The doctor-paient relaionship under the inluence
of the bioethical reference point of autonomy
José Marques Filho 1, William Saad Hossne 2
Abstract
Objecive: To analyze the inluence of the bioethical reference point on the doctor-paient relaionship, the efects of the Internet on this autonomy and the importance of the relaionship vis-à-vis technological ad-vance. Method: A study with a descripive and exploratory technique, uilizing a quanitaive and qualitaive approach. Findings: Ten per cent consider the appearance of the reference point of autonomy to be the most important factor in the changes in the relaionship; 96% consider the introducion of autonomy important or very important, making the relaionship more complex (84%); and 77% consider that it has been a great ad-vance for the paient. Fity-six per cent airmed that the paient takes informaion obtained on the Internet to the doctor’s oice, 85% that this aitude increases the paient’s autonomy, and 32.2% that it interferes with the doctor’s autonomy. Conclusion: The bioethical reference point of autonomy was a great advance for the paient and has made the relaionship more complex; the Internet increases the paient’s autonomy and may improve the relaionship and increase his or her paricipaion in decision making.
Keywords: Doctor-paient relaions. Personal autonomy. Bioethics. Internet.
Resumo
A relação médico-paciente sob a inluência do referencial bioéico da autonomia
Objeivo: analisar a inluência do referencial bioéico da autonomia na relação médico-paciente, o efeito da internet nessa autonomia e a importância dessa relação frente avanços tecnológicos. Método: estudo com técnica descriiva e exploratória, uilizando abordagem quanitaiva e qualitaiva. Resultados: 10% viram o surgimento do referencial da autonomia como o fator mais importante nas mudanças da relação; 96% consid-eraram a introdução da autonomia importante ou muito importante; 84% declararam que ela torna a relação mais complexa e 77%, que foi um grande avanço para o paciente; 56% airmaram que o paciente leva infor-mações da internet à consulta; 85,5% consideram que essa aitude aumenta sua autonomia, e 32,2%, que interfere na autonomia do médico. Conclusão: o referencial bioéico da autonomia foi um grande avanço para o paciente, acrescentando complexidade ao relacionamento; a internet aumenta a autonomia do paciente, pode melhorar a relação e aumentar sua paricipação nas tomadas de decisão.
Palavras-chave: Relações médico-paciente. Autonomia pessoal. Bioéica. Internet.
Resumen
La relación médico-paciente bajo la inluencia de la referencia bioéica de la autonomía
Objeivo: Analizar la inluencia de la referencia bioéica de la autonomía en la relación médico-paciente, el efecto de internet en esa autonomía y la importancia de la relación frente a los avances tecnológicos. Método: Estudio con técnica descripiva y exploratoria, uiliza abordaje cuanitaivo y cualitaivo. Resultados: el 10% consideró el surgimiento de la referencia de la autonomía como factor más importante en los cambios de la relación; el 96% consideró la introducción de la autonomía como importante o muy importante, que torna la relación más compleja (84%) y que fue un gran avance para el paciente (77%). El 56% airmó que el paciente lleva informaciones de internet a la consulta; el 85,5% consideró que esta acitud aumenta la autonomía del pa-ciente, el 32,2% consideró que interiere con la autonomía del médico. Conclusiones: la referencia bioéica de la autonomía fue un gran avance para el paciente e incrementó la complejidad en el vínculo; internet aumenta la autonomía del paciente, puede mejorar la relación y aumenta su paricipación en la toma de decisiones.
Palabras-clave: Relaciones médico-paciente. Autonomía personal. Bioéica. Internet.
Aprovação CEP Centro Universitário São Camilo nº 124/2011
1. Doutor [email protected] 2. Livre-docente [email protected] – Centro Universitário São Camilo, São Paulo/SP, Brasil.
Correspondência
José Marques Filho – Clínica de Reumatologia e Fisioterapia. Rua Silva Jardim, nº 343, Centro CEP 16010-340. Araçatuba/SP, Brasil.
Declaram não haver conlito de interesse.
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The physician-paient relaionship, a special process of human interacion, forms the basis of clin-ical pracice in its technclin-ical, humanisic, ethclin-ical and aestheic dimensions. Hossne1 deems that this
pro-cess is so important that no physician’s acion can be referred to as “medical act” if there is no appropriate relaionship between physician and their paients.
