A defence of medical paternalism: maximising patients'' autonomy.

All illness represents a state of diminished autonomy and therefore the doctor-patient relationship necessarily and justifiably involves a degree of medical paternalism argues the author, an American medical student. In a broad-ranging paper he discusses the concepts of autonomy and paternalism in the context of the doctor-patient relationship. Given the necessary diminution of autonomy which illness inflicts, a limited form of medical paternalism, aimed at restoring or maximising the patient's autonomy is entirely acceptable, and indeed fundamental to the relationship he argues. However, the exercise of this paternalism should be flexible and related to the current 'level of autonomy' of the patient himself. An editorial in this issue comments briefly on this paper.     

Pregnancy, autonomy and paternalism

Modern medicine is increasingly aware of the significance of patient autonomy in making treatment choices. This would seem to be particularly important where the therapy requested was "voluntary" as in fertility treatment or cosmetic surgery. However, the Hippocratic doctrine "Primum non nocere", seems especially relevant where the treatment sought may have a low chance of a successful outcome or even be life-threatening. Mrs A's case demonstrates the difficulty faced by the physician who wants to maximise her patient's autonomy, but "Above all, do no harm".     

Supply of medicines: paternalism,autonomy and reality.

Radical changes are taking place in the United Kingdom in relation to the classification of, and access to, medicines. More and more medicines are being made available over the counter both in local pharmacies and in supermarkets. The provision of more open access to medicines may be hailed as a triumph for patient autonomy. This paper examines whether such a claim is real or illusory. It explores the ethical and legal implications of deregulating medicines. Do patients benefit? What is the impact on pharmacists? Are the true beneficiaries of change largely the pharmaceutical industries?     

Doctor-patient communication starts from medical students

Currently,with the increasing tensionin doctor-patient relationship and medical disputes,it is of great practical importance to train medical students’communication skills in order to establisha harmonious doctor-patient relationship to improve the quality of clinical teaching.This paper emphasizes the importance of cultivation of communication skills in medical education and suggests ways to improve communication skills among medical students.     

Doctor-patient relationship: Islamic perspective

The doctor-patient relationship is an intricate concept in which patients voluntarily approach a doctor and become part of a contract by which they tend to abide by doctor’s instructions. Over recent decades, this relationship has changed dramatically due to privatization and commercialization of the health sector. A review of the relevant literature in the database of MEDLINE published in English between 1966 and August 2015 was performed with the following keywords: doctor-patient relationship, physician-patient relationship, ethics, and Islam. The Muslim doctor should be familiar with the Islamic teachings on the daily issues faced in his/her practice and the relationship with his/her patients.The basis of Islam is to believe that there is no God but Allah, and Muhammad (PBUH) is the messenger of Allah. The life of a human being on earth is just a preparation or examination for the eternal life after death. Good is from Allah in the Holy Quran and demonstrated by Prophet (PBUH), and bad is the influence of Satan (who again is created by Allah). The good or bad consequence of eternal life depends on how much a Muslim believes in and obey Allah. Medical practice is considered a sacred duty in Islam, and the physician is rewarded by God for his good work. Islamic scholars have agreed that the study and practice of medicine is an obligation that falls upon Muslims to have sufficient numbers of followers to practice (Fard Kifayah). Among a doctor and patient, both can be Muslim, or either can be Muslim. The Islamic perspective of the doctor-patient relationship is applicable to these groups; but possibley not the non-Muslim doctor- patient groups. A Muslim is first a Muslim then he/she is a doctor/patient. Therefore, those who claim themselves as Muslim should obey Allah, hence, should obey what Allah has said or Prophet Muhammad (PBUH) has demonstrated regarding the doctor-patient relationship. Obviously, like other Islamic issues, there should be the scope of “Ijma” (Consensus of Islamic Scholars) and “Qiyas,” (analogy) when any new issue arises. Building a fruitful doctor-patient relationship is a vital part of successful medical care, and one of the most complicated professional responsibilities of physicians. Despite worldwide emphasis on the distinguished responsibility of physicians, teaching the art of physician-patient relationship has not yet been incorporated, into the curriculum of many medical schools.1 Every medical practitioner should possess an adequate degree of knowledge and skills and should exercise a reasonable degree of patient’s care. Doctors are expected to act according to acceptable medical opinion and current medical knowledge.2 Over the years, the relationship between doctors and patients has evolved from a largely paternalistic model to a more interactive relationship. The principles of autonomy, beneficence, informed consent, patient’s access to medical information, and medico-legal concerns all now influence the doctor-patient relationship.3 The UK General Medical Council published “What to expect from your doctor: a guide for patients”. The guide is a provisional step trying to help patients getting the best outcome from the interaction with their physicians.4 The importance of the intimate personal relationship between the doctor and the patient cannot be over emphasized, as both the diagnosis and treatment are directly dependent on it, and the failure of a young physician to establish this relationship is attributed to his inefficiency in the care of his patients.5 The only and sole interest the doctor should consider, is the best interest of his/her patient. Dr. Francis Peabody ended his speech to medical students of Harvard University on 21 October 1926 by saying: “Time, compassion, and understanding should be generously dispensed, but the reward is to be expected in that personal binding, which creates the greatest satisfaction of the practice of medicine. One of the greatest qualities of a physician is his interest in humanity, as the secret of care of the patient lies in the caring for his patient”.5

