In spite of the conflicts in ethics to do with beneficence and non-maleficence, respecting autonomy is relatively easy when the patient is competent and has the full mental capacity to refuse treatment, when a person can apply reason, and their own morals, beliefs or value system, we as healthcare professionals must respect this. In respecting patient autonomy, a person has the right to refuse treatment even if this decision may result in harm or death.
When such conflicting issues arise, healthcare professions must be aware that they should not disclose their personal beliefs and values to the patient, as this may distress them and exploit their vulnerability (1). Competence if defined as having the mental capacity to make a decision. Capacity is defined as the ability of the patient understand and retain information given about their treatment, weigh up or use information to progress to a decision about their treatment and to then communicate their wishes effectively.
The next part of research I came across was the Mental Capacity Act 2005, which states that if a person cannot do the things I just listed, they are deemed incapacitated and are not in control of their treatment. Carers and healthcare professionals are able to make the decisions that are vital to the health of the patient for them. Capacity can be lost through the onset of or progress of a mental disorder or other disability and in this case, if the patient has made a living will or advance directive stating their preferences for care, then these must be carried out as the patient made these requests when they were competent so their autonomy must be respected.
If a patient lacks the mental capacity to consent, a doctor can compulsorily treat them, but only for the mental illness and physical disorders arising from that illness. This prevents the exploitation of vulnerable patients being subjected to experimental treatments while unable to refuse their use. When capacity is lost, the high regard for patient autonomy is replaced by the high regard for beneficence and teleological or utalitarianist theology is employed, in which the right thing to do is that that brings about the best outcome. In this way, the integrity of the patient-centred approach is maintained.
Healthcare professionals have a duty of confidentiality owed to their patients. In accordance with the respect for patient autonomy, the medical information about them is private and for them to disclose how they see fit. Medical information can influence a number of things in a patient’s life, such as employment, social and personal life and lifestyle so a breech of this confidentiality can lead to the patient becoming vulnerable in some way.
Although members of the healthcare team can discuss the notes of a patient in relation to their care and treatment, no other discussion is permitted outside of that perimeter. Discussion must be in private, notes must be properly protected to prevent a breech and all disclosures must be discussed with the patient. Only in the cases of serious crime prevention, such as murder or rape can medical details be released without the individuals consent.
Confidentiality is in place to protect vulnerable people, and also, to instil trust in the doctor patient relationship. If a person knows that no matter what they say (within legal perimeters) the information will go no further, they are far more likely to give a true picture of their health and circumstances. This is vital for the patient-centred approach, where the doctor relies on patient disclosure to make accurate diagnosis and assess the best approach for treatment. In reality, the fact that this law is upheld by the entire healthcare team is an opportunity for nurses to get a better picture of the personal circumstances of a patient, which they often do due to the more one-on-one role with individual patients.
The Doctor-Patient relationship
There are some key features of the doctor-patient relationship that are in place to directly achieve a patient-centred approach, including the establishment of rapport and the use of empathy, which I will be focusing on in this part of the essay. Building rapport is the process of building a relationship of mutual trust and understanding between the healthcare professional and the patient. It involves the non-verbal communication of welcoming, openness and receptiveness. It is important that the patient is greeted with a friendly and pleasant manor as this makes the conversation more likely to flow and for the patient to feel at ease. It is as important that a doctor greet all her patients in this way and is not judgemental or make people earn or deserve her respect.
This shows a respect for patient autonomy and allows the doctor to be more receptive to the things the patient is disclosing about their lifestyle, culture or religion. Rapport is also about noticing the mood or emotional state of the individual and addressing this appropriately, taking an interest in their wellbeing. The integrity of the rapport between doctor and patient can directly affect the likelihood of patient adherence to treatment.
A friendly, sympathetic doctor is more likely to get a positive response from their patient, in a similar way that negative feelings between the doctor and patient can lead to resentment and treatment advice being ignored (1). A study by Rogers in 1967 stated that ‘the core therapist attitudes of empathy, congruence and unconditional positive regard are both necessary and sufficient for effecting therapeutic change in clients’, an attitude still upheld today and one fundamental to patient-centred care. The trust between patient and physician is sacred with a good rapport the patient is more likely to disclose more personal information that could aid the doctor in their treatment.
Empathy can be shown to patients by acknowledging, understanding and validating their perspective/emotions, and by offering support and solutions. It can be shown in the tone of voice, facial expressions, posture and even the touch of an empathic doctor. Engaging the patient in eye contact during the consultation and showing that you have listened by checking the information you have received with them, all of the above are key communication skills required to establish a good relationship with the patient.
From the doctor’s perspective, it is important to empathise rather than sympathise, as the weight of other people’s problems would gradually become unbearable. Empathy is about understanding that illness has a personal meaning for each patient; a compound leg fracture would not affect an office worker in the same way it would an athlete; the economic position may be jeopardised by illness; cultural and social influences may affect the patient’s response to illness (1). Listening to the patient and gaining insight into their psychology may give indications of their attitude to their illness and recovery.
This brings me to the idea of mutualism, a concept which is inclusive of the doctor and the patient both having an equal say in the outcome of a consultation, sharing the responsibility of the care prescribed and for the modern patient to be respected as an individual. With the knowledge of ‘lay’ people expanding due to better access to information and better knowledge of patient choice and rights, patients have become active consumers of care, so demand the chance to have a say in their treatment. This is patient-centred care in its entirety, allowing the patient to have a large input into their care and to effectively work as part of the healthcare team.
Mutualism also includes the view that doctors are human and also have emotional response to patients, in the same way that we anticipate the way in which the patient will react to certain factors in the interview. Self awareness is therefore an element which doctors must master as an outward emotional response to a patient may evoke negative behaviour such as constraint or aggression, damaging the relationship. If a doctor is aware of which things will trigger an emotional response in her, there is an opportunity for management of outward emotions.
The laws and ethics applied in the healthcare environment are all in place to direct healthcare professionals towards the same outcome: a patient-centred approach. If the autonomy of each individual patient can be respected by every healthcare professional, there can be a higher standard of medical care given as the patient will have the right to an equal input in the decisions about their care, and so will be more involved in the recovery and management of illness, leading to a sense of well being. It is the duty of all healthcare professionals to have a high standard of communication skills in order to facilitate and understand the needs of the individual and to be responsive to their questions, worries and requests and to ensure the safety, health and well being of each patient to the full extent of their power.
1) Seeking Patient’s consent: the ethical considerations, GMC
2) Patient-centeredness: a conceptual framework and review of the empirical literature, Nicola Mead and Peter Bower 2000
3) Confidentiality guidelines for doctors, GMC