The classic doctor-patient relationship is asymmetrical in a similar way to the parent-child relationship is: the doctor knows best what is good for his patient, just as the parent knows what is best for their child. The relationship does not need to be equitable, so long the doctor displays a number of intellectual virtues and virtues of character in healing the sick and injured. Indeed, most of the virtues listed are not out of place in a traditional (paternal) doctor-patient relationship. That is:
 
• Fidelity to trust in a doctor’s integrity as an expert whose intellectual knowledge and practical wisdom is trustworthy.
• Benevolence of doctor’s intentions and behaviour towards their patients
• Effacement of self-interest of doctors helping their patients through the recovery process.
• Compassion and caring of doctors towards their patients
• Intellectual honesty of doctors towards their patients
• Medical humility on behalf of doctors in wisely judging that the cure is no worse (long-term) than the disease 

Inter-personal trust between professionals and patients is so central because professionals have exclusive power and knowledge that others rely on. For example, if I go and see a consultant then I go not knowing enough about medicine and placing my trust in my consultant’s ability to diagnose and cure me of a specific health problem that only she and others with that particular specialist knowledge, can tell me about. In other words there is a level of some dependency that means that I have few options but to trust both their intellectual virtues – e.g. judgment required in diagnostic skills for example – and virtues of character – e.g. their capacity to tell me the truth while at the same time being compassionate.
  
The major disadvantage of thinking about the old fashioned virtuous doctor is three fold.

First, at psychological sub-personal level, the doctor may not be trusted. If professionals lack the integrity as virtuous professionals, they are likely display inter-personal behaviour that is at times vicious and wicked. Take the examples of the GP Harold Shipman and the children’s nurse Beverley Allitt. The GP Harold Shipman was the UK’s worst serial killer, murdering 215 patients under his care. Beverley Allitt, on the other hand, with Munchausen’s by proxy syndrome, murdered four children. Part of the reason for the public of outrage around these scandals stems from the very fact that what we take for granted, as a medically untouchable virtue, sanctity and reverence for life, without so much as a second thought that this may be abused by certain wicked and disturbed individuals. Whilst there are statistically few that display such extreme behaviours, most virtuous practice in the medical practice is undermined by poor standards of care and neglect. Indeed, far removed from virtuous health care practices, there are a statistically significant number of anecdotal examples from patient feedback sites where complaints within the NHS point towards, at least the possibility, of poor medical care. For example, the website of Patient Opinion, which is open to anyone to post their experiences of healthcare in the UK, receives an approximate three ways split between stories of excellent care, those of very poor care and those which, though complaining, mention good aspects of care. In short, the classical virtue ethics model within medical paternalism in no way guarantees virtuous medical practitioners. In practice a whole range of experiences are reported by patients.

Perhaps one of the biggest difficulties with a more classical account of the traditional doctor patient relationship – that is paternalistic in nature – is that it does not recognise any power in the patient at all. That is to say, the fruit of virtuous medical practice is bestowed on a grateful, complaint and receptive patient. The doctor-patient relationship, much like the father-child relationship, is one where weaker party is ‘infantilized’ by the virtuous doctor – that is, treated as ‘a child’, which denies their maturity and ability to make their own choices for good health and well-being. The patient is thus regarded as ‘an object of information rather than a subject of communication’ (Foucault, 1973). One of the implications of this is that the patient is denied autonomy and decision-making capability. This can lead to unjust treatment when their might be other treatment options available, that the patient could be empowered to make a decision about.

For example, the Tuskegee Study in the USA spanned forty years and conducted an experiment on 399 illiterate black men in the late stages of syphilis, without ever being told about the nature and seriousness of the disease they were suffering from. Treated like children, they were informed that they were being treated for “bad blood.”  Whilst this is an extreme example of an abuse of the principle of patient autonomy and does not necessarily follow an asymmetrical doctor-patient relationship, classical medical paternalism is becoming increasingly irrelevant in modern healthcare where autonomous patients need to make choices in particular clinical situations.

Patient autonomy and choice is especially significant in cases of high risk to health and low certainty of outcome (as regards treatment option).  In the case of certain early stage breast cancer, for example, the risks are high (if left untreated), but the treatment options present a low certainty of what might be best for the patient. In these cases there is a vital and authentic choice to be made by the patient between a lumpectomy and a mastectomy. In such cases, patient autonomy needs to be respected and no presumption of treatment should be taken. In such cases, ethical use of informed consent is totally appropriate and necessary (McCollough & McGuire et al 2007)

Once patient autonomy is increased then the practical wisdom of patients becomes increasingly relevant as generations are more informed of rival healthcare treatments through such resources as the internet. In this way the doctor patient relationship has changed over time; the patient becoming more like a ‘client’ in which the healthcare professional becomes more of a trusted advisor to empower the patient to select between options. Such a culture of trust – where the patient autonomy and choice is respected is very different, from old fashioned doctor-patient relationship where it was accepted that the virtuous doctor always knew best.

At the level beyond practical face work in healthcare, there are cultural and institutional considerations where trust in people breaks down. Examples of institutional failure, where cultures became untrustworthy are legion. The improper retention and use of organs at Alder Hey in the late 1990’s for example, highlighted cultural and institutional excesses that eroded any semblance of virtuous post-mortem practices. Importantly, such national scandals, could not be dealt with through any internal medical regulation, because the implications were national not local (the practices were not exclusive to Alder Hey) and impartially conducted, not least because the consequences of the public inquiry into improper retention of organs were in the public interest.

In other words, the modern doctor-patient relationship has also increasingly become subject super-accountability, where trust in doctor respecting patient choice is replaced by trust in systems that ironically do not trust the individual on an inter-personal level. This, to an extent, has been the legacy of the Public Inquiry.    

To conclude, trust in the doctor-patient is complex and should be appropriate and specific to clinical context and levels of decision making. In other words, the doctor does not always know best for a number of reasons, not least because in certain cases we have authentic choices to make between certain treatment options that only we can make under sound advisement from the medical profession. However, we also need to be protected from failing NHS cultures, where public inquiries have made doctors more accountable in their professional practice. While, ironically, this undermines interpersonal trust, if it accountability becomes too pervasive, some accountability is necessary to counteract systemic failures in trust.

Note on Style – Non-academically orientated polemic

Foucault, M., (1973) Discipline and Punish: the birth of the prison New York: Vintage

McCollough, B., & McQuire. A et al (2007) Consent: Informed, Simple, Implied and Presumed The American Journal of Bioethics vol.7:12 New York: Taylor Francis

Adapted from:

Pilgrim, D. Tomasini, F. Vassilev, I. (2010) Trust in Health Care? Ethics and Professional Values Palgrave MacMillan, Forthcoming

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