In his study “La relación médico-enfermo”, Pe-dro Laín Entralgo 2 highlights the delicate sensiivity
of this relaionship in view of the changes through-out human history. The authors menions that the coninuous progress of diagnosic and therapeuic resources has a large and logical impact on progres-sive changes of this relaionship over ime. He also emphasizes that, on the other hand – perhaps the most important -, changes in the coexistence among men have changed the own fundamentals of the physician-paient relaionship.
Laín Entralgo 2 considers that four periods
were paradigmaic in the history of this relaion-ship: Ancient Greece, early Chrisianity, the Middle Ages and the bourgeois society of the 19th centu-ry. Whereas Lázaro and Gracia 3 classify it in three types, according to their characterisics through-out history: monarchical (relaionship asymmetry), oligarchical (healthcare team) and democraic (sym-metrical relaionship).
According to Hossne 4, at least six scieniic rev-oluions occurred in the 20th century, all with strong impact on medical pracice: atomic, biological, spa-ial, informaion technology, nanotechnology and the most recent one, referred to as “pan-episte-mological”. In this scenario, two concepts – the bioethical principle of autonomy 5 and informaion technology (therefore, communicaion itself) – has, in recent decades, indisputable inluences on med-ical pracice in general and in the physician-paient relaionship, in paricular.
The concept of autonomy is associated with the progressive consolidaion of human rights, es-pecially with the fundamental contribuion of the English, American and French revoluions, between the mid-17th century and late 18th century. From these movements, the principal of autonomy of hu-man beings arises and is established, understood as an enitlement to self-determinaion, mainly based on Kant’s philosophy, who formalized the principle according to which, man exists as an end in himself, and not as a means 1. It is worth noing that the
principle of autonomy, having emerged in the 18th century, was only incorporated to the physician-pa-ient relaionship two centuries later, more precisely from the 1960s.
This study aimed to analyse the inluence of the bioethical principal of autonomy in the physi-cian-paient relaionship nowadays, as well as the inluence of the Internet on the autonomy of the physician and paient and the importance of this re-laionship in view of technological advances.
Method
The study uses the descripive and explor-atory technique. The methodology adopted was the quanitaive and qualitaive approach 6. The technique used in the qualitaive approach was the “categorizaion of answers” and the parial use of the discourse of the collecive subject (DCS) 7.
Members and former members of the Regional Council of Medicine of the State of São Paulo ( Con-selho Regional de Medicina de São Paulo – Cremesp) took part in the study, who served in three admin-istraion periods of the enity between 1998 and 2013. The total number of members during these three administraion periods were 73 physicians. The sample choice was mainly due to the fact that the council members are acive professionals – all of whom with wide experience in relecions and discussions on topics regarding professional and bioethical ethics -, as well as their performance as judges of the medical profession and coninuous contact with complaints and claims iled by paients and families.
The instrument chosen for data collecion was a semi-structured and self-applied quesionnaire with 17 quesions (Exhibit). The scale survey tech-nique devised by Likert was used. Three quesions with statements (Likert’s items) were used, increas-ing the lexibility of the quesionnaire 8.
Results
Of the 73 quesionnaires sent, 62 (84.9%) were duly completed upon return. Of the coun-cil members and former members, 51 were males (82.3%) and 10 were females (17.7%). The mean age was 59.6 years, the minimum age was 30 years and the maximum age was 82 years. In relaion to grad-uaion ime, the minimum ime was 5 years, and 46 (74.2%) had graduated for more than 31 years. Of all respondents, 51 (82.2%) have served for more than 10 years as council members and 11 (17.8%) have served in the funcion for less than ive years.
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Results of the study quesions
In quesion 1, when asked about what was the factor that most caused changes in the physi-cian-paient relaionship in recent decades, 52% of respondents answered the emergence of the inter-mediary element (health insurance, public health); 11% indicated the great scieniic and technological development; 10% considered the introducion to the concept of the paient’s autonomy; 8% credited it to the loss of presige of the profession; 6% to a greater access to the paient’s informaion due to the Inter-net. The raio of those who answered other was 13%. When quesioned about other factors that caused such change, the respondents who marked other answered: poor remuneraion, work overload; lack of proper training in bioethics in the graduate course, which allows to situate the physician’s con -diion in view of the social transformaions caused by the other marked items; poor working condiions; low educaional level of society; overwork, inancial aspect that leads physicians to work in several plac-es to have a suitable wage and, therefore, having litle ime to give atenion to paients, as well as
‘get on with work’.This last expression, used in
med-ical jargon, refers to ‘perform every service quickly, even if in large amounts’.
