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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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Professor Maddocks’ statement: “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.” indicates his work relates to public hospital patients. Any patient, for instance wishing to return home who can afford it must have their need and request met. Prof. Maddocks appears to be arguing in favour of “compromise”, as he appears to regard outcomes as “elusive”. One has to ask, “from whose point of view?”.
“Best interest” is a personal viewpoint [1]. If the patient’s viewpoint is not respected, and is within the Law, what is elusive is the necessary support and care required to achieve the patient’s preferred and choicest outcome. Failure to respect the patient’s wish is the explanation that Victorian Inquiry into “End of Life choices” failed to include in their report [2], by not referring to my submission that pinpoints this [3], yet in which it is reported that more people who wanted to return home were prohibited from doing so than those who went to other destinations/supportive care/residential care/nursing homes [2].
The failure to support their choices occurred by those who consider themselves the best, including Geriatric Assessment teams, and even the Medical Board President’s, Dr Joann Flynn’s viewpoint, which was that sending the patient to a nursing home was not a bad decision, albeit not what the patient wanted, which falls short of ethical standards of care, as the Victorian Legislative Council reports now makes resoundingly clear. Unfortunately, even the High Court decision, not to approve special leave to Appeal the Medical Board decision showed conspiracy to side with the Chief Justice whose decision abetted Elder Abuse [4,5].
Action taken to prevent patient choices, by whomever they happen to come under following an incident or event, creates situations where the patient views were not respected, usually because because it was in their view a “safety” issue, yet living anywhere is subject to “risk”. Professor Maddocks’ view leans towards doing so as well, yet wishing to guide us to respect patient choices. He is of that old school. He speaks in terms of patient autonomy instead of patient centred care.
His point is clear, but his view is patronising and wrong and contradicts the point he wishes to make, which needs to be defined in the context of the patient’s viewpoint – that and only that is in the patient’s “best interest” also termed social and psychological wellbeing [6], namely to act in the person’s best interest, and do whatever is possible to ensure the outcome of choice for the patient.
Usually any dissonance can be managed by ensuring the patient has a trial, e.g. of home support. If this fails the patient will usually agree to what they can best tolerate, and which is part of the agreement between the treating team, family and the patient, with input from the doctor that the patient trusts or anyone they trust, not anyone, family or doctor, they do not, or who may be thrust upon them, as well as the patient. The guiding focus of any decision must be the patient’s choice and be patient centred, with goals agreed to in achievable time frames.
As written years ago [7] and more recently [5], the goal of treatment is patient happiness. That means the outcome is one that the patient wishes to live with. No-one has any right to interfere with that, but to provide the necessary information so that the patient can make their choice according to “best interest”[1,5,8]. The patient’s view provides the context that makes decisions ethical [4]. Failure to grant the patient autonomy fails ethical standards and due process [4,5,8].
Context is the basis of ethics [4]. The basis of ethical practice is having regard for the patient’s best interest [4,5,8]. That is the context that will determine an ethical outcome and best practice, for the scientific as well as personal viewpoint, based on respect and sanctity of the doctor-patient relationship [1,4,5,8] i.e. where third party interests, be they family, Medical Board or judicial interference or Tribunal imposition or by the Office of the Public Advocate have no relevance where they seek to deny the patient’s best interest, i.e. preferred choice, as such third party interference is unethical [1,4,5,7]. Ethics demands that the patient’s viewpoint is be respected, which is the basis of previous as well as updated legislation, but that needs to state, whether or not capacity is demonstrated, bearing in mind that cognitive and neuro-psychological testing tests cognition, but does not test capacity [1], and one cannot be extrapolated from the other. Capacity is demonstrated where patient wish is asserted by the patient despite Tribunal decisions to the contrary [5,7,8]. Unfortunately irresponsible and unethical practices that do not respect patient wish, and therefore “best interest”, occur in most public hospitals, Aged care services and mental/psychiatric services and hospitals and Tribunals in Australia, and which deny the main issue that Professor Maddocks does address, i.e. respect, but does not define, as respect for the patient’s wishes, in the light of all resources available to the patient, including their own personal, financial, family or friends.
Safety issues do not override Rights and responsibility issues [9]. Safety provisions must be provided. That is the difference between the rehabilitation approach and the palliative care approach or being patronising. Whichever, does not give anyone the right to undermine patient choices and supporting the patient to achieve their goals. This determines whether there is equality and justice, not as Professor Maddocks defines justice, who takes a one shoe fits all approach. That is not the standard of justice that recognises personal choice and best interest. In fact, the definition of justice purported by Prof. Maddocks does not define justice at all, rather it defines an injustice that abets being abusive.
It is a disgrace that patient wishes are not respected by those who “pretend” to care about the needs of patients, as exemplified by the decision of the Medical Board President, including it’s Dr Joanna Flynn, the Chief Justice Margaret Warren CJ, and the High Courts failure to grant leave to Appeal against their decisions, and that of the Victorian Administrative Tribunal, which not only failed to recognise Elder Abuse, they also abetted Elder abuse, when they had the opportunity to prevent it throughout Australia [4,5], but chose not to for their own self-serving, wrongful and unethical reasons [5-8].
And of course, in agreement, people feel good towards their doctor in whom they have trust. Good relationship indicates mutual respect, that can only also ever exist when one is dealing with grateful and well-intended medico’s and all well-intended and grateful patients.
1. Myers JB. ‘Ethics and professional medical opinion and Guardianship and Administration legislation’. Intern Med J. 2006, Volume 36(8), 540-541.
2. Edward O’Donohue, Nina Springle, Margaret Fitzherbert, Cesar Melhem, Daniel Mulino, Fiona Patten, Inga Peulich, Jaclyn Symes, 2016, Inquiry into end of life choices: final report, Legislative Council Legal and Social Issues Committee (Vic). http://apo.org.au/node/64524.
3. Myers JB. Submission to the Inquiry into end of life choices: final report, Legislative Council Legal and Social Issues Committee (Vic). http://apo.org.au/node/64524.August 2015, to:
4. Myers JB. ‘Duty to care’, or, ‘duty of care’ and the goal of medical treatment. Intern Med J, 2007, Vol 37(3), 211.
5. Myers, J. (2014) Medical Ethics: Context Is the Key Word. International Journal of Clinical Medicine, 5, 1030-1045. doi: 10.4236/ijcm.2014.516134.
6. Office of Senior Victorians(2005) Elder Abuse Prevention.Consultation Paper.Vic.gov.au.
7. Myers John B. Erratum to “Is Alzheimer’s Disease an Adaptability Disorder? What Role Does Happiness Have in Treatment, Management and Prevention.” World Journal of Neuroscience 5 (2015) 180-188]. DOI: 10.4236/wjns.2015.54027 Pub. Date: July 31, 2015.
8. Buchanan, J. and Nettle, J. (2005) Supreme Court of Appeal. Leave Application made 01 April 2005, Authenticated 14 April 2005. Myers vs Medical Practitioner’s Board of Victoria. VSCA No. 2005/7516-04-11.
9. Myers JB. Is The Future Direction in Health About Bureaucratic Self Interest or Creativity, Professionalism and Wellbeing? Rights and Responsibility Must Replace Quality And Safety In Health Care. RACP Future Directions in Health Congress. Perth, Australia 26-29 May 2013. Int Med J. May 2013: 43, Issue S3, Page 1-55.
And of course, in agreement, people feel good towards their doctor in whom they have trust. Good relationship indicates mutual respect, taht can only also ever exist when one is dealing with grateful and well-intended medico’s and all well-intended and grateful patients.