Chapter 4: Professionalism, Elitism and Health Care

Section 3. Presentation of Issues

Code Contract Covenant

Three Models of the Relationship between Health Care Provider and the Recipient

In examining how moral questions are death with by health care providers it is instructive to consider the self concept or the model of the relationship of the health care provider to the recipient of health care and how those ideas factor into the deliberative process. This is so because the members of the health care professions carry with them a model or basic idea of how it is that they relate to those whom they serve in one model or to whom they render care in other models. Since most of health care is controlled by the physician the nature of the relationship of the physician to the recipient of medical care will serve as the focus here. With some modification the same basic models are also evidenced in the other health care professions.

Medical Practice and Models

Practitioners of medicine operate with a set of relationships. At times the different relationships can cause a strain or present a dilemma for the physician.

Consider that on the one hand the physician has a relationship with the recipient of health care , called a patient and on the other hand the physician has a relationship with all other physicians, whom they call colleagues.

The Physician's Relationships
Physician >Recipient of Care (Patient )	Physician > Physician (Colleague)
Physician > Family of Recipient
Physician > Public

The symbol > means "in a relation with"

There will be times that a doctor feels torn between a sense of loyalty towards and responsibility for professional colleagues and a sense of obligation towards the well being of the recipient of health care. The resolution of that conflict often has more to do with the more general conception the doctor has of what the doctor is, the role of the doctor and the nature of the relationship with the patient. Both physicians and patients may be willing participants in the holding to these conceptions and model dynamic therefore it is inappropriate to simply apportion the origin or responsibility for these with the physicians.

Consider these different and basic self conceptions a physician might hold and operate with:

1. Paternalistic (Authoritarian)

Some physicians consider themselves to have responsibility for the physical well being of those who come to them for assistance. They think of themselves as a parent would think in relation to their children. The professional practitioner of medicine then assuming the role of parent will make decisions for the child (patient and provide only as much information as the parent thinks best for the patient (child The physician might even act in ways to influence or coerce the decisions or actions of those considered to be that physician's child.

This attitude is one that has the doctor acting in a most authoritarian manner.

Problem: Most mature adults do not want to be treated as if they were children. Most human beings want to maintain their autonomy and right of self determination. The law supports the rights of individuals to make their own decisions and their right to the information needed to make good decisions.

2. Priestly Model extended the role of the physician beyond that of an expert in medicine to that of a supposed expert in morality. This fallacious move promotes the unjust aspects of medical paternalism whereby the patient's role is severely reduced. The Priestly model is closely associated with the Hippocratic Oath.

3. The Warrior Model or "General and his troops" Model sees the physician fighting against the enemy. The patient is the battleground, and the illness is the 'enemy'. Accordingly, the patient gets lost...

4. Employee (less Authoritarian)

As an opposing alternative to the paternalistic approach some physicians consider themselves to be contracted employees and the person in need of assistance is the employer who contracts for certain services to be supplied by the physician. There is no obligation of the one toward the other beyond that of employer to employee.

Problem: Most physicians are not willing to see themselves and simply employees of the patient and obliged to do only what they are instructed to do by those patients. Doctors think of themselves as more knowledgeable about the ill person's condition and thus in a better position to make decisions concerning treatment than the ill person.

5. Collegial (non-authoritarian)

In this approach the physician would be seen as a colleague of the recipient of care, as an equal. The collegial approach to the basic relationship is one which attempts to be non-authoritarian in as much as neither party has a position of power over the other. The provider of care and the recipient of care are as equals. They meet and share a common concern for the physical and mental well being of the person seeking assistance. Together they discuss the situation, consider the options available and reach a decision as to the most appropriate and desirable course of treatment.

Problem: Physicians are not the equal of the recipient of health care in so far as medical knowledge and skill. They do not see themselves on equal footing with those who they treat.

6. Contractual (non-authoritarian)

In this approach the physician would be seen as a party to a contract and as such contracts with the recipient of care to perform services. If both agree to terms there is a contract. The physician is obliged to do only what is stated in the contract and the recipient of the service must in turn provide remuneration as stated in the contract.

Problem: There are several problems (see also below) not the least of which is that the parties to the contract usually have different educational backgrounds and knowledge of the medical condition. It is difficult , if not impossible, to arrange a fair contract between parties who are so unequal in their knowledge and interests.