In quesion 2, on the “efect of the introducion of the concept of autonomy in the physician-paient relaionship”, 52% of respondents answered that it was very important; 44%, important; 2%, more or less important; 2% not important. When added, the two most frequent answers - important and very important -, we observed that 96% of respon-dents considered the introducion of the concept of autonomy in the physician-paient relaionship as relevant.
In quesion 3 – which asked the opinion of the professional as to the meaning of the intro-ducion of the concept of autonomy regarding the physician-paient relaionship -, 84% of respondents stated that the relaionship became more complex; 13% less complex and, for 3% this concept had no importance.
Quesion 4 asked the professional to what ex-tent the introducion of the concept of autonomy was an advance or regression to the paient. For 77% of respondents, it was a signiicant advance, and for 16%, an average advance. No respondent indicated a regression. In this quesion, 7% of answers were disregarded, due to duplicity in the choices.
Whereas quesion 5, which asked to what ex-tent the introducion of the concept of autonomy
was an advance or regression to the physician, pre-sented the following percentages of respondents’ answers: 73%, a signiicant advance; 18%, an aver-age advance; 2%, a small advance. No respondent considered it a regression. Again, in this quesion, 7% of answers were disregarded, due to duplicity in the choices.
Quesion 6 had the following statement: The principle of autonomy, in a totally capable person, as to a mental point of view, should be absolute. In rela-ion to this statement, the answer totally agree was indicated by 43% of respondents; 42% answered agree, while only 15% marked disagree. No respon-dent answered totally disagree.
In quesion 7 – Considering that the ver-bal consent of the paient, for diagnosic and therapeuic pracices, is an ethical requirement and demonstraion of respect for the bioethical principal of autonomy of the paient -, of the respondents who claimed to know such concept and to put it into pracice, 75% do it frequently; 16%, someimes; 6%, seldom. Only 3% know the concept, but do not apply it in pracice.While adding the two irst answers – frequently and someimes -, we observed that 91% of respondents claimed to know the concept and to put it into pracice with a certain frequency.
Quesion 8 had the following statement: Some authors consider that the “informed consent form” (ICF), formally signed by physician and paient, is necessary in the current medical pracice. In relaion to it, 32% of respondents marked the answer knows the recommendaion [of the ICF], but does not put it into pracice; 29% seldom put it into pracice; 26%, oten; 11%, someimes, while only 2% claimed to not know the recommendaion.
As to quesion 9 – which asked the opinion of the professional on concept of paternalism, in which the medical pracice was historically based (since Hippocrates to mid-20th century) -, the following
an-swers were given: 43% of respondents considered that this concept should be applied someimes; 13% answered that it shall be applied oten, and only 8% believe that it should be rouinely applied. It is worth highlighing that 34% of respondents considered the concept of paternalism as outdated, and 2% of them did not answer the quesion.
Quesion 10 asked the respondent’s opinion regarding the phrase “The biggest cause of claims (ethical and legal) against physicians is the inadequate physician-paient relaionship or the inadequate re-laionship of the physician with the paient’s family”, in relaion to which, 64% of respondents stated that
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they totally agree; 29% agree moderately; 2% slightly agree,3% of respondents moderately disagree with the statement, and only 2% totally disagree. None of them answered slightly disagrees.
Quesion 11 asked: In your daily pracice, is it common for a paient to arrive for consultaion or return for medical review with informaion obtained from the Internet? We observed that 56% of respon-dents answered generally and 42% indicated that the situaion someimes occurs. Only 2% of respon-dents did not answer the quesion.
Quesion 12 – which asked the professional’s opinion on the fact that the paient searches for in-formaion on the Internet about their own diseases - was subdivided into two parts: the irst part asked if this fact increases the paient’s autonomy, and the second part, if it interferes in the physician’s autono-my, also with the alternaive no opinion. As to the irst part, 85.5% of respondents answered yes (i.e., the fact that when the paient searches for informaion on the Internet about their own diseases, it increases their autonomy), whereas 12.9% marked no. On the second part of the quesionnaire, 66.1% of respon-dents stated no (i.e., internet search for informaion, by the paient, does not interfere in the physician’s autonomy), while 32.2% answered yes. Only 1.6% of respondents have no opinion on the topic.
