III. ETHICAL ISSUES

Until recently in the history of healthcare, writing about and reflection on ethical issues in the health professional–patient relationship have focused primarily on the interactions and expectations of two individuals: a professional (traditionally, a physician) and a patient. The relationship usually is between a patient and a wide range of health professionals. Today, several basic ethical values, moral duties and rights, and virtues continue to be relevant to their interaction. The emphasis in this section of the entry is on concrete questions related to morality. Thus, enduring normative ethical foundations of the relationship as well as issues that have become relevant because of changes in the character of the relationship and the institutional settings in which it takes place will be discussed. In normative ethics, basic questions include, "What types of acts are morally right (or wrong)?" and "What are the morally praiseworthy (or blameworthy) virtues of the individuals or groups involved?"

Conduct, Virtue, and Context in the Professional–Patient Relationship

Normative ethical judgments about a relationship can be made on the basis of whether right conduct is exhibited by the parties toward each other, and whether praiseworthy character traits and dispositions (virtues) that ought to manifest themselves within the relationship are present. The context in which the relationship takes place also has moral relevance. Ethical issues can arise from any of the three.

CONDUCT-RELATED ISSUES. Issues related to morally right conduct in a relationship are understood through an examination of moral obligations and rights in the relationship. Today some of the most fundamental have been developed into general categories called principles. Several key principles that ought to be present in the professional–patient relationship are described later in this section.

VIRTUE-RELATED ISSUES. A second area of ethical issues is understood through an examination of the good or praiseworthy habits and dispositions of the parties in the relationship. Here the focus is less on the things people do and more on the types of people they are. Just as we can engage in reflection about ethical principles that help to elucidate right from wrong conduct, so can we make reasoned judgments about the character traits and attitudes that people ought to exhibit in a relationship. For example, we expect a person with virtue to be more disposed to honor another's values and to try to create a better community than would a person who lacks it. On this basis alone it is justifiable to place expectations of virtue on certain relationships. Some of the most basic virtues that have bearing on the professional–patient relationship also are discussed later in this section.

CONTEXTUAL CONSIDERATIONS. Issues involving judgments about the conduct and virtues that are morally appropriate may vary according to the larger social and institutional context in which the relationship takes place. One needs to assess, for example, the special peculiarities of the way in which the relationship was formed, the genesis of explicit or implicit expectations of the parties, the utility and function of the relationship, and the role of society's expectations.

A consideration of several dominant models that have been proposed to characterize this relationship will aid in the reader's understanding of the ethical issues discussed in this article.

Moral Models of the Relationship

Robert Veatch was one of the first contemporary bioethicists to seriously consider that various moral models exist. He offered four models of the physician–patient relationship: the priestly model, an explicitly paternalistic and value-laden approach in which the physician assumes competence not only for medical facts but also for naming and interpreting value dimensions of healthcare decisions on the patient's behalf; the engineering model, in which the physician acts as a scientist dealing with facts divorced from questions of value; the collegial model, in which physician and patient become pals assuming equality through mutual trust and loyalty; and the contractual model, which entails a mutual understanding of benefits and responsibilities incumbent on each person involved (Veatch, 1972).

In 1992, Ezekial Emanuel and Linda Emanuel, two physician bioethicists, also presented four models with some parallels, but set the context as one in which each model demonstrates the tension between patients's autonomy and their health as well as among various physician and patient values: In the paternalistic model, the physician independently acts on behalf of the patient's well-being; at the opposite pole, in the informative model, the patient receives all information and the physician serves as a technical expert only; in the interpretive model, the patient's life is viewed as a specific story or narrative from which a mutual understanding of appropriate goals and interventions are derived; and in the deliberative model, the physician, who provides the relevant information to the patient, also acts as a combined teacher-friend to empower the patient in ways that are consistent with the patient's health-related values.

Sheri Smith was among the first to distinguish models of the nurse–patient relationship, though others have followed. In the surrogate mother model, the nurse is morally obliged to assume ultimate responsibility for the well-being and care of an essentially passive patient; the technician model characterizes the nurse's responsibility as limited to competently applying technical knowledge and skills to meet the patient's needs; and the contracted clinician model defines the nurse's responsibility by the values and rights of the patient and assumes that the patient is capable of determining her or his own best interests (Smith).