Doctors manners

During the history-taking period, the doctor should not only obtain essential clinical information, but must use this opportunity to understand his patient as a human being. This is also when the patient begins to identify his/her doctor as a person and decide whether he is a caring and kind person or not!6 Globally, patients expect a certain kind of treatment from their doctors because of the nature and goals of the medical profession. The physician is expected to be kind, humble, compassionate, honest, trustworthy, and respecting confidentiality (Figure 1). He must have the interest of the patient at heart. He should avoid wrongdoing, not abusing his/her status for monetary gain, and not misleading his/her patient because God does not love the liars and wrongdoers.7 The Prophet (PBUH) said: “Those who have a perfect faith are those who have the best character”.8Open in a separate windowFigure 1The doctor is expected to be kind, humble, and compassionate.Islamic ethics instructs human beings not only to be virtuous, but also to contribute to the moral health of society. The Qur’an says:“You enjoin what is right and forbid what is wrong”.9 The character of the Muslim is exemplified in a verse of the Holy Qur’an saying:(“Indeed, Allah orders justice and good conduct” … and “forbids immorality and bad conduct and oppression”).10 The characteristic features of a virtuous physician are firmly rooted in the Qur’an and the Sunna. Consequently, the Muslim physician, guided by these 2 primary sources of Islamic law, should possess the essential manners of a good physician, and this will lead to a healthy doctor-patient relationship.7 The major distinction of Islamic medical ethics in relation to principalism-based medical ethics is that the former gives a religious basis to morality.11 Prophet Muhammad says; “The best of you is the one who is most beneficial to others”.12 “Hazrat Jaber (Radiallhu tala anhu)”, a companion of the Prophet said: “We were with the Prophet when a scorpion bit one of us. A companion asked, “O Prophet, may I do Ruqyah (recitation of Qur’an and supplications) to him.” The Prophet said: “Whoever can do anything beneficial to one of his brothers, he should just do it”.13During the time of the Prophet (PBUH) a man was injured and the blood was congested in the wound. The man then called 2 doctors from Bani Amir to examine him. The man then claimed that the Messenger of Allah asked them, ‘Who is the best doctor among you?’ They Asked: Is there preferability among physicians, O Messenger of Allah? He said, ‘The One, Who has sent down the disease also sent down the cure. Those who Know it will know it, and those who do not know it will not know it.” This Hadith indicates that Muslims should seek the best authority in each and every matter and field because such expertise will ensure that the job is carried out with excellence.14Islam has enjoined 3 important points on which the doctor establishes a sound and healthy relationship with his/her patients: The first of these is justice among his patients. The second point enjoined is “Ihsan”, which has no equivalent in English. It means to be good, tolerant, sympathetic, forgiving, polite, cooperative, and so forth. The third point, which has been enjoined, is good treatment of a patient’s relatives, which is a specific form of Ihsan.11Prominent physicians of the Islamic civilization involved themselves with medical ethics; among these were Al-Ruhawi, and Al-Razi. They wrote the earliest and most meticulous books on medical ethics over a thousand years ago. Al-Razi,15 in his book “Akhlaq Al-Tabib”, the physician duties to the patients. The first of which is to treat the patients kindly, not to be rude or aggressive, but should be soft-spoken, compassionate, and behave modestly. The physician should inspire the patients even those who have no hope for recovery. To Al-Razi, another duty of the physician to his patients is to treat the patients equally regardless of their wealth or social status. The aim of the physician should not be the money he will get after treatment, but the cure. Doctors should be even keener on treating the poor and needy than the rich and wealthy.15