Quesion 13 asked the professional on their approval or not as to the fact of the paient brings, for consultaion or return for medical review, several informaion from the Internet.In response, 68% of respondents stated that they approve the fact; 24% stated that they do not consider it relevant; 5% do not approve it, and 3% did not answer the quesion. Those who do not approve this paient’s aitude jusiied their answer as follows: “The anguish in-creases with informaion that is not interpreted correctly”; “It is rarely applicable”; “I do not approve it because most of ime informaion is wrongly in-terpreted”.The respondents’ answers that approve the paient’s aitude could be classiied in three categories: 1) right and autonomy of the paient; 2) increase of the paient’s involvement; 3) improve-ment of the physician-paient relaionship.
Regarding the irst of these categories – right and autonomy of the paient -, the following answers were obtained: “It is a proof of the paient’s autono-my”; “I respect the paient’s right. I keep my conduct and my rights”; “Search for knowledge”. Regarding the second category – increased paient’s involve-ment -, it was reported:“It increases the paient’s involvement and responsibility in the treatment”; “It demonstrates the paient’s interest in their own care
and adherence to therapeuics”; “It is a sign that the paient is assuming their responsibiliies”. As to the third category, concerning the improvement of the physician-paient relaionship, the respondents informed: “It provides the paient with the oppor -tunity for clariicaions and reinforces the paient’s conidence in the relaionship with their physician”; “The dialogue during the consultaion lows beter and the discussion and conduct to be indicated by the physician becomes more transparent”; “It helps the physician-paient relaionship”.
In quesion 14, healthcare professionals were asked how they see the importance of the phy-sician-paient relaionship nowadays, in view of the extraordinary advances in the diagnosic and therapeuic areas. For 74% of respondents, the physician-paient relaionship has a great relevance nowadays; 26% believe it is reasonably relevant, and no respondent answered that it is slightly or not rel-evant.
Quesion 15 listed some factors deemed as relevant for competent medical care, and asked the professional to indicate that which they considered predominant. For 37% of respondents, the most important factor for competent medical care is the proper physician-paient relaionship. Then, next to it the scieniic development of the professional, the most important factor for 23% of respondents. Good condiions for professional pracice is the most important factor for 16% of respondents, while 18% believe that all factors menioned contribute to improve medical care. In this quesion, 3% of re-spondents answered other, and, when asked about what would be this factor considered by them as the most important, we had the following answers: “Good ethical, moral and professional values (char-acter)”; “Development and proper physician-paient relaionship”. Due to their lack of clarity, 3% of an-swers were deemed invalid.
Quesion 16 asked healthcare professionals on the future importance of the face-to-face rela-ionship between physician and paient, in view of technological advances in the diagnosic and therapeuic areas. We observed that, for 90% of respondents, this relaionship will always be essen-ial and indispensable, regardless of technological advances, whereas 10% believe that face-to-face relaionship will be less and less important, but will always occur. None of them considers that this rela-ionship will be less and less important, unil be no longer necessary in the future.
Finally, quesion 17 addressed the represen-taions and emoions involved in the professional
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pracice, going from Hippocrates’s proposiion ac-cording to which the physician should have a feeling of love for the paient, not an eroic kind of love – but one deined as philia -, and such friendship for the paient being fundamental in the therapeuic relaionship. The respondents were asked whether such proposiion would be acceptable, in the cur-rent techno-science age. We observed that, for 87% of respondents, the concept of philia is current and very important in the physician-paient relaion-ship; 10% considered that it may be important in certain cases and 3% deemed the concept as com-pletely outdated.
Discussion
We had a return of 84.9% of quesionnaires sent to members and former members of Creme-sp, and such fact makes this study sample very consistent. It is worth highlighing that 84% of re-spondents are aged between 51 and 70 years, and 96% had been medical graduates for more than 21 years and 82.2% have served as member of Creme-sp for more than 10 years.