In spite of important differences, the similarities among all three models are more important. They point to a progression over time from traditional paternalism to more mutuality and shared decision making. Several models support the idea of the professional as a patient (or client) advocate. The advocacy idea suggests that a patient's health-related rights must be protected and the health professional is in a unique—or at least opportune—position to protect these rights. Lively debate continues for and against adopting the advocacy idea as the central moral role of the health professional in relation to the patient (Bandman and Bandman).

U.S. law places the professional–patient relationship in the class of fiduciary relationships. In fiduciary relationships "each [person] must repose trust and confidence in the other and must exercise a corresponding degree of fairness and good faith," because the two persons cannot expect to have all of the usual facts that would allow them to contract as equals (Garner, p. 640). This law is used by the legal profession to help hold physicians (and, to varying degrees, other health professionals) accountable for the fact that they have the greater measure of power within the relationship and may not be able to equalize that power merely by disclosing relevant information to patients or their families. Trust is the bridge to the success of the relationship, and the burden is on the professional not only to engender the patient's trust but also to build a solid foundation of trustworthiness upon which the patient can depend.

The following discussion provides the reader with some basic components of ethical thought common to all of the models.

Ethical Principles in the Professional–Patient Relationship

Several ethical principles are relevant in an analysis of the professional–patient relationship and provide insight into its ethical foundations. Among the most important are respect for persons, nonmaleficence, beneficence, veracity, autonomy, and justice.

RESPECT FOR PERSONS. Respect for persons, highlighting the dignity of the patient as a person, is found in the preambles of most professional codes of ethics, mission statements of healthcare organizations, and patients's rights documents, as well as many other ethics writings. The principle assumes that persons have inherent or essential worth simply because they are human beings. Diverse philosophical, religious, and scientific understandings of the nature of persons provide a wide base upon which the health professions can ground this ideal (Lammers and Verhey). But the principle also presents challenges to health professionals: One is to discern categories of beings that are persons; another is to discern practical direction from such a general ideal. For example, two health professionals may agree on a Judeo-Christian-Islamic interpretation that all persons have worth or dignity because they are equally children of God. They may follow the influential notion of the philosopher Immanuel Kant (1724–1804) that persons must be treated as ends and not as means to ends, yet the two may differ in their positions regarding the moral status of the fetus and come to different conclusions about whether a life-saving liver transplant should be given to a person who has an acute alcohol addiction. In spite of its difficulties, however, this principle makes a signal contribution to the understanding of the professional–patient relationship by counseling professionals against making hasty or arbitrary distinctions.

NONMALEFICENCE. The maxim to do no harm, primum non nocere, often is cited as the first ethical principle of medical practice. Its meaning and usefulness can be gleaned from the serious thought given to the concept in deontological (duty-oriented) approaches to moral philosophy. W. D. Ross argues that it is our stringent duty to inflict no harm intentionally, because to live in any other type of society would make each of us too vulnerable. This duty, he adds, is not covered by the duty to prevent or remove existing harm, or to do good (Ross).

The duty of nonmaleficence places the professional on alert that society reasonably expects him or her not to be an agent of harm. Debate about physician-assisted dying, euthanasia, and abortion often focuses on the interpretation of harm and the physician's, pharmacist's, nurse's or other health professional's role in participating in activities that cause harm. Discussion of maleficence must take into account that some types of harm are necessary in the name of a patient's greater good: For example, the patient undergoes the harm of the surgical knife in order to have the pathology removed.

BENEFICENCE. The principle of beneficence delineates conduct directed to the welfare of others and is pivotal in the understanding of the professional–patient relationship. Since its inception, the relationship has had its grounding in the idea that the professional's ethical priority is to further the welfare of a patient. Other worthy goals, such as furthering the knowledge about disease and its cure, or earning a just wage, or maintaining the efficiency or financial solvency of the institution, must take a lesser position on the scale of priorities.