7. Engineering Model has the physician as a 'hired gun' resulting in giving the patient too much power as well having no social norms governing over the physician patient relationship.

8. Covenential

The fifth approach would have the physicians seeing themselves as involved in a covenant with a deity or society itself and as such obliged to society to render care unto its members in return for what society had provided to the physicians.

Problem: There are not many physicians who are ready to acknowledge any indebtedness to society (see also below) and the concurrent obligation to provide service to others in return.

Code Contract Covenant

Three Models of the Relationship between Health Care Provider and the Recipient

Now keeping in mind these five basic forms of self conception,next in order is an examination of three basic models for the relationship of the health care provider to the recipient of the care. Each of these models has its own governing ideals, a different conceptual framework and the resultant perspectives that influences the decisions made and actions taken by the practitioner

The three models are: I. Code, II. Contract, III. Covenant

I. CODE

The model based on Code is one that harkens back to the mediaeval guilds. There are written and unwritten, traditional guides, and rules to govern the conduct of the members of the guild. The purpose of such regulations is the development and maintenance of technical proficiency. The knowledge and skills of the members of the guild is of he greatest importance and value.

There are written and official pronouncements made by the governing authorities of the guilds and the aim is to foster a sort of etiquette amongst guild members and to promote the members rendering service to those outside of the guild but as a matter of philanthropy and not out of obligation to any but fellow members of the guild.

Members of such professional associations have their own special language and often have initiation rites and are under an obligation of secrecy concerning the inner workings of the profession. Members have duties towards one another.

Members have deep feelings of solidarity which has them support one another and to be more cooperative rather than competitive. There would be a sort of anti-competitive monopolistic practices, such as price fixing, including the use of a sliding scale in order to maximize income.

In a time of managed care there are efforts to surmount the restrictions on practices that would drive the price of medical care higher. Doctors form their own group and corporate practice in order to maximize income and minimize the pressures of the competitive market.

For the members of the professional organizations (guilds) the overarching aim appears to create those institutions and practices that provide for a life style, an image, a sense of decorum and basically a beautiful life . The codes aim for the realization of an aesthetic ideal. They are not founded upon a concern for the welfare of society.

Concern for colleagues is greater than that for those served. Five (5) factors militate against self-criticism and self regulation

1. Sense of community -this is very strong

2. Power of the priestly caste - this is undermined by doubts and questions raised by colleagues

3. Power of the modern physician unstable- based on power over death -undermined by admission of limitations

4. Suspicion of officiousness, injustice, hypocrisy - caused by the special language, attitudes and secrecy of guild members

5. Basic conflict- there are two sets of obligations: to guild and to patient

On the one hand professionals appear to acknowledge obligations to colleagues. Such obligations are seen as being responsive as an obligation or a debt owed to other members of the guild for training , admittance and privileges of membership.

On the other hand obligations to patients are seen as being self-incurred and any duties involved towards the recipients of care are the result of the philanthropic acts of guild members.

Consider this shortened form of the most famous of the oaths.

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Hippocratic Oath By Hippocrates Written 400 B.C.E Translated by Francis Adams

I SWEAR by Apollo the physician, and Aesculapius, and Health, and All-heal, and all the gods and goddesses, that, according to my ability and judgment, I will keep this Oath and this stipulation- to reckon him who taught me this Art equally dear to me as my parents, to share my substance with him, and relieve his necessities if required; to look upon his offspring in the same footing as my own brothers, and to teach them this art, if they shall wish to learn it, without fee or stipulation; and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the Art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others. I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel; and in like manner I will not give to a woman a pessary to produce abortion. With purity and with holiness I will pass my life and practice my Art. I will not cut persons laboring under the stone, but will leave this to be done by men who are practitioners of this work. Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption; and, further from the seduction of females or males, of freemen and slaves. Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret. While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the art, respected by all men, in all times! But should I trespass and violate this Oath, may the reverse be my lot!

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Interesting sites concerning this oath and contemporary doctors.

Classical Version

Is the Hippocratic oath still relevant to practising doctors today?

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Notice in this ancient oath that the physician enters the profession acknowledging debts owed to those who trained the practitioner and to their families. This oath establishes a special relationship amongst those who take it that sets them apart from the general public. It establishes a relationship of debt and obligation amongst the professionals. Towards the recipients of their care the oath establishes a relationship of largess.

The physician regards other members of the profession as colleagues, teachers, and progeny.

