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Consultation instead of prescription—a model for the structure of the doctor–patient relationship

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Poiesis & Praxis

Abstract.

Against the usual paternalism, this article develops the proposition to structure the interaction between the doctor and the patient as an inter-subjective consultation. This means that the "information" of the patient prior to treatment, when "informed consent" is secured, as well as the actual medical treatment would have to be turned into an interaction between two responsible individuals. The "irresponsibility" of this patient, which is supposed to result from his "uninformedness", as is often argued in favour of keeping to paternalism, does not have to lead to an interaction model of prescription and compliance. Even for the interaction with patients who are unable to understand or consent, the concept of dialogical interaction must be maintained counterfactually; it has only to be supplemented by the variant of "tutorial action". The prescriptive model of behaviour is extended by the obligation—even when the doctor is the sole decision maker—of acting in the well-understood self-interest of the patient and, if necessary, of providing evidence for this orientation of the treatment. Thus, the model of dialogical interaction is shown to be the comprehensive model, because it covers the interests of the doctor and of the patient.

Zusammenfassung.

Gegen den gängigen Paternalismus entwickelt der Aufsatz den Vorschlag, die Interaktion zwischen Arzt und Patient in Form einer intersubjektiven Beratung zu strukturieren. Das bedeutet, dass sowohl die der Behandlung vorangehende "Information" des Patienten, die Einholung des "informed consent" als auch die ärztliche Behandlung im engeren Sinne als Interaktion zweier mündiger Individuen zu gestalten ist. Die als Argument für die Beibehaltung des Paternalismus angeführte "Unmündigkeit" weil "Uninformiertheit" des Patienten muss nicht zwangsläufig in ein Interaktionsmodell von Vorschrift und compliance münden. Auch im Fall der Interaktion mit nicht einsichts- oder zustimmungsfähigen Patienten kann und muss das Konzept dialogischer Interaktion kontrafaktisch aufrechterhalten werden; nur ist es um die Variante "tutorischen Handelns" zu ergänzen. Hier wird das Vorschrift-Verhaltensmodell erweitert um die Verpflichtung, auch bei alleiniger Entscheidungsfindung durch den Arzt im Sinne des wohlverstandenen Selbstinteresses des Patienten zu handeln und gegebenenfalls den Nachweis dieser Orientierung der Behandlung anzutreten. Damit erweist sich das Modell der dialogischen Interaktion als das umgreifende, weil sowohl die Interessen des Arztes als des Patienten abdeckende Modell.

Résumé.

À l'encontre du paternalisme ambiant, l'étude développe la proposition consistant à structurer l'interaction entre le médecin et le patient sous forme d'entretien de conseil inter-subjectif. Cela signifie que tant "l'information" du patient précédant le traitement, la recherche du "consentement informé" (informed consent) qu'également le traitement médical doivent prendre la forme d'interaction entre deux individus majeurs au sens strict. L'argument avancé pour conserver une attitude paternaliste et consistant à invoquer "l'irresponsabilité" du patient découlant de sa "non-information" ne doit pas obligatoirement aboutir sur un modèle interactif de prescription et de conformité. Dans le cas également d'une interaction avec des patients incapables de réaliser la situation ou d'y consentir, le concept d'interaction dialogique peut et doit être maintenu en dépit des faits; il doit simplement être complété par une variante "d'action tutélaire". Le modèle prescription-comportement est complété ici par l'obligation d'agir, même si le médecin décide seul, au sens de l'intérêt bien compris du patient, et le cas échéant de donner la preuve de l'orientation choisie pour le traitement. Le modèle de l'interaction dialogique apparaît ainsi comme étant le plus large puisqu'il couvre tant les intérêts du médecin que ceux du patient.

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Notes

  1. To avoid the common fallacy according to which "autonomy" means the patient's ability to decide authoritatively on medical issues (as is assumed in the—then justified—critique of the postulate of patient-autonomy), the practical concept of "responsibility", also introduced by Kant, is used here in the sense of the execution of the autonomy, which must be assumed and demanded, but can also be delegated.

  2. See also the reflection on this by Klaus Gahl (2002).

  3. See also Gethmann (2001).

  4. The following concept for structuring the doctor-patient relationship is developed at greater length in aStudienbrief (course text) on medical ethics, published by the FernUniversität Hagen as part of its continuing education program. The alternative approaches—the paternalistic model and the contract model, which can only be touched on here—are also discussed there in more detail (Gethmann-Siefert 2002). Only the paternalistic, the contract, and the discursive-dialog model are discussed here. Another common variant of defining the doctor–patient relationship is the consumer model described by Klaus Gahl (2002).

  5. A more detailed characterization of the model, and the problems surrounding it, can be found in part 1 of the study by A. Gethmann-Siefert (2002).