Taken in combination with the principle of respect for persons, the principle of beneficence highlights that health professionals have a moral obligation to provide optimum care to all kinds of patients with whom they are in a professional relationship, assuming that the patient's problem lends itself to healthcare intervention and the professional is competent to treat the patient's type of condition. Therefore, the principle is put to the test when the professional is prejudiced against persons of a certain ethnicity, age, gender, religious conviction, sexual orientation, or any other characteristic, and therefore finds it difficult to give a full measure of attention to members of such groups. A health professional also may judge an individual patient undesirable on the basis of poor personal hygiene, irritating personality traits, or lifestyle choices. In each case, the health professional must regard the patient in the relationship as worthy of treatment however great a gulf exists between their respective values. If their differences create so great a barrier on the part of the professional that it prevents good care, he or she must attempt to assure that the patient receives it from someone else. In short, the health professional must focus on the person's needs whether the patient be model citizen or thief, old or young, man or woman, likable or not.

VERACITY. Philosophers may treat the principle of truth telling as a separate principle. More often today, however, it is conceived as derived from respect for persons (Veatch, 2003). However, treating it as a derived principle in this case only strengthens it since it is derived from such a fundamental moral premise of healthcare.

Given the moral stringency of truth telling, an interesting ethical quandary arises when it falls to the professional to convey bad news to patients and families. Health professionals long have believed that patients want professionals to help them maintain hope in the face of catastrophe. In 1932, Nicolai Hartman noted that for centuries this was interpreted as requiring the professional to protect patients from the truth at times, engaging, if necessary, in a benevolent lie and bearing responsibility for having breached the patient's moral expectation that veracity would be honored.

Today this belief has shifted, at least in some major subcultures of North America and Europe where the belief is that hope is enhanced by the patient's ability to take control of important life events. In other words, the fostering of hope is not dependent solely on whether the truth is shared directly with the patient. More determinative is the role of veracity in maintaining a patient's exercise of autonomy and capability to actively participate in decisions. This interpretation, however, does not necessarily lead to professional conduct consistent with it. For example, Nicholas Christakis observed that physicians tend to convey information about a poor prognosis in a way that avoids giving the worst aspects and conforms to what the physician believes the patient's expectations are.

AUTONOMY AND SELF-DETERMINATION. In the tradition of medical ethics, discussion regarding autonomy did not focus on patient autonomy but on the professional's autonomy, the assumption being that freedom from impingement by others on his or her clinical judgment and practice was a key means to acting beneficently on behalf of the patient's best interests. However, there are numerous government regulations and other controls within healthcare today that restrict professional autonomy, causing thoughtful health professionals to worry whether they will be able to honor basic professional tenets of the professional–patient relationship.

By the beginning of the twentieth century the historical roots of libertarianism in the United States, first introduced as a political theory under the influence of such British thinkers as John Locke (1632–1704) and John Stuart Mill (1806–1873), had begun to seriously influence the character of the professional–patient relationship in the direction of honoring the patient's agency in healthcare decisions. Although related to the idea that the patient should have access to the truth in accordance with the principle of veracity, autonomy goes beyond that aspect.

The principle of autonomy provided a social groundwork for the introduction of the idea of patients' rights within the relationship. Applied to the patient's situation the principle evolved from being viewed as the patient's prerogative to refuse treatment to the negative right to refuse it, and finally to the positive right to play a central role in determining the course of treatment. For example, the increased emphasis on informed consent as the brokering chip in the relationship places a major focus on the patient's role as an active agent in treatment decisions. Today informed consent modes range from explicit or presumed consent in special situations to the more commonly discussed explicit consent. Moreover, in 1990 the U.S. Congress passed the Patient Self-Determination Act, which took the idea of patient autonomy as a right more deeply into the legal and life-span arenas. The law was a legislative mandate that patients have an opportunity to express their wishes about potential treatments in critical situations. This form of advance consent was buttressed through numerous cases and laws affirming use of living wills, durable power of attorney and other surrogate/proxy or substituted judgment mechanisms that are effective when the patient is unable to express his or her wishes on the spot.

