DEFINITIONS of “the good” have long exercised philosophers and will vary, depending on the particular standpoint of the enquirer. In medicine today, “good practice” needs to demonstrate that it is evidence-based, patient-centred and that it accords with the principles of medical ethics, including satisfying patient autonomy, affirming practitioner beneficence, avoiding maleficence and operating with justice.
These principles will not always cohere into a single clear or obvious decision concerning what is best for the patient in a particular situation.
If autonomy is held by the patient as an absolute affirmation of personal authority, it may challenge the practitioner’s opinion of what it is in the patient’s best interest; if what the patient demands requires extravagant resources beyond what can readily be made available to others, it will fall outside the boundary of what justice allows.
Each patient is different; each clinical situation is unique and constantly changing.
We need a process that does not separate ethical consideration into separate components which are inconsistent in their effects. We need an understanding of best practice that encourages the practitioner to accompany the patient along a pathway of decision making, taking note of all the complexities of disease, family context, life history, ideology and faith, and to seek common ground on which to consider current and future issues, and how they might be best resolved.
That process calls first for respect.
Respect has many components; basic to all is an attentive and patient attitude that encourages the consideration of each one. There is respect for the law; allowing no criminal action. There is respect for the disease process, its potential and realities for prognosis, discomfort, improvement or deterioration. There is respect for the science of medicine, offering evidence to guide management options in this particular situation. There is respect for the patient’s background, expressions of need, hopes and desires; respect for the family setting and its involvement and contribution. There is respect for time, for the balance of urgency and patience; and the practitioner’s respect for self, which offers protection against being swayed towards a hasty or unwelcome conclusion.
Relationship grows from respect. Respect facilitates an exchange that builds a sincere mutual regard. Relationship does not necessarily imply an element of love or liking, though a sense of emotional attachment will be neither uncommon nor improper (it is remarkable how often a “difficult” patient becomes a friend). It is founded in honest, open exchange of perceptions and a revelation of feelings, a willingness to return to formerly unresolved issues or disagreements to undertake a further consideration of what might be possible and mutually acceptable.
Respect and relationship are both two-way processes; they impact on the practitioner and on the patient, affirming both personalities. They start from no prior, fixed or necessary outcome, but work towards the common understanding, cautious and tentative though it may initially be. They offer a stimulus for a fuller consideration of matters in contention, and an opportunity for change in attitudes, prejudices, beliefs and intentions.
Though a final definite agreement may remain elusive, a sense of progress is likely to be experienced by both parties, with a new appreciation of each other in the exchange, and a greater comfort with whatever outcome finally emerges – and that is surely “good”.
Ian Maddocks, AM, is emeritus professor of Palliative and Supportive Services at Flinders University. He is an eminent palliative care specialist, recognised internationally for his work in palliative care, tropical and preventive medicine. He was Senior Australian of the Year in 2013.
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