Professional power
This article was published in Living Ethics: issue 84 winter 2011
One of the predominant, recurrent complaints brought against doctors by patients is their failure, in many circumstances, to adequately communicate. Patients claim that their stories are not heard, their complaints are not understood, diagnostic tests are not explained, the nature of their illness is not unfolded, their prognosis is unclear and instructions about therapy, medicine and pills are mumbled. indeed, the patient-doctor relationship is the focus of a growth industry in behavioural science research.
One must acknowledge the complexity of the patient-doctor relationship if an inquiry into truth telling and lying within it is to be understood. Although it is true that the majority of medical consultations, as carried out in general practice, are not major life events, in a minority of patient- doctor encounters there is intense anxiety. Each individual carries with them into the patient- doctor encounter a burden of anxiety – a fifty year old woman presenting to her doctor with a lump in her breast that she discovered while showering that morning, a sixty three year old businessman who wakes and discovers that his left arm is weak, an eighty year old, previously fit, man who experiences severe chest pain following unusual exertion – about their future, about the meaning of the symptoms and signs that they have discovered and about their likelihood to live or die. As well, they take anxious memories of similar past encounters; visiting the dentist today reminds us of previous drilling, injections and suckers under the tongue.
It is in those encounters in which the patient comes bearing anxiety that miscommunication and lies are likely to occur and where, if they do occur, they damage and distort most.
What may not be so obvious in such encounters between patient and doctor is the anxiety which the doctor brings with him or her. Doctors have been the subjects of many psychological studies. Our capacity to confront and handle our own mortality, and threats to it, is not great. We know too much but, in possession of that knowledge, we find it difficult to apply it accurately to ourselves and to our families. It is a wise dictum of medical practice that one should never treat one’s family. Less honoured is the notion that doctors should, themselves, have a physician or medical confidante to whom they can transfer their anxiety about their own health. This is no easy thing and, in my own case, a challenge that I cannot claim to have met adequately.
The anxiety which manifests itself within the patient-doctor relationship is, to use the jargon, at once both existential and pathological. The discovery of a breast lump, a weak limb or prolonged pain in the chest are, in reality, significant threats to survival and provoke justifiable anxiety and fear of death. They are part of our existence and features of our mortal lot – that is, in every sense, existential. In addition, though, anxiety can be pathological, deriving from deep sources within the psyches of both the doctor and the patient, relating to fractured or unresolved difficulties in distant, important relationships.
The importance of distinguishing between existential and pathological anxiety relates to our understanding of the way in which these different types of anxiety affect the exchange of truth within the patient-doctor relationship. A tightly integrated focus of psychopathology in an individual – doctor or patient – may deny them the possibility of facing and handling the truth honestly.
It is inevitable that there are certain clinical encounters which are so stressful that there will always be communication difficulties. This should be accepted. The stress might be mitigated by using other means of clarifying what is said. When telling a patient she/he has cancer, we could offer to write down or record on a cassette the information we give so that patients can go over it in their own time and place, possibly with their families. This would also give ‘permission’ to patients not to be able to remember things and to contact doctors for clarification.
Another dimension to this issue is the need for doctors to feel they can do something to help, preferably cure, their patients. We have such high expectations of this (and so does the community) that we have not developed the skills and do not feel comfortable with a more supportive role in cases where we cannot cure but only palliate.
As a physician and as an educator, it is my view that much can be done to assist future doctors toward greater sensitivity and competence in the patient-doctor relationship. There is no clear line between educational development and what we might term psychotherapeutic assistance to the future medical practitioner to come to grips with his or her areas of neuroticism in such a way that they cease to interfere with their practice of medicine. It is only when sensitive understanding and developmental acceptance of one’s own inadequacies and likely areas of vulnerability have been achieved that a tolerant and accepting attitude to other people’s vulnerability can occur and lead to the development of a relationship in which truth prospers. There are quite enough distortions, incomplete understandings, troubling probabilities rather than certainties and other pressures in the patient-doctor relationship for us not to be perennially troubled by a doctor’s own need for psychopathological pacification or gratification through their clinical encounters.
This educational remedy or preventive intervention would require a major rethink in our approach to medical education. At present we do next to nothing about it. We have a wealth of patient and community complaints about the inadequacy of this dimension of the performance of doctors and yet we dither as though this ‘soft stuff’ can be dealt with on the run, providing one knows anatomy, surgery and many technical details about the configuration of the chromosomes and genes.
I see very few, if any, circumstances in the clinical encounter where not to tell the truth is the preferred approach. I would argue in favour of telling the truth even when for example, a test result, performed on blood taken for some other purpose or as a result of a battery of tests which includes one which one did not order specifically, indicates some pathology which, at the very least, requires further investigation. This could extend to HIV and hepatitis carrier status which may have profound implications for the future professional practice of dentists and physicians. The principle which I believe should be followed here is that of respect for the autonomy of the individual. Denying an individual access to information which one possesses by virtue of one’s professional status is to diminish the autonomy of that individual.
From time to time a conflict can occur between one’s ethic of duty to the individual, which encompasses implicit and explicit commitment to confidentiality, and what might be perceived as the greater community good. This is an area of profound significance for the future practice of medicine. Divulging medical information about an individual, let us say their HIV status, may present the doctor with the choice between two evils – silent deceit (not informing the public) and broken confidentiality.
A further area of difficulty relates to the increasing knowledge we have about the genetic potentialities of individuals. The human genome project has yet to make its impact but even without it we have now more knowledge about the risks individuals carry by virtue of their biochemical and genetic profiles. How much of this information should be disclosed? Should the identity of all donors who have participated in fertility programs be available to children who are born as a result of such programs? How should this form of truth be handled? There are many issues like this, where the community has to debate and make explicit its views, for example, euthanasia.
While it is not possible to ‘teach experience’, our growing cultural sophistication in terms of psychosocial understanding and developmentally based education makes it possible to do more in educating our future professionals about the meaning of autonomy, the sensitivity required to protect and promote it and the value that can come from a program which limits the impact of one’s own neurotic needs. The aim is to render the therapeutic relationship between client and professional a clear table on which to transact what is often terrifyingly complicated business including life and death issues.
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