In spite of the central role of patient autonomy in bioethics discourse and the medical-legal aspects of health professions' practice, lively discussion about its appropriate moral limits is growing (Schneierman).

For example, new attention is being devoted to tensions that develop when there is a serious disjuncture between the patient's expressed wishes and the professional's judgment of how best to carry out the professional obligations of beneficence and nonmaleficence. In other words, under what conditions is it morally permissible for the physician or other professional to go against the patient's informed preferences (hard paternalism) or not seek the patient's input (soft paternalism)?

The weight of moral opinion today supports at least four areas of paternalistic conduct. In the first instance the conduct is justified when the professional knows for a certainty that the intervention will harm the patient. (How harm is defined becomes extremely important. For instance, if death is judged an unacceptable harm the professional may engage in a kind of vitalism that imposes additional suffering on a dying patient). A second situation exists when the intervention being sought goes beyond or against the public moral mandate of medicine and the other health professions. Third, professionals need not be held hostage to patient wishes that will be of no benefit whatsoever to the patient even if it does no harm. The idea of futility, though imperfectly developed to date, is an attempt to provide criteria for setting boundaries that will prevent these potential misuses of healthcare. And fourth, a request by a patient that the professional engage in a clinically indicated and legally sanctioned option that is morally repugnant to the professional may cause moral distress for the professional and can be denied. In this case, although he or she is not morally obligated to personally participate in the intervention, the patient must be placed in the hands of another competent professional who can more sympathetically assess the patient's informed wishes.

Two critical concerns are being raised regarding the centrality of patient autonomy in the professional–patient relationship. The first addresses an increased awareness of the importance of diversity by professionals In order to meet the moral mandates of cultural sensitivity and cultural competence, the professional must have a deep understanding of how various cultures conceptualize individual, family and clan roles in regards to decision making (Hyun). In some groups the professional's insistence on the patient's individual informed consent is morally and socially antithetical to healing or other appropriate reasons for seeking out professional attention. A second concern arises in instances of high medical/clinical uncertainty. The professional's disposition to shared decision making often falters, likely due to a fear that an admission of uncertainty will undermine the patient's or family's confidence or create additional stress for them (Parascandola, Hawkins, and Danis). Both of these concerns warrant careful attention and research.

JUSTICE. The principle of justice, stated simply, is that each should get his or her due. What is due must be derived from the high moral standards of healthcare and the information available about what will create the most benefit. At the level of the professional–patient relationship, this has several implications. First, its relationship to beneficence is apparent: The patient can expect to be treated fairly. Persons seeking treatment should not be given advantage on the basis of arbitrary favoritism or be left out on the basis of arbitrary dislike. The rules will be applied consistently, taking into account legitimate departures from the norm. For instance, a procedural rule of first come, first served will be applied except in cases where greater need morally requires that the rule be flexible enough to allow for valid exceptions.

The principle of justice raises important ethical issues related to the allocation of scarce resources. Health professionals abide by a duty of beneficence, but that duty does not entail the prerogative of automatically providing a disproportionate amount of a scarce resource to any one person, even if that person's need could warrant receiving all of it. The resulting allocation may have a relatively deleterious effect on one or more other patients because their optimum benefits are compromised. For example, a nursing shortage on a unit may require the nurses to make difficult (though not arbitrary) decisions about patient-care priorities.

Compensation for harm also derives from our understanding of what justice requires. A patient who is harmed in the relationship through, say, professional error, has a right to know that the harm has occurred and may wish to seek compensation for the harm.

Serious barriers to justice often arise outside of the relationship. Societal discrimination against patients on the basis of race, ethnicity, religion, sex, and age are well documented, and continue to contribute to serious disparities in the distribution of U.S. healthcare benefits and burdens in spite of legislation designed to prevent them (Garner). Other barriers are imposed by today's bureaucratic context of healthcare: institutional mechanisms and societal arrangements designed to foster efficiency, profit, or other goals, but not the patient's well-being (Stein). The relationship does not stand in isolation from these influences, all of which have profound effects on it.

The health professional who is committed to upholding the profession's moral ideals must work not only to preserve justice within the relationship directly but also to remove barriers to it on a broader scale so that the appropriate ends of healthcare can be realized.