Communication

Globally, a patient’s complaints of doctors’ communication skills are recorded at the top of the analyzed complaint lists.1 It is crucial to treat the patient, not only the disease. Modern technology makes the physician’s skills focused on the treatment of the disease with less emphasis on the patient himself. Consequently, the symptoms of the disease are temporarily alleviated, while the root of the problem is still present. Hippocrates made an invaluable remark saying “where there is love for human being, there is love for the art of healing”.16 It was reported that Avicenna used to tell his patient: Look!. You, I and disease are “3”. If you help me and stand beside me, we become “2”, and the disease will be left alone; then we will overcome it and compel your illness. But if you stand beside the disease, you will become “2” and I will be alone, then you will overcome me, and I will not be able to cure you.17A physician taking a history from his patient in a way similar to an interrogating lawyer, and paying little attention to his patient’s answers is doomed to be a poor clinician.6 Many doctors are reluctant to improve communication, which is one of the crucial elements of treatment. Despite the efforts of some medical universities to reform their medical curriculums and implement communication skills, it seems that many doctors do not appear to build effective relationships with their patients.1 Since the clinics became more crowded, with an increase in referrals to specialists, doctor-patient exposure decreases as visits became shorter, and patients are frequently exposed to different physicians. Unfortunately, patients are becoming more distant from their doctors. They have more access than ever to medical information. They are far more knowledgeable on pathology and modes of therapy, and often express their desire to participate in treatment decisions. We are going to see an amazing progress in technology shortly, and the practice of medicine will be very interesting, but very different from today.18

Communication with children’s parents

Most parental complaints of dissatisfaction are attributed to lack of communication or due to a cold, rough, or indifferent attitude, or behavior, of the doctor or any member of the treating team, and not due to lack of knowledge and skills or unsatisfactory treatment of the patient. The patients and parents should have the feeling of being treated with respect and dignity at all times.19 Physicians should be tactful and careful in deciding not only “what to tell the parents” but “how to tell” as well. Parents should be informed the condition of the child in a simple language without medical jargons. They should also be pragmatic and honest in telling them the true medical status of the child, while keeping the hope alive, which has great healing capacity.19

Patient’s satisfaction and trust

Improvement of patient’s satisfaction is a major target for hospitals and is often dictated by patients’ perception of the level of communication of the hospital team.20 When doctors communicate effectively with patients, they identify patients’ problems more accurately, and the patients are more satisfied.21 An American study22 of 500 difficult patients in general medicine revealed that only one patient out of 2 is leaving the doctor’s office satisfied with the care provided. This satisfaction increased to 63% when the same patients were asked about their feelings 3 months later. The most satisfied patients were those over the age of 60 who saw an improvement in their health.22 A relationship characterized by a high level of trust in the physician leads to an increase in adherence to treatment, improvement in follow-up, and reduction in unnecessary investigations, and requests for a second opinion. Consequently, the overall cost of healthcare will be significantly reduced.23 A greater number of problems may be solved during a consultation when patients have a deeper relationship with their doctors.24

The gender issue in the doctor-patient relationship

Modesty is an important issue for Muslim women, and many female patients may tune out what the doctor is saying, out of nervousness over having their bodies exposed. For a Muslim woman, it could be very stressful to expose her body in front of a male physician, or even to discuss with him sensitive issues related to her health. Consequently, some Muslim women may not reveal their health problems to a male physician or may not even seek medical care.25Patients typically prefer same-gender providers and may feel uncomfortable when alone with a physician of the opposite gender. If that’s unavoidable, leave the door or privacy curtain partly open (as long as your patient is dressed). It is quite common for the husband to ask to stay with his wife during a physical examination. Having a female nurse available for examinations may help a Muslim woman to feel more comfortable, and is mandatory in all countries in the world. Posting a sign stating, “Please knock on the door before entering.” may also be-helpful.