  6. The issues surrounding scientific psychology are still under debate, especially in terms of the "body–soul problem". According to the ideal of scientific exploration, i.e., following an approach based on the knowledge of scientific laws, psychology becomes a suitable instrument for predicting behaviour and, hence, for the corresponding examinations required in medicine. However, as soon as one leaves behind this parallelism of scientific explanation and mental events, psychology enables specific predictions only up to a point, and hence does not provide the required prognostic certainty. We cannot discuss any further here at what costs one would embrace the concept of a so-called "scientific" psychology. Nonetheless, these consequences are considerable, at least in a similar way as the present, often repeated reduction (for the same reasons) of the Cartesian dualism to a materialistic monism (albeit under a different concept of science) caused by such models of scientific psychology, if they are to work.

  7. For a critique, see Kamlah 1973, especially p 55.

  8. D. von Engelhardt has pointed out that the definition of the doctor–patient relationship, which is inherent to the scientific-technological self-image of medicine, is not valid for every situation of medical consultation and help (von Engelhardt 1996). Further sharpening this argument, the following remarks are meant to show that exactly the combination of the medical ethos and the anthropological and ethical foundations of modern medicine following from that ethos results in the problems mentioned above.

  9. These considerations already appear in a lecture given in 1958,Der Arzt im technischen Zeitalter, given at the 100th Convention of theGesellschaft Deutscher Naturforscher und Ärzte in Wiesbaden; cited here from Jaspers (1986), p 57.

  10. Cf. Jaspers (1986).

  11. Again, this skepticism has, of course, also a basis in philosophy, which is of continuing validity even in the present discussion, in the controversial theses of Peter Singer, namely the assumption that personality, reason, and responsibility can be assumed only if they are articulated in an empirically verifiable manner. The consequences of such an empirical concept of the person, making personhood dependent on thearticulation of self-awareness, are pointed out, in an exemplary manner, by Nuland (1994). Nuland advocates the thesis that human dying in misery and pain—for which he describes, from his medical experience, some most drastic examples—contradicts the assumption that there is such a thing as dying with dignity. "On the whole, dying is a wearisome business" (ibid. 217), anything but an appropriate indicator of human dignity. The human being rather appears, and experiences himself, in all his creaturely desolation. This empirical absence of dignity makes Nuland reject any talk of a death "with dignity". Here we see the typical misunderstanding of an empirical approach that links the recognition of human dignity to its apparentness.

  12. The definition of the term "person" preferred in the following has proved momentous, in my opinion, especially for the ethical and medical ethics debate, since the concept of the person assumed here is of considerable consequence not only for the discussion about the doctor–patient relationship, but also for numerous other highly acute discussions concerning medical ethics, for instance about the permission or inhibition of research involving human embryos, about pre-implantation diagnostics and many other issues.

  13. The linkage between personal dignity and recognition involves further consequences especially—as already mentioned—concerning the issues surrounding prenatal diagnostics and embryo research, which cannot be discussed here. In this context, too, it is more sensible, in my opinion, not to call upon a metaphysical or even theological foundation if one wants to avoid the empiristic view of the person/personality, which would coerce us towards unacceptable ethical consequences. However, this concept of personhood, which does not require many metaphysical preconditions, can only be had at the expense of having to engage in substantial discursive examination and backup work in order to avoid cultural relativism and arbitrariness in dealing with persons. A society that parts with "assured" values because it cannot and should not accept any heteronomous guaranties is, eo ipso, more complex than one based on traditionalistic foundations. However, for this very complexity ,i.e., because of its dependence on the ethical discourse about political commitments it turns out to be more humane.

  14. This thought is developed in more detail in Gethmann (1993a).

  15. The doctor in charge acts without a mandate in every case where no treatment contract with the patient was concluded in advance. The content of such a contract would be the very illness that caused the unconsciousness. We thank A.J. Gethmann for the legal notes.

  16. Gethmann (1993a), p 158. This definition of the doctor–patient relationship also starts from the assumed meaning of medical action: "A therapeutic measure is ... not the application of expert knowledge to a concrete 'case', who only needs a little persuasion (to make him comply). Such interpretation would assume, wrongly, that a risk decision is still calculable, ultimately, in an 'objective' (trans-subjective) manner ... It would be reassuring if the objection would appeared, at this point, that this is exactly the procedure that has always been followed by "good' doctors." (ibidem).

  17. In legal terms, the quasi-objective minimization of risks without reducing the prospects of a cure means that the violations are already enumerated. For, when an agent of necessity acts against the will of the principal, and if this should have been obvious to him (i.e., if he decides on the individual and, therefore, imponderable parameters of the expected risk acceptance in a way that is non-verifiable itself), this gives rise to lawful damages. The rules concerning the onus of proof already exist, in so far as the statutory regulation with regard to putting the intention of the principal (the patient) last considers that this intention is negligible if either, without the doctor's intervention, obligations are violated whose fulfillment by the patient is in the public interest, or there is a demonstrable case of averting immediate danger. In this case, not the tutorial decision, but only the "intent" and "gross negligence" resulting in harm to the patient have to be assessed with regard to a liability for damages.

