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Caring, Curing, Coping: Nurse, Physician, and Patient Relationships / Edition 6 available in Paperback
- Pub. Date:
- University of Alabama Press
A popular conception of medical care is that nurses care, physicians cure, and patients cope. The significant theme that runs throughout this volume is that the fundamental mission of medicine is caring, and curing may be only one component of that broad mission. Each of the chapters speaks to that theme, although each approaches it from a different perspective.
|Publisher:||University of Alabama Press|
|Edition description:||1st Edition|
|Product dimensions:||5.25(w) x 8.50(h) x 0.50(d)|
Read an Excerpt
Caring, Curing, Coping
Nurse, Physician, Patient Relationships
By Anne H. Bishop, John R. Scudder Jr.
The University of Alabama PressCopyright © 1985 The University of Alabama Press
All rights reserved.
The Caring Ethic: The Relation of Physician to Patient
Edmund D. Pellegrino
This symposium deals with the most fundamental topic in medical ethics today: the relationship between the person who is ill and those who profess to heal him — physicians, nurses, the family, the minister, and the social worker. My assignment is to focus on the ethical aspects of this relationship which have become so complicated in recent decades. I will base my comments not so much on the application of specific ethical principles regarding the rights of patients or the duties of health professionals. Rather, I will focus on the humane aspects of what it is to be ill and what it is to be healed. I want, in short, to concentrate more on the caring than the curing aspects of the relationship, and on the moral obligations subsumed in the notion of caring.
I make this distinction because in those two words, cure and care, the recent history of medicine is capsulized. The dominant notion in medicine for most of its history has been caring, even when the physician may have thought he was curing. It is only with the introduction of truly scientific means of therapeutics that cure has become possible in any real sense. As a result, the caring aspects of the healing relationship have come to be neglected, and even denigrated.
What is the relationship between caring and curing? What are the moral obligations of healers — physicians, nurses, all who come into direct hands-on contact with sick people?
It is interesting to note at the outset that both words, curing and caring, have the same Latin root: curo, curare — "to cure," "to take care of," "to take trouble," and later "to treat" medically and surgically, to "heal" or "restore" to health. For the greater part of medical history these various senses of curing and caring were essentially one. It is only with the beginnings of truly scientific and therapeutically effective, discrete therapies that the possibility of cure without care has existed.
The word cure is now used by many health professionals in a radical sense: to refer to the eradication of the cause of an illness or disease — to the radical interruption, and reversal, of the natural history of a disorder. The result of a "cure" is to restore a patient to at least the state he or she was in before the onset of illness and, possibly, to an even better state of functioning. The possibility of "cure," in this sense, turns on the availability of scientific medicine: truly effective therapeutic modalities which make it possible to cure without caring.
Specific, radical, and effective cures — in the technical sense — have been acquired in greatest profusion during the lifetime of physicians who entered the profession following World War II. Here and there, largely through empirical good fortune, some truly effective cures existed before that time (cinchona bark for malaria, foxglove for heart failure, mercury for syphilis), and some were discovered by scientific investigation earlier in this century (insulin, liver extract, sulfonamides). But the golden era of specific therapy has just begun, and its promises are still to be fully apprehended. We are now in the era of synthesis of natural and man-made agents, designed to attack the molecular and cellular sources of disease. We can invade any body cavity to excise, reconstruct, or transplant diseased organs and tissues. Radical cure and restoration — not amelioration or disease containment — have become realistic and legitimate goals of medicine.
It is easy, and perhaps some think it desirable, to forget that the greatest part of the history of medicine was based in a different conception of cure, associated with care of the ill and sick. To be sure, the extensive pharmacopoeias of the Chinese, Indian, and Roman physicians implied curative powers. Fortuitously, some items in them did cure; but most were worthless or even dangerous. Cure, if it occurred, resulted largely from the body's self-healing powers and the physician's compassion, caring, encouragement, and emotional support.
The ancient grounding of medicine in care and compassion is now challenged by a biomedical model which defines medicine