Informed consent

Informed consent is the cornerstone of the doctor-patient relationship, and is a recognized legal obligation for the medical profession. Physicians must obtain informed consent from the patients or their legal guardian, in case of minors or mentally deficient, before undertaking any medical or surgical procedure, providing a clear explanation of the planned procedure, intended benefits, potential risks, and complications.26 DelPozo and Fins27 note that informed consent addresses the individual rights of patients. However, Islamic law respects the privacy of person and family. They conclude that the Western way of obtaining informed consent in a patient from the Eastern culture may involve providing “too much information and may leave the patient feeling misinformed.” Giving too much information, at times, may raise suspicion that the physician might be withholding information or even concealing the truth.”27,28 To respect the autonomy of the patient, the doctor should have more knowledge of the cultural values and behaviors of his/her patient. For a Muslim patient, absolute autonomy is very rare; he/she will have a feeling of responsibility towards God, and live in social cohesion, in which the influence of relatives play a significant role.29 The patient-doctor relation is continuously changing, and informed consent will never prevent unfortunate outcomes, leading to serious questioning of doctor’s performance and the proper use of resources. Even if this reaches an exemplary level, it does not guarantee the patient’s satisfaction with the medical service provided, and avoid possible legal accusation.30

The role of family/companions in medical consultations

The family is the basic structural element of a stable Islamic society. Family members frequently accompany patients to the clinic or hospital, and medical decision-making usually involves the patient’s immediate family even when the patient is compos mentis. The family may deliver bad news gradually to the patient. Although a patient may choose to pay attention to the influence of family and friends, the ultimate decision to agree with the procedure, or surgery must be made by the patient. The role of the family should be affirmed and respected, but this recognition must be balanced with the priority of patient autonomy. All communication regarding the risks and benefits of medical procedure, or surgery must be understood by the patient. It is not acceptable to ask a surrogate for consent for a capable and conscious adult patient unless the patient chooses to permit it.31 Companions usually play a supportive role in the majority of consultations. They give emotional support, help in transport, and may express patients’ concerns.32 During the procedure or surgical operation, relatives often recite prayers or read the Quran, appealing for the cure of their loved ones.

Ethical issues in visual recording

Visual recording of patients is commonly used for clinical, research, legal, and academic purposes. It is frequently used in the specialties of plastic surgery, dermatology, wound care, maxillofacial surgery, and otolaryngology. Guidelines for biomedical recording have been issued by several health authorities, associations, and journals.33 Photographing patients may have an indirect effect on treatment, by aiding diagnosis; and written consent should be obtained from the patient or his/her legal representative before carrying out the procedure.33 The identity of the patient should always be concealed. In recent years, doctors have been investigated for uploading medical data that can identify patients onto public internet forums. Muslim jurists’ rulings on human recording vary from being permissible to bing discouraged, and forbidden. However, the ruling is ultimately dependent on the intended use of the images or recording, the way images were obtained, and the potential usage of the whole procedure. For images to be permissible, the procedure must not contradict Islamic law. Only the minimum necessary area should be photographed. Subjects’ rights and dignity must not be violated, and their religious and cultural background respected.33,34

