Patient Ethics.

Lately, I’ve been thinking a lot about ethics; I’m not sure why, although I suppose it’s a common attribute of age: a way, perhaps, of appraising one’s own affect on the world. I’ve written before about the usual constituents of an ethical assessment: Respect of Autonomy -respect, in other words, for a different opinion; Justice -or fairness in decisions and judgments; Beneficence -acting in someone’s best interest; and Non-maleficence -doing no harm.

The value and importance of these principles is hard to deny. I suspect the thrust of them is much the same as that of politeness and consideration in dealing with others -a more complicated re-wording of the Golden Rule: the ethic of reciprocity that seems to have appeared in all of the great religions. It is a set of precepts that should apply equally to both parties in a relationship of whatever kind.

Ethics are certainly a requirement in a medical relationship: a doctor/patient duality. It is a recognized and appropriate expectation on the part of the patient, of course… But what about the doctor? Does the artificially engendered inequality ( the fact that it is his opinion that has been solicited) obviate the reciprocal duty to behave ethically in response? Or, put another way, do patients have an implied obligation to be polite -ethical- in their dealings with the person from whom they sought help? It is a vexing question, to be sure.

Of course there are those who will insist that the very inequality inherent in the encounter, the power asymmetry implied in the act of requisition, excuses the petitioner from the need to adhere to the same principles as the petitioned.

Perhaps my expectations are unrealistic, but it seems to me that it is reasonable to expect a complementary gain in my encounter with the patient. It is of a different kind, for sure, and no doubt is assessed as more trivial than hers, but it is, nonetheless, of value to me and therefore, in my mind at least, helps to neutralize the power inequity between us.

As I see it, understanding -or attempting to understand- another person is an experience that should not be trivialized, or underrated. It is a gift to be allowed the opportunity to share another’s world; it is not given lightly, nor freely. It is obviously a privilege not accorded to everybody, a recognition that the opinion sought is valued. Important. And although not immediately evident, thoughtful consideration of the relationship suggests there is reciprocity inherent in the transaction…

Or am I deluding myself in expecting a relational reward? Am I too bound by the process, too inextricably entwined to assess it impersonally? Objectively? Realistically? Is it even possible to judge from the other foot?

And yet… If I do my part, shouldn’t they do theirs? Do we not both share responsibilities as constituents of a contract -however loosely defined? Is there not a moral obligation to deal ethically with each other? Do I also have a right to feel slighted if we do not… Or more to the point, if my patient does not?

I suppose these are merely the ruminations of a person who expects civility to be reciprocal, responsibilities to be shared and ethics to be the warp and weft of a consultant practice. When they are not it is a disappointment that I sometimes feel more keenly than perhaps I should. Who would have thought that I would even have an expectation of bicameral courtesy in such a profession?

Thankfully, the vast majority of people -doctors and patients alike- share these values, but that only makes their occasional absence all the more evident and egregious. Respect for each other is important: something to embrace. It is what we expect of each other…

Virtue, perhaps, is nothing more than politeness of soul (Honore de Balzac). Who could disagree?


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