The Ethics of Relationships

Healthcare is unique among modern professions in that the primary focus is care of the OTHER, the patient. It is an occupation built on a fiduciary relationship. “FIDES”, the Latin root of the word, means “trust”. As such a fiduciary relationship is one built on a sense of abiding trust and confidence that you are acting and making decisions in the best interests of your client, the patient. This trust is the foundation of the special relationships that exists between care-giver and client, between patient and healthcare provider. I would not say it is strictly altruistic, but it is built on a deep sense of acting selflessly.
The key relationship, then, between any healthcare professional and their patient is based upon the twin poles of trust and selflessness. Nevertheless, you are in the position of authority. The patient comes to or is referred to you for care. The patient is seeking your knowledge, skill or insight to allow them to heal, get better or relieve a stressor such as pain. As such, the patient in many cases is emotionally compromised. Because you are in a relationship that exists with this difference, then the relationship is one where special concern must be made by you. For example, you are or will be viewed as an authority in possession of what may be seen by many as a complex and arcane knowledge; this alone places extra duties on you to communicate therapies, policies, protocols, options and alternatives to the patient in clear, easily-understood and accurate language. Much will depend on your ability to accurately and concisely convey complex information to your patient. For example, the patient’s rights to know depend entirely on this aspect. This is one aspect among many that structure this unique set of relationships. Let’s turn to the constellations of issues grouped around the patient-provider relationship.

The set of issues around the patient-provider relationship have to do with the communication of knowledge and services, the delivery of quality treatment, the protection of client information, the ascertainment of permission and the safeguarding of the patient’s autonomy.
Medical ethicists group these issues into and under the following concepts:
Confidentiality
Consent
Disclosure
Right to Know
But before we delve into a closer examination of each of these important topics, I would like to say a bit about professionalism in healthcare. In 2002, several professional medical societies gathered together to charter a set of “fundamental principles” concerned with maintaining and advancing professionalism in the delivery of health care. Leaders from the American Board of Internal Medicine (ABIM) The American College of Physicians and the European Federation of Internal Medicine sought to establish the primacy of patient autonomy and welfare and articulated the following ten “professional Commitments 1 :
• Professional competency
• Honesty
• Confidentiality
• Appropriate relationships with patients
• Improving quality of care
• Improving access to care
• Just distribution of finite resources
• Scientific knowledge
• Maintaining Trust/ managing conflicts of interest
• Professional responsibilities

What we see here is that the Physicians held certain concepts as central to their practice of good medicine and chief among these are the all-important set of relationships between patient and physician. We may rightly extend these to all areas of healthcare from the actual clinical practice to administration.
This echoes the millennia-long tradition enshrined in the Hippocratic Oath (see PPT) that begins with patient care and introduces such important concepts as confidentiality.
Confidentiality:
In the United States, patient information is viewed as privileged and protected information and is covered by privacy regulations. It is the cornerstone of healthcare because so much depends on a person’s willingness to share and disclose behaviors, symptoms and lifestyle choices to the healthcare provide. This candid sharing of personal information allows that provider to make the correct assessment of the patient’s condition and if a person feels that their personal information will not be kept secret, they are likely to not be candid. In the U.S. federal law further safeguards the widespread practice of keeping personal information private with the HIPPA regulations (Review HIPPA the U.S. Department of Health and Human Services webpage: http://www.hhs.gov/ocr/privacy/)
Consent:
Consent is achieved when a patient or client is fully informed of and understands the implications of, a diagnosis, treatment, costs, side-effects, and short- and long-term consequences of a procedure. In the U.S. a stronger version called INFORMED CONSENT is practiced. The standard of INFORMED CONSENT is what any reasonable patient would want to know about their treatment and what the particular patient needs to know.
As we will see some of the most flagrant violations of human rights have occurred in the history of medicine as a result of not seeking the patient’s consent.

Disclosure and Right to Know:
Closely related to consent are the two concepts of disclosure and right to know. A patient has a clear moral right to know the potential costs, outcomes and goods and harms of any medical treatment. Moreover, the professional has a duty to inform the patient. This may be viewed as a prima facie right so it follows that the healthcare provider has a corresponding moral duty to provide that information in a clear and accessible manner.

Case study:
Susan is a public assistance case worker and one of her clients, George, with whom she is working on a Medicaid claim has HIV. George does not have a phone but provides Susan with his sister’s number. Susan needs to contact George and calls the number. When she talks to his sister she asks how George is doing since she has not seen him since he was hospitalized with PCP pneumonia2. Did Susan violate George’s right to confidentiality?

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