Confidentiality

Breaching confidentiality can be acceptable or required by medical authorities, when failure to act can lead to physical harm, to either the patient or people in contact with that patient; such as the case of certain infectious diseases, where the doctor or researcher has a duty to protect the health of those who may be at risk.35 Certain circumstances demand a breach of patients’ confidentiality to protect other individuals or society as a whole. Breach of confidentiality under such conditions is justifiable in Islam. Examples include reporting, to the assigned authorities, probable criminal acts (such as domestic violence or child abuse), serious communicable diseases or circumstances, which pose a threat to others’ lives (such as an epileptic patient working as a driver), notification of births and deaths, medical errors, and drug side effects. If the patient agrees to disclose the complexity of his medical condition to the family, then there is no breaking of confidentiality. If a consort has an HIV infection, then the physician’s duty is to inform the other consort of the true diagnosis. The doctor should take the permission from the infected person, or ask him to tell his consort, in his presence, the true diagnosis.34In a fatwa issued by the International Islamic Fiqh Academy in 1993, jurists affirmed that a breach of confidentiality can be acceptable only if the harm of maintaining confidentiality overrides its benefits. The fatwa describes some situations in which breaching confidentiality is allowed, or mandatory.36 “Such cases are of 2 categories: a) Cases where a confidence must be broken on grounds of the rational of committing a lesser evil and obviating the greater one, and the rational of seeing to a public interest, which favor enduring individual harm so as to prevent public harm if needed. These include 2 sets: Those which involve protecting society against some prejudice, and those which involve protecting an individual against some prejudice. b) Cases where a confidence may be broken: 1) To ensure a public interest. 2) To prevent a public damage. In all such cases the objectives and priorities are set out by Shari’ah (Islamic law) regarding preserving the faith, human life, reason, descendants, and wealth”.37

Breaking bad news/disclosure

Breaking bad news, defined as “any information that seriously and adversely affects an individual’s view of his or her future,” is a nerve-racking moment in the relationship between doctors and their patients. It is very stressful for patients, especially if the clinician is inexperienced.38 Health care workers in Muslim communities are required to modify the Western-based recommendations to match the culture of their patients and their families.39 In all cultures and communities, the statement of Buckman40 firmly stands: “…if the breaking of bad news is badly done, patients and their families may never forgive us, but if it is done properly they will never forget us.”Full disclosure and patient’s autonomy are the focal point of medical ethics in the West. Consequently, Western medical practice advocates free and open communication with patients, to the point that they are fully aware of their disease and treatment. Nondisclosure of a cancer diagnosis is common practice in many Eastern communities. Consequently, families often approach oncologists with requests for nondisclosure. As a result, most doctors opt to break a cancer diagnosis to the family before informing the patient himself. Nondisclosure may carry high costs to the patient and family, who may receive less than optimal supportive and medical care. The patient may be deprived of the chance to finalize his affairs and say goodbye.41 For many Muslim patients, it is God who permits death, hence giving up hope is not welcome in religious teaching.In conclusion, the practice of medicine firmly relies on the relationship between the doctor and his/her patient. Consulting with a patient is a complicated skill that is gradually learned during medical training and perfected when one grows to take his/her role as a doctor. Medicine is not a business to be learned, but a profession to be satisfied with. Medical technology should not be allowed to dehumanize further medicine, and the declining image of the medical profession should be rectified. The caring doctor is the one who does not over-test or over-treat his/her patients and communicate with them properly. The success of the doctor-patient relationship is evident when doctors treat patients with respect and courtesy. Physicians are expected to possess scientific knowledge, technical skill, and a human touch and understanding. Physicians should be kind, decent and modest, well mannered, and insist on the treatment of poor and needy patients as much as law and regulations can permit. However, these regulations may hamper such good will. These are considered to be doctor’s essential duties to the patients and the society.Continuous education and model leadership are required to maintain the portrait in which doctors see their patients as people and not a disease. This will not only improve the relationship between physicians and patients, but often improve the clinical outcomes. All medical schools should initiate regular education programs in medical ethics, social, and behavioral sciences, and the art of communication for both undergraduate and postgraduate medical students. We also recommend developing a monitoring and evaluation system for doctors working in hospitals, clinics in public and private sectors to monitor for how they adhere to the “Code of Islamic medical ethics.”     