In Brazil and, possibly in South-American countries, several authors, among which, we are included 1,9,10, consider that the physician-paient relaionship is sill fundamentally important in the medical care provided to our paients. To Hossne 1,
the principle of autonomy is one of the most signii-cant bioethical achievements of the last century.
Due to the relevance of the physician-paient relaionship in our culture, we could quesion if, among us, the impact of the bioethical principle of autonomy in this relaionship was not greater than in other countries. Possibly yes, but the data ob-tained by us do not favor this hypothesis. Only 10% of respondents viewed autonomy as the factor that most caused changes in the physician-paient rela-ionship, whereas 52% considered the introducion of the intermediary element (health insurance, pub-lic health system), the most important factor.
Another aspect highlighted by three respon-dents as the one which caused most changes in this relaionship was “poor medical working condiions”, characterized by work overload and low wages in this professional category.
Our data demonstrate that, for most respon-dents, the introducion of the concept of autonomy in the physician-paient relaionship was important or very important (96%) and made this relaionship more complex (84%).
The introducion of the principle of autonomy was viewed as a great advance for the paient by most respondents (77%), while 73% considered it a signiicant advance for the physician. Hossne 1 also
views the introducion of autonomy in the clinical relaionship as a great advance, but draws atenion to the emergence of new ethical conlicts and the increased complexity of this relaionship.
Only 15% of respondents disagreed with the phrase “The bioethical principle of autonomy, in a totally capable person, as to a mental point of view, should be absolute”. The vast majority (85%) agreed with this statement, showing the strong impact of the bioethical principle of autonomy in the medical pracice, mainly in the view of a speciic group of physicians, responsible for assessing the profession-al pracice.
Such view is not supported by the literature. Several authors, among which Engelhardt Jr. 11 and
Rothman 12, consider that the current relecion
about the bioethical principle of autonomy includes the right of having the self-determinaion of people respected in the context of broader issues, such as social reality, distribuion of funds for health, com-pliance with laws in force, fair cause, etc.
In relaion to the necessary consent of the pa-ient for diagnosic and therapeuic pracices as an ethical requirement and a sign of respect towards the self-determinaion of people, our results widely conirm literature data 13,14. Almost all respondents (96.7%) know, agree and put into pracice this re-quirement, duly contemplated not only in bioethical relecions, but also in pracically all professional codes of ethics of western medicine.
As to the informed consent form (ICF), formal-ly signed by paient and physician for diagnosic or therapeuic procedures, out of the study protocols, there is no consensus, nor in the literature nor in our results, and there are no legal, deontological or eth-ical devices in Brazil, as in the case of research with human beings. Only 26% of respondents know the recommendaion and oten put it into pracice, and approximately one third of them knows the recom-mendaion, however they do not put it into pracice.
We consider that the signature of the ICF, in itself, is not a guarantee that the paient was duly clariied, in addiion, the obligaion of presening this document may lead to the “bureaucraisaion” of the physician-paient relaionship 10. The con-sent should be, above all, a construcive process of consensus in a relaionship of trust, and not only a simple contract signed at a certain moment.
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As to the current pracice of paternalism, ap-proximately one third of respondents (34%) deemed this concept as outdated, while 64% believe it is nec-essary to use it. These data are in accordance with the current literature trend of rediscussing the role of the paternalist acion of the physician in the rela-ionship with their paients.
According to Cohen and Marcolino 15, in the physician-paient relaionship, autonomy and paternalism are complementary, and the igure that best represents it, would be a pendulum in which, at one end, we would have a radically au-tonomous relaionship, and, on the other end, we would have a centre with absolute predominance of paternalism. And both – physician and paient – would have to ind the ideal point of this pendu-lum movement.
In this sense, the applicaion of the Greek concept of philia in the physician-paient relaion-ship nowadays, coninues to be viewed by most respondents (87%) as very current and essenial. To Hossne 1, philia presupposes equality of the paries,
the search for symmetry in the physician-paient re-laionship and, evidently, a greater respect for the autonomy of the paient and healthcare profession-al, in the broadest possible sense.
Our understanding is that a proper physi-cian-paient relaionship is impossible without the presence of emoional involvement and the rela-ionship of trust and partnership between those who seek the physician to treat their health issues and the professional itself, technically trained and oriented to take care of this person.