Conflicts among Principles

As illustrated by the issue of paternalism in truth-telling situations and the compromise of beneficence in situations of scarce resources, conflicts among this set of general principles inevitably arise in everyday professional–patient relationship situations. In actual situations, professionals usually can use the basic moral ideas imbedded in the principles as guides to set priorities consistent with the values of healthcare, the professions's moral codes and standards, and patients's informed preferences. At the same time, not all conflicts can be resolved and sometimes principles seem to remove us a step further from the immediacy of the situation.

Virtue in the Professional–Patient relationship

Cognizant of the limitations in an ethics based entirely on conduct, Aristotle in Nichomachean Ethics suggested the alternative of a focus on virtues by those who are decisionmakers so that they approach moral conflict in the right frame of mind and heart. A life of moral virtue is characterized by dispositions and attitudes that can be cultivated into habits of preparedness that enable a person to act in ways that further the good of a relationship or community. Aristotle also underscored the importance of the person's desire to become a good person, which in turn requires knowledge of ultimate goods and ends. Aristotle did not divorce virtue from the realm of feelings and emotions, suggesting instead that acts arising out of various dispositions will give pleasure and that, at the same time, ethical action resulting from a virtuous disposition requires the exercise of reason.

Since the late twentieth century, several leading ethicists have led a lively re-examination of the virtues that should be expressed by health professionals. Notable among them are Edmund Pellegrino and David Thomasma who propose that the contemporary reappraisal is not an attempt to demean the emphasis on rights-and-duty-based ethics, "but a recognition that rights and duties notwithstanding, their moral effectiveness still turns on dispositions and character traits of our fellow men and women" (Pellegrino and Thomasma, p. 113).

A challenge throughout the ages has been to identify dispositions that the professional should cultivate so as to further the good and proper ends of healthcare. Many virtues have been proposed, among them benevolence and kindliness, compassion, integrity, honesty, fairness, conscientiousness, fidelity beyond duty, and humility.

These virtues are as appropriate in today's professional–patient relationship as they have always been. However, some things about the relationship are understood differently today than in the past, and our understanding of human relationships in general continues to undergo new evaluation. It is not surprising that our understanding of the virtues also continues to evolve. The following two illustrations of this evolution by no means exhaust the important work that is being conducted in this area.

BENEVOLENCE AND CONSIDERATIONS OF TRUST. The traditional professional virtue of benevolence or kindness has enjoyed a long history in the writings on the professional–patient relationship. This character trait evokes pictures of a physician, midwife, or nurse sitting quietly at the bedside, reassuring a patient, an image consistent with a period in which the professional was viewed as a kindly person who used the limited technologies available to minister to the clinical and emotional needs of a trusting, mostly passive patient. Today the notion of benevolence must be refined to adapt to a relationship in which patients are active participants in the interaction, suggesting that kindness met by blind trust taken alone are not adequate ingredients for the tasks of this relationship to be accomplished. At the very least an adequate notion of professional benevolence today must include an examination of how the professional's trustworthiness figures in the professional–patient relationship.

For example, traditionally confidentiality focused on the physician's duty. To the extent that the physician had cultivated a benevolent disposition toward the patient, the duty would come more naturally. Today the moral focus has shifted to the patient, particularly to his or her right to expect confidentiality. Only trustworthiness based on the professional's authentic commitment to respecting the patient's rights and dignity assures the patient that he or she is in the hands of a benevolent professional.

Benevolence as traditionally understood is challenged further by a revitalized emphasis on professionalism in the medical profession. In this broader conceptualization benevolence commitments explicitly include competence, honesty, confidentiality, maintenance of appropriate boundaries, improvement of the quality of and access to care, and management of conflicts of interest, to name some. Moreover, a rise in the literature on such dimensions of the physician's moral role as that of dealing positively with professionals' errors (Kohn et al.) and fatigue (Gaba and Howard) are expanding the scope of what benevolence entails today.