论医患关系认知与医学实习生伦理道德教育

医学伦理学（以下简称医伦）教学是医学生素质教育的重要内容，是医学生社会化，专业化的保障，是健全医学职业人格的催化剂。在临床实习中，医患关系是医学生学习和应用医伦知识的焦点，是医学生实现其学习主体性的载体，充分认识在医患关系。了解医患关系矛盾产生的原因是我们加强医学生医伦教育，培养职业素养的重要途径。只有在正确处理医患关系的基础上，才能不断增强医学生学习医伦的自觉性，不断增强认同，接受，悦纳医德理论的自觉性，不断增强医德修养的自觉性，医伦教学才会有效益。     

Doctor-patient relationship: a covenant of trust

The goals of medicine as a profession dedicated to healing and caring of the sick in a dignified manner depend very much on a stable and trusting doctor-patient relationship. In the last decade, rapid changes in the healthcare delivery system and socio-political climate have resulted in considerable strain on this relationship. What is needed is a reiteration of the fiduciary obligation of the physician and the central role of the patient in the relationship. Concrete steps and changes at the institutional and individual levels need to be taken to preserve the element of trust in the patient-physician covenant. Only then can the medical profession retain the moral dimension of its role in society.     

医患沟通内涵分析及对医学教育的启示

医患沟通既是一个过程性的框架结构和程序性任务,同时也涵盖具体的能力要素。通过对当前教学实践的系统回顾,从课程设置、教学形式、师资力量建设以及考核与评价方面提出新的思考,提出未来医患沟通教学应当以"过程为框架,能力为核心,技能训练为载体",分阶段、分层次开展。     

医患互动与医德行为

医德的覆行存在于医疗行为中，存在于医患互动中。作者从医患的心理互动、医患的行为互动和医患的语言互动三个方面，阐述了医患互动的内容及其道德内涵。作者认为医患互动是在人道关怀原则指导下展开的。医患间的认知、情感和意志的互动，其关键是调动患者的主体力量，使之能积极地与与疾病作斗争，促进康复尽早和尽量完善的实现。医患间技术行为、经济行为和文化行为的互动，尊重病人，全面替病人设想，是实践医德的重要环节。医患间的语言互动是医患进行心理沟通和行为互动的中介环节，它要求必须具有高素质的人文修养和运用语言艺术的技巧，因而要求医者必须注意语境、语气、语情和语知，从而利用语言交流更好地为病人服务，提高医疗服务质量和医疗技术质量。     

Doctor-patient sexual relationships in medical oaths

BACKGROUND: Doctor-patient sexual relationship is considered to be unfair because the first party would be abusing the second party's vulnerability. The prohibition of this relationship is noted in the Hippocratic oath. Currently, a reprise of the use of oaths in medical schools can be observed. AIM: To determine whether the prohibition has been maintained and how its expression has varied in the oaths during different periods. METHODS: 50 oaths were studied: 13 ancient-medieval and 37 modern-contemporary. Of the 50 texts, 19 were versions of the original oaths. The oaths that pointed out the prohibited doctor-patient relationship referred to any sexual aspect or included paragraphs that began as the Hippocratic oath does were noted. RESULTS: Of the 24 (48%) texts that expressed the prohibition, 8 (62%) were ancient-medieval and 16 (43%) were modern-contemporary. Some expressly call it Hippocratic oath, many use general terminology (corruption or vice) and others describe it in association with other commitments (abortion and euthanasia). CONCLUSIONS: The clause on the prohibition of the doctor-patient sexual relationship in Hippocratic oath was included to be for legal, economic and social reasons at the time. That the clause is found mostly in the ancient-medieval oaths can be attributed to the influence of the original. This commitment is generalised and associated with others by contemporary formulas. Currently, sexual relationships are the subject of legal and ethical analysis and their inclusion in the oaths is being debated.     

论医患关系与图书馆建设

解析了医患关系恶化的原因，论述了医院图书馆对缓解医患关系所起的作用。     

医事法学课程中对父权主义理论的批判与继承

在医事法学课程的教学中不断强调病人是医疗中心的这一观念正瓦解着传统的医疗父权。课程中教师对病人自主权的重视与在实践环节病人自主权仍停留在概念阶段形成了一对矛盾。对父权主义在批判基础上的继承能有助于解决这一矛盾,并能在实践中保护和提升病人的自主权。     

Non-conventional approaches to allergy testing: reconciling patient autonomy with medical practitioners' concerns

It may be difficult for patients to distinguish current concepts of immune function from other, non-conventional explanations of illness.