In the codal model there is the ceremonial taking of an oath in which the member of the guild professes what is owed and what obligations are incurred. Further there is a recitation of what is appropriate and what is inappropriate conduct for a group member.

From the classical time of the Greeks there has been a Hippocratic Oath repeated, at least in part, in graduation ceremonies from medical school.

This oath includes the codal duties to patients and the conventional obligations to colleagues. It is set in the context of an oath sworn before the gods as witnesses but not as the originators of what the guild members possess. Their is no obligation to the gods incurred in return for any gift bestowed upon the physicians. They are what they have become due to what their predecessors have given them: knowledge and training.

So there is no reference to a gift from the gods and no promise to return anything to the gods. But there is such for their senior colleagues.

So this initiation oath and the acceptance of a code is seen as involving the physician in a profession because it was chosen, a chosen profession and a transformation that has occurred as an act of self transformation.

There are no obligations to a god or gods or to any transcendent source or authority.

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II. CONTRACT

In the contractual model there is a certain symmetry in the relationship of the members of the medical profession and those for whom they render service.

They are seen as nearly equal parties engaged in a voluntary association for mutual benefit. This model is one promoted in a time of frequent litigation. The enforcers of contracts promote envisioning the basic relationship between human beings in terms of an instrument that has a feature of legal enforcement.

It is a model in which the participants are seen as singularly motivated by self-interest and not philanthropy, e.g., informed consent is desired by the recipient of care as needed for intelligent decision making in keeping with the goals and values of the recipient of care and in acknowledgment of the right of self determination. Informed consent is seen by the provider of care as desirable as a means of protection against charges of coercion or any other charge that would hold the provider liable for the outcomes of the services rendered.

This model is beset with difficulties and despite its being urged by litigators, medical practitioners are not taking to it in its entirety. It has influence medical practice in so far as the taking of measures to minimize exposure to liability.

Here are some of the problems.

A. Minimalism - With a contract the physician is obliged to do only what is set out in the terms of the contract-no more and no less- or else there may be a claim ( and possible damages-monetary damages) against the physician by the other party in the contract.

B. Unpredictability - Often in health care and particularly in surgery there are unpredictable circumstances that could arise. If they are not covered by the contract then there is no ground for the physician to respond to those circumstance including those that may pose a strong threat to the well being of the other party in the contract.

C. Maximalism- Defense Mechanism - The physician in order to protect the practice from possible claims against it by the other parties to the contracts for services, would be pressured to include procedures, practices and treatments in the contract not so much for the well being of the recipient but to protect against possible malpractice suits. Thus, more tests may be ordered than are strictly need in order that there not be a claim that the physician had and anything less than was in order to detect or prevent a harm to the recipient of care.

D. Inequality - The parties to a health care contract between the provider and the recipient of care are not equal in knowledge or skill, nor do they have equal aims or values. Thus any contract between them is less likely to be a fair one as one party is usually much more knowledgeable and likely to influence the other due to that knowledge. The recipient of care is often ill and under the pressure and anxiety to well. Such a condition operates against a mind needed for rational decision making.

E. No freedom of choice - Often the recipient of health care has little or no choice but to accept the terms of a contract as produced by the provider when that provider of care is the only one near to or affordable to or provided to the recipient of that care.

F. Denies transcendent rights and duties - This model does not allow for the physician to acknowledge that there is any ground for an obligation to provide service other than the one voluntarily incurred by the parties entering into the contract and then that obligation is only to the extent indicated by the terms of the contract.

III. COVENANT

The key elements of the Covenant Model are promise and fidelity to the promise. In this model the physician has received a gift of the knowledge and skills needed to practice the healing arts. In return the physician has made a promise to incur a debt in return for what was provided to prepare the physician to be a member of the profession of medicine .

The physician is responsive to the debt and has taken on an obligation to the society that extended itself to provide the knowledge , training and skills of the physician to those who enter into the medical education programs.

The Covenant Model involves a Canon of Loyalty and Fidelity. The physician under the debt to society is obliged to provide society with the truth and be faithful to the promise to provide care. The aim of this model is not proficiency but genuine care.