COMPASSION AND CONSIDERATIONS OF CARING. Compassion also has long been viewed as a virtue that should characterize the professional–patient relationship. Compassion often has been interpreted according to its etymological root, "to suffer with." Theories vary about what, exactly, this means in the healthcare context, but one central theme is that healing is enhanced when professionals exhibit a disposition and ability to sympathize deeply with the patient's plight. The cultivation of this disposition leads the professional to recognize that the key issue is not only "Have I done my duty?" (e.g., truth telling) but also "Have I been sensitive to the effect my approach will have?" (e.g., how, when, by whom, and where this information should be disclosed). The central notion of caring in the professional–patient relationship sheds light on important ways in which the virtue of compassion might manifest itself in the everyday work of professionals. Among contemporary bioethicists Warren Reich makes an important contribution to the understanding of compassion by relating different modes of compassion to different phases of a patient's suffering. Care in the relationship between health professional and patient also has been seen as an activity that reflects an attitude of sensitivity to the patient's deepest values and concerns.

Anne Bishop and John Scudder propose that "Being compassionate is not something that human beings can achieve by an act of will. It is possible, however, to be open to compassion, to be situated so that compassion is likely to be evoked…" (p. 81). They conclude that professionals who do not feel compassion but have a deep desire to show caring(i.e., feel called to care) can actually express care by a focus on fostering the patient's well-being as well as a commitment to full participation in being an excellent practitioner. In some current approaches to professional care, compassion or other virtues are not invoked at all; rather the emphasis turns exclusively to conduct and behaviors that various professions describe as caring behaviors with the goal of incorporating them into an assessment of measurable outcomes in patient management (Galt). This latter approach diverges dramatically from the traditional and most contemporary research on the role of care and its relationship to compassion in the larger ethical context of the professional–patient relationship. There have also been serious caveats raised about a professional ethic based primarily on the concept of care.

Aware of problems created by sexism, and that caring and the care-giving role are associated with women, social devaluation of professions that promote care as a centerpiece of their identity could follow to the patient's detriment (Nelson). Therefore, when a health professional expresses care to a patient he or she may also appear to condone injustices that derive from being in a society that devalues women in a care-giving role (Condon). At the same time, recipients of care may be forced into stereotyped roles of dependency. Eva Feder Kittay calls for a reassessment of the dichotomy often viewed as existing between caregiver and care receiver. Clearly, the role of care and its relationship to compassion warrants continued attention.

Existential Dimensions of the Patient's Experience: Implications for the Professional–Patient Relationship

The existential dimensions of the patient's experience also deserve consideration in the relationship. Existential, as used here, refers to the human quest for meaning in the face of our limitations, among them illness and death. Especially significant are new insights regarding the health professional's role in exploring the existential meaning of illness for a patient.

One aspect of the exploration has focused on the professional's desire and ability to individualize the patient's situation and story: Respect in the relationship rests on a premise that health professionals are called into a particular relationship with patients because of the importance of the illness experience to the patient, and the medium of that relationship is the patient's story (Purtilo and Haddad). The notion of patients's patterns is the term used by Margaret Newman to describe what has value—is meaningful—in a patient's life. The professional's skill in helping the patient recognize aspects of him- or herself that the person may not even be conscious of is the professional's act of pattern recognition. The professional, acting as facilitator, can show how the pieces fit. Once identified, professional and patient can work together toward mutually agreed upon health goals. Bishop and Scudder capture the essence of the professional's position in this task as being a caring presence, a "personal presence that assures others of another's concern for their well-being" (Bishop and Scudder, p. 41).

Narratives, the patient's and the professional's, are the professional's means of gaining insight into the existential complexities of the professional–patient relationship (Greenhalgh and Horwitz). Sociologist Arthur W. Frank, drawing partially on his own illness experiences (from patienthood to survivorship roles), powerfully illustrates how the moral responsibility of survivorship is to reconstruct, put back together, a life that had been altered by interventions and professional interactions. Through that process the wounded also becomes healer, but the process requires the mutual effort of professional and patient. When the professional, through narrative, shows to the patient a personality with emotions, likes and dislikes, fears and dreams, hopes and faults, the patient has a greater opportunity to understand that there is a person in the professional role, not just a bundle of competencies and technical skills. The patient becomes more trusting that his or her own personality has a chance of being taken seriously (Purtilo).

