The Fiduciary Covenantal Relationship: A Model for Physician - Patient Relationships
Suits, G. Steven, Ethics & Medicine
The two principle players in the delivery of health care are the physician and the patient.1 The relationship between these two suffers from the effects of societal transformation. Advances in medicine have brought about unprecedented ability to address disease. Information systems allow physicians and other health care workers to better educate and inform patients. These have led to greater expectations by patients. No longer do patients approach the physician hoping he has a cure for their ailment. They expect him to! These increased expectations lead to increased demands. Appendicitis is treated with simple outpatient surgery and is almost never life threatening as it was just five decades ago. Streptococcal pharyngitis requires but a single injection and is rarely complicated by scarletina or rheumatic fever. So why should patients not expect and demand successful treatment of carcinoma of the pancreas? Added to the successes of medicine is the popular propagation of medical information through the media. Anyone can see open heart surgery (the easiest, uncomplicated cases) and walk away with no sense of the minute details that allowed the successful operation. Television newsmagazines report on "advances" in medicine before the profession has had time to verify preliminary results. Commercialism, especially pharmaceutical companies pushing "consumers" to ask their physicians to prescribe them Product X, fuels the flames of patient demand.
Yet many surveys and commentators have reported patient distrust for the medical profession more than in the recent past. "The decrease in trust between patients and physicians, along with other factors, has demoralized physicians . . . diminished trust probably also accounts for the increased number of malpractice claims against physicians."2 Decreased trust makes the physician and the patient moral strangers. "As moral strangers, the physician and patient must be extremely careful in their relationship with each other. There is no longer any room for assumptions as patient meets physician and as physician meets patient."3
The degeneration of culture has challenged the physician - patient relationship and it suffers under the burden of societal agony.4 Western culture is characterized by the loss of transcendence. Spirituality, which informed Everyman until the past half century, has taken its culture "willing to sacrifice pleasures and immediate goals for the sake of its high principles."5 In its place is the demand for immediate release from the displeasure of illness, for remaking the self through the skilled knife of the "plastic" surgeon, for the sensual pleasures (e.g., Viagra(R)) that alone are left when transcendence is lost.
Our sensate culture thrives on those things that stimulate the senses; "it encourages self-indulgence."6 Because of this, the predominant approach to ethics is utilitarianism: maximizing pleasure and minimizing suffering. This has pushed the concept of the physician as the reliever of suffering rather than as the healer. As such, the sensate culture regards dismembering a fetus that gives angst to his mother or injecting drugs into a patient with amyotrophic lateral sclerosis to bring about his death (and his relief from suffering!) appropriate for the physician.
There are signs that our culture has entered a stage that Pitirim Sorokin described as a "late, degenerate sensate culture."7 This is essentially equivalent to what others call "postmodernity." A "postmodern medical world sets off a whole series of elaborate scenarios concerning physician and patient."8 In this stage, the culture has lost faith in its source for truth: scientific materialism. Up until now, our culture has been "underwritten by the conviction that knowledge gained through the scientific method is secure."9 But in this century Einstein's relativity theory and Heisenberg's uncertainty principle combined with a general realization that there can be no observation without subjectivity to disarm scientism as infallible. …