributed to an increased awareness of the medical relationship over the past sixty years. To be sure, the elucidation of Nazi atrocities conducted under the aegis of “medicine” was catalytic, but so too were the ethical iniquities of Tuskegee and Willowbrook.4 The progressive growth of the civil rights movement in the 1960s, coupled to reactions against an increasingly impersonal, third party-regulated medical system enthused a strongly libertarian posture that expressed wariness of, if not explicit challenge to paternalistic medical practice.5
It cannot be denied that the obligations and responsibilities of physicians to patients has become and remains a prominent focus of medical philosophy, ethics and law; and rightly so given that the physician-patient relationship is characterized by inherent asymmetries of knowledge, ability, and power. As Laurence McCullough has astutely noted, describing the clinical encounter in order of the physician-patient relationship is semantically important to articulate the burden of responsibility borne by the physician in light of 1) her intellectual and practical skills and abilities, 2) the public offering of these skills in the service of any and all who need them, and 3) the fact that patients are forced to seek these skills by their predicament of disease, injury, or illness, and must place their trust in the physician to act in their best interest.6
The Patient-physician Relationship
Undeniably, this reflects the realities of the practice of medicine. But if we regard that practice as an exchange of good between agents in relationship,7 then how can we assume that the patient does not have responsibilities? While the medical relationship is most assuredly asymmetrical, these imbalances are not wholly unilateral, and I argue that it is this relative distribution of inequalities that define the responsibilities—if not obligations—of the patient as well as the physician. Furthermore, I argue that like the physician, the patient has responsibility as both a moral person, and a participant in a relationship that is focused upon the patient’s own benefit. It is this last point that I maintain to be particularly important; although sickness and suffering are usually not discretionary,8 the act of becoming and/or remaining a patient can be. In other words, in most cases, rational and competent persons can, in fact, choose not to be treated9 or, less conspicuously, can choose not to actively participate in (and thereby may passively reject) the care provided to them by physicians.
It is in this light that I believe we must examine the patient-physician relationship with regard to the potential roles that patients can, and perhaps should play in ensuring the authenticity of medicine as a practice. More simply put: for the good of the practice to be obtained, both physician and patient must uphold particular responsibilities and obligations; in many ways. These are reciprocal and mutually sustain the ends of right and good care. But what are these responsibilities and what realistic expectations can we maintain that patients will be able to uphold them?
While the knowledge, skills, and power of the physician are obvious; it is equally important to view these dimensions of the patient as I opine that much of the physician’s power is enabled by the responsible participation of the patient. While the physician possesses considerable expert knowledge of the objective facts of disease(s), treatments, and prognostic possibilities, these are little more than esoteric information unless and until they are focused upon the unique contexts of a given patient.10 But the intersection of the physician’s expert capabilities (and perhaps their beneficence) and the patient’s needs relies upon the patient’s permission.11,12 Such permission is expressed in a number of ways.
First is that which arises from the patient truthfully representing their needs and condition. This “allows” the physician to engage in the first steps of the act of medicine, namely, the determination of what is wrong and how to help. A patient’s failure of truthful representation “disallows” the physician’s expert knowledge to be used appropriately, misleads the physician, and is subversive (to the ends of a right and good healing).
Second is permission representative of trust. In the most literal sense, this is the basis and provision of informed consent; but here too, such consent must be a truthful representation that 1) the patient has faith in the physician’s (professed) abilities, 2) that the patient will participate and cooperate with the treatments provided, and/or 3) if such treatments become unacceptable, the patient will inform the physician of the decision to refuse or comply with such interventions. In this way, the patient empowers the physician to enact appropriate care.
Michael Meyer claims that it is the medical relationship itself– with it’s centeredness upon the patient—that constructs these “rules” and obligations.13 In this way, just as we have described how certain professional obligations are mandated by the rules (i.e. - the deontic frameworks) that establish the structure of medical practice,14 according to Meyer, so too are the obligations of the patient. Howard Brody has taken a broader view of these duties that is more of a Kantian account.15 Brody describes patients’ relative duties not only to physicians and health care professionals, but to others in general, and to society, as well. These duties are grounded, at least in part, upon a responsibility to oneself as a moral person who must 1) justify her actions to herself, and 2) respect and regard others as equally worthy of moral consideration. While these extra-medical duties are important, a complete discussion of their merits, limitations, and implications is beyond the scope of this essay, and so I will restrict my discussion to only those responsibilities and obligations that are critical to the reciprocity of patient and physician in relationship.