With this approach the doctor undergoes a change in Being, a change in ontological nature, e.g., temporal aspect of being. The physician is now a physician and not just at those times when in the office or hospital but at all times. The person has undergone a transformation into a different sort of being, one possessed of knowledge and skills not found elsewhere in the populace. AS such whenever such a person encounters someone in need of those skills there is an obligation to provide service. And so such physicians would not hesitate at an accident scene to stop and render assistance if possible. This would be done out of a sense of obligation and without a sense of fear of lawsuit.

The problem with this model is that it needs a transcendent reference for the proper context. It needs a transcendent norm for rights and duties of physicians and patients. It needs a transcendent source of limits for expectations and duties.

If there is a god and that god gives someone the gift of knowledge and skill then the person owes it to that god to return something for what has been given. The source of obligation that is the basis for the sense of duty is the transcendent being. If there is no god or no effective belief in a god or no acknowledgment of anything being given by such a being to members of the medical profession then upon what shall the covenant rest. Who is in the covenant with the physicians?

In place of a supreme being or transcendent deity as the source of the indebtedness society itself may serve as the origin of the gift and as the party in a covenant with the medical profession.

The physicians’ indebtedness to society may be established by five (5) factors:

1. Education - no medical school is self sustaining. All teaching institutions receive state and federal aid and the students receive a variety of financial aids, most stemming from government or others in society.

2. Privileges - members of the medical profession are permitted what others in society are not. They may park where others do not. They may presume a certain deference that others must earn. They are taken before others for reservation and service.

3. Social Largess- The payments for medical services appear to many to be far beyond what ordinarily would be accepted as reasonable. The fees that are paid enable many in the medical profession to afford life styles most others may only envy. Society tolerates the gross disparity in the incomes of the average physician to the average member of society if only the physicians continue to render their services effectively.

4. Experimental Subjects - There can be no medical knowledge and no development of skills without human beings or the bodies of human beings. Medical research is needed and medical training must take place to gain the knowledge and skills that make a members of the medical profession what they are. People volunteer for such service in the hopes that they or others after them will benefit in some way from what is done to them. The physicians who acquire that knowledge so obtained owe a return to those from whom that knowledge was secured.

What form of return from the physicians?

1. debt of service- provide health care to the society that gave the physician the knowledge without which the physician is not a physician
2. return on knowledge -make it known what was learned-publish and share the knowledge with society
3.make themselves available as subjects for further research

5. Continual Support of profession and individuals -Society continues to support the Institution of Health Care and physicians through the continuing support for medical research, education, and the financial disparity. Society may expect something in return.

The Covenant Model includes and extends beyond that of code and contract . It include aspects of the code: fidelity to duty, responsibilities to patients and colleagues. It includes elements of the contract model in terms of fidelity to the terms of a contract.

However, the Covenant Model requires more because there is a surplus of obligations to society and these are the final advantage of this model over the others.

The obligations (debts) to society in the Covenant Model are greater than debts to colleagues in the Codal Model.

The Covenant Model has its advantages:

1. Permits possibility of self-discipline

2. Not so personal- applies to the whole profession, a covenant with society broadens accountability

3. Permits setting professional responsibility for one human good (health) within social limits

Problem with the Covenant Model:

" Also, the concept of being a physician at all times is too idealistic as well. Just last week at work I heard two surgeons talking about the new cars that they were going to purchase. One surgeon asked the other if he was getting "MD" license plates on his new car. The second surgeon responded, "Why do that? I don't want everyone knowing that I am a doctor." I interpreted this as meaning, without MD plates no one will know I am a doctor and I will not have to stop and help out in an emergency situation where my skills as a physician may help save a life. I don't know if this is what he meant, but it sure sounded like it. "

In each of these models the "Patient" Role relates to the physician's self image and general model for the relationship between the provider and recipient of care.

If the physician's self conception is as parent or priest , then the patient is seen as dependent.

If the physician's self conception is as technician, then the patient is seen as passive host of disease.

If the physician's self conception is as contractual partner, then the patient is seen as equal participant .

If the physician's self conception is as covenantor, then the patient is seen as active participant and is there are with all other parties, providers and recipients, mutual reciprocal rights and duties, gifts and debts, promises and obligations .

Now consider the application of the models and images to the three cases offered at the start of this module. In so doing you should see fairly clearly the rather different results that might emerge in the same situation but using a different conceptual setting, a different model for examining the nature of the relationships and whatever obligations may be involved.

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Web Surfer's Caveat: These are class notes, intended to comment on readings and amplify class discussion. They should be read as such. They are not intended for publication or general distribution.

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