Regarding the introducion of the Internet use by the paient in order to search for informaion about their health, our data evidence the strong inluence of this tool in the relaionship between pa-ient and physician. More than half of respondents (56%) answered that in general, paients come to the consultaion with informaion from the Internet. For the vast majority (85%) this acion increases the paient’s autonomy and, for 32% of them, it inter-feres in the physician’s autonomy.
The results of our study, as well as of other published studies16, not only show the considerable impact caused by the Internet in the physician-pa-ient relaionship, but also in the indisputable reality of the use of this resource in the healthcare area. Thus, the principle of autonomy led to increased ethical conlicts in this relaionship, the Internet made it more complex, and it may facilitate or hin-der the respect for the autonomy of the paient and
physician, which essenially depends on the quality of the relaionship established at each meeing.
Regarding the fact of the paient having used the Internet to know more about their disease, most of them (68%) approve such aitude and 5% do not approve. Among those who approve it, the jusiicaions are that this procedure increas-es the autonomy and engagement of the paient in decision-making processes and improves the physician-paient relaionship. However, our data corroborate the indings of Broom 16, who states that the Internet use can improve the treatment of paients, but that part of the physicians sill inds it diicult to deal with this inevitable reality.
In our view, the fact that paients refer to the Internet may lead, on one hand, to an improved di-alogue with the physician, to an easier building of “bridges” and greater atenion of the professional regarding their paients. Conversely, it may create resistances and diiculies, if the physician feels that they are being “checked” by the paient as to their knowledge and update, which may generate a situa-ion of mutual distrust.
Regarding the importance of the physi-cian-paient relaionship nowadays, in the current techno-science age, a signiicant part of respondents (74%) considers it very important, and for the vast majority (90%) it will always be fundamental and in-dispensable. It is worth emphasizing that, for 35% of respondents, the most important factor for com-petent medical care is the suitable physician-paient relaionship and that, for 18%, factors such as due scieniic development, proper physician-paient relaionship and good condiions for professional pracice are necessary for competent medical care – however it is impossible to point out which of them is more important.
Nor can we fail to menion the fact that most respondents (93%) agree with the statement ac-cording to which, the greatest cause for ethical and legal claims against physicians is the inadequate re-laionship between physician and their paients or their family members, conirming the assumpion advocated by Hossne 17. The importance of the phy-sician-paient relaionship nowadays is a topic for relecion, now under the bioethical view, reliving paradigms consolidated by Balint 18 and Tähkä 19. To Godolphin 20, we are deiniively in the age of “shared decisions”, where physician and paient should as-sume the respecive responsibiliies for their choices.
Obviously, we do not aim to generalize the results obtained here. The indings are valid, in
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Recebido: 14.11.2014 Revisado: 28. 3.2015 Aprovado: 23. 4.2015
last analysis, for the studied group. Future studies should be conducted with paients and physician assistants, for a more global view of the topics dis-cussed here.
Final consideraions
Finally, our data, as well as the literature re-view, signal to aspects such as the fundamental relevance of the introducion of the bioethical principle of autonomy in the physician-paient rela-ionship, the diiculies of its introducion in clinical pracice, the remarkable philosophical importance that it acquired in recent years, without forgeing the considerable and welcome ethical conlicts arising thereof - a result of philosophical and tech-nological advances of our ime.
They also point to the urgent need of rescu-ing, as fundamental factors of the physician-paient relaionship, the emoional engagement of the physician in the care for their paients and the be-nevolent paternalist aitude, adapted to nowadays.
In short, this study allowed us to reach three important conclusions, which we believe may con-tribute to future discussions in the bioethics ield: (1) the introducion of the bioethical principle of autonomy in the physician-paient relaionship was a great advance for the paient and increased the complexity of the relaionship; (2) the Internet use in healthcare increases the paient’s autonomy and can improve the physician-paient relaionship and increase the paient’s paricipaion in decision-mak-ing processes; (3) the physician-paient relaionship is very important nowadays and will always be es-senial and indispensable.
This aricle is based on a PhD thesis of 2012, prepared in accordance with the Graduate Program in Bioethics of São Camilo University Centre (Centro Universitário São Camilo), São Paulo/SP, Brazil.
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Paricipação dos autores
José Marques Filho, doutorando do Centro Universitário São Camilo, autor do texto. William Saad Hossne, orientador da tese de doutorado e coautor do texto.