  18. On this, see also the more differentiated reflections in theStudienbrief Arzt und Patient (Gethmann-Siefert 2002); in Souchon (1999).

  19. To describe this process of considering and eliciting the presumptive self-interest in terms of a well-understood self-interest of the patient, the concept of risk acceptance and expectable risk acceptance were adopted deliberately in the way in which C. F. Gethmann (1993b) developed his thoughts on risk acceptability and risk acceptance, instead of recurring to "values", as suggested elsewhere (see also, e.g., the demand to find out a "value history" and hence the presumptive, specific value considerations of the patient through narrative anamnesis: Honnefelder 1994, 183 ff.). A rationalizable and hence verifiable strategy for weighing risks and chances appears to be more suitable as a basis for tutorial action because determining the presumptive self-interest through such a weighing process is less fraught with difficulty than achieving the same end through the concept of values (which is less clear, by far, in philosophical terms). To which substantial values a patient, who cannot be interviewed about his life plan, may have committed himself, and how far he can be expected to reduce them remains incalculable, in principal, because such values are subject to considerable individual variations; even the individuals themselves are often not clearly aware of them. Therefore, it is much easier to determine values from risk decisions already taken (by considering the life circumstances of the patient) than by a physician, who, as a medical practitioner, may not even be qualified for establishing an anamnesis.

  20. The present discussion as to whether the "closest relatives" should also be consulted in the process of arriving at a decision about self-interest, risk attitude etc., and if they should have to play the part, as it were, of the patient, who has lost his receptiveness and ability to decide, is deliberately omitted here. Such a question cannot be prejudged from the philosophical perspective. However, even if the situation reaches a crisis point where no "closest relative" is available as a dialog partner and decision maker, the doctor–patient interaction can still be structured in the sense of the consultation model.

  21. Concluding reflections from the practical point of view, presented in the course "Das Verhältnis von Arzt und Patient" (Gethmann-Siefert 2002), show that this model is not purely academic, but can also be applied meaningfully in the reality of medical consultation and treatment. In this course text, which was developed for the continued-learning program "Medical Ethics", possibilities for structuring various situations, from consultation to the treatment accompanying the consultation, which have stood the test of medical praxis, are presented in terms of the proposed model of interaction between responsible individuals.

References

  • Gahl K (2002) Der Patient als Kunde? Aspekte des Wandels der Arzt-Patient-Beziehung. In: Beckmann JP, Gethmann-Siefert A et al (eds) Das Arzt-Patient-Verhältnis. Course text for the continuing education program "Medizinische Ethik", Institute of Philosophy, FernUniversität Hagen

  • Gethmann CF (1993a) Langzeitverantwortung als ethisches Problem im Umweltstaat. In: Gethmann CF, Kloepfer M, Nutzinger HG (eds) Langzeitverantwortung im Umweltstaat. Economica, Bonn, pp 1–21

  • Gethmann CF (1993b) Zur Ethik des Handelns unter Risiko im Umweltstaat. In: Gethmann CF, Klöpfer M (eds) Handeln unter Risiko im Umweltstaat. Springer, Berlin Heidelberg New York, pp 1–54

  • Gethmann CF (2001) Tierschutz als Staatsziel. Ethische Probleme. In: Thiele F (ed) Tierschutz als Staatsziel? Naturwissenschaftliche, rechtliche und ethische Aspekte. Graue Reihe der Europäischen Akademie, no 25

  • Gethmann-Siefert A (2002) Das Gespräch zwischen Arzt und Patient. Strukturen und Voraussetzungen. In: Beckmann JP, Gethmann-Siefert A et al (eds) Das Arzt-Patient-Verhältnis. Course text for the continuing education program "Medizinische Ethik", Institute of Philosophy, FernUniversität Hagen, 56 ff

  • Honnefelder L (1994) Grundlagen der medizinischen Ethik. In: Honnefelder L, Rager G (eds) Ärztliches Urteilen und Handeln. Zur Grundlegung einer medizinischen Ethik. Insel, Frankfurt

  • Jaspers K (1986) Der Arzt im technischen Zeitalter. Piper, Munich

  • Kamlah W (1984) Philosophische Anthropologie. Sprachkritische Grundlegung und Ethik, 2nd edn. Bibliographishes Institut, Mannheim

  • Nuland SB (1994) How We Die. Knopf, New York

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  • Souchon R (1999) Das Gespräch mit dem unheilbar kranken Patienten. In: Gethmann-Siefert A, Beckmann JP (eds) Das Arzt-Patient-Verhältnis. Course text, FernUniversität Hagen, pp 257–287

  • von Engelhardt D (1996) Die Arzt-Patient-Beziehung—gestern, heute, morgen. In: Lang E, Arnold K (eds) Die Arzt-Patient-Beziehung im Wandel. Enke, Stuttgart

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Gethmann-Siefert, A. Consultation instead of prescription—a model for the structure of the doctor–patient relationship. Poiesis Prax 2, 1–27 (2003). https://doi.org/10.1007/s10202-003-0036-3

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