Howard Brody, a physician bioethicist, notes that the challenge does not lie only in the professional's desire and willingness to hear and respect the patient's story. Even those who are so disposed may meet barriers because both professional and patient believe that the professional holds the key to knowing the real problem (i.e., the medical problem). The power differential built into the structure of the relationship means that the professional is believed to be empowered to impute the real meaning of the patient's story. A concentrated effort must be made to overcome such a barrier (Brody). Merging from such thinking and reflection on the existential aspects of the relationship and its key members are new materials for refining their encounter, new ethical dimensions to build on the traditional foundations of moral obligations, rights, and virtues. The healing quest will be for the discovery of the patient's lost or changed self, not just for removal of a disease that resides in that person, and the recognition that in the deepest sense each party is affected by the relationship.

Mechanisms for Resolving Ethical Conflict in the Professional–Patient Relationship

Ethical issues in the professional–patient relationship are receiving more attention in the everyday environments of healthcare. Inevitably, differences in judgment, even deeply held differences, arise between professional and patient (or the patient's family). Conflict does not always denote a feeling of animosity. Often it signals a frustration shared by all involved in not knowing the best way to proceed.

There are several mechanisms designed to assist patients in such situations. First, the patient representative or patient ombudsperson is an employee of the provider institution who is charged with being available to patients and their families when dissatisfaction or questions arise. This advocate may learn that a patient or family believes that the patient is being harmed by receiving substandard treatment. While not all such situations involve ethical issues, many do. The advocate may act as a direct liaison between the parties or may refer the issue to one of the other mechanisms designed to provide assistance.

Second, ethics consultants are being hired by many major hospitals. Their charge is to deal with ethical issues regarding patient-care decisions. Depending on the institution, the ethics consultation service may be accessed by the physician, nurse or other professional, patient, or patient's family. Usually the consultant meets with all the relevant parties to help them identify the ethical issues involved, reason about the issues, and make recommendations for how to weigh conflicting priorities. The consultant does not make the final decision, which is correctly left to be decided within the professional–patient relationship.

Third, clinical ethics committees are present in many healthcare environments. Usually multidisciplinary, they function in a manner similar to the ethics consultant. Sometimes an ethics consultant will be called first, and if he or she thinks that the issue merits further deliberation by several different disciplines and personalities, may call the ethics committee together.

Everyone would agree that whenever possible, prevention is the best approach to moral conflict in a professional or institutional setting. The professional's diligence in communication, technical competence, and caring are keys to conflict prevention, as well as powerful instruments for resolution of conflict when it does occur in the professional–patient relationship.

ruth b. purtilo (1995)

revised by author

SEE ALSO: Authority; Autonomy; Beneficence; Care; Compassionate Love; Confidentiality; Conflict of Interest; Informed Consent; Justice; Medical Codes and Oaths; Medicine, Art of; Narrative; Paternalism; Profession and Professional Ethics; Rights, Human; Trust;Virtue and Character; and other Professional-Patient Relationship subentries

BIBLIOGRAPHY

ABIM Foundation. 2002. "Medical Professionalism in the New Millenium: A Physicians Charter. ABIM Foundation. American Board of Internal Medicine. ACP-ASIM Foundation. American College of Physicians-American Society of Internal Medicine. European Federation of Internal Medicine." Annals of Internal Medicine 136: 243–246.

Bandman, Elsie, and Bandman, Betran. 2002. "Models of Professional Relationships." In Nursing Ethics through the Lifespan, 4th edition. Upper Saddle River, NJ: Pearson Education, Inc.

Bishop, Ann, and Scudder, John. 2001. "Caring Presence." In Nursing Ethics: Holistic Caring Practice, 2nd edition. Sudbury, Canada: Jones and Bartlett.

Brody, Howard. 2002. Stories of Sickness, 2nd edition. New York: Oxford University Press

Christakis, Nicholas A. 1999. Death Foretold: Prophecy and Prognosis in Medical Care. Chicago: University of Chicago Press.

Condon, Esther H. 1991. "Nursing and the Caring Metaphor: Gender and Political Influences on and Ethics of Care." Nursing Outlook 40(1): 14–19.

Emanuel, Ezekiel J., and Emanuel, Linda L. 1992. "Four Models of the Physician-Patient Relationship." Journal of the American Medical Association. 267(16): 221–225.

Frank, Arthur W. 1995. The Wounded Story Teller: Body, Illness and Ethics. Chicago: University of Chicago Press.

Gaba, David M., and Howard, Steven K. 2002. "Fatigue among Clinicians and the Safety of Patients." New England Journal of Medicine 347(16): 1249–1255.

Galt, Kimberly A. 2000. "The Need to Define Care in Pharmaceutical Care: An Examination across Research, Practice and Education." American Journal of Pharmaceutical Education 64: 223–233.

Garner, Bryan A., ed. 1999. Blacks Law Dictionary. 7th edition. St. Paul, Minnesota: West Group.

Greenhalgh, T., and Hurwitz, B. 1998. "Why Study Narrative?" In Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, ed. T. Greenhalgh and B. Hurwitz. London: BMJ Books.

Hartman, Nicolai. 1932. "Truthfulness and Uprightness." In Ethics, vol.2, tr. Stanton Coit. New York: Humanities Press.

Hyun, Insoo. 2002. "Waiver of Informed Consent, Cultural Sensitivity, and the Problem of Unjust Families and Traditions." Hasting Center Report 32(5): 14–22.

Kittay, Eva Feder. 2000. Loves Labor: Essays on Women, Equality and Dependency. New York: Routledge Press.

Kohn, L. T.; Corrigan, J. M.; and Donaldson, M. S., eds. 2000. To Err is Human: Building a Safer Health System. Washington, D.C.: National Academy Press.

Lammers, Stephen E., and Verhay, Allen, eds. 1998. On Moral Medicine: Theological Perspectives in Medical Ethics, 2nd edition. Grand Rapids, MI: William B. Eerdmans.

May, William F. 2000. The Physician's Covenant: Images of the Healer in Medical Ethics. Lexington, KY: Westminster/John Know Press.

Nelson, Hilde Lindemann. 1992. "Against Caring." Journal of Clinical Ethics 3(1): 8–15.

Newman, Margaret A. 2002. "The Pattern That Connects." Advances in Nursing Science 24(3): 1–7.

Parascandola, Mark; Hawkins, Jennifer; and Danis, Marion. 2002. "Patient Autonomy and the Challenge of Clinical Uncertainty." Kennedy Institute of Ethics Journal. 12(3): 245–264.

Pellegrino Edmund, and Thomasma, David. 1993. The Virtues in Medical Practice. New York: Oxford University Press.

Purtilo, Ruth B. 1999. Ethical Dimensions in the Health Professions, 3rd edition. Philadelphia: W. B. Saunders.

Purtilo, Ruth B., and Haddad, Amy M. 2002. Health Professional and Patient Interaction, 6th edition. Philadelphia: W.B. Saunders.

Reich, Warren T. 1989. "Spreading of Suffering: A Moral Account of Compassion." Soundings 72: 83–108.

Ross, William D. 1930. The Right and the Good. Oxford: Clarendon Press.

Schneider, Carl 1998. The Practice of Autonomy: Patients, Doctors, and Medical Decisions. New York: Oxford University Press.

Smedley, Brian D.; Stith, Adrienne Y.; and Nelson, Alan R., eds. 2002. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, D.C.: National Academy Press.

Smith, Sheri. 1980. "Three Models of the Nurse-Patient Relationship." In Nursing: Images and Ideals: Opening Dialogue with the Humanities, ed. Stuart Spicker and Sally Gadow. New York: Springer.

Stein, Janice G. 2001. The Gulf of Efficiency. Toronto: Anansi.

Veatch, Robert M. 1972. "Models for Ethical Medicine in a Revolutionary Age." Hastings Center Report 2(3): 5–7.

Veatch, Robert M. 2003. The Basics of Bioethics, 2nd edition. Upper Saddle River, NJ: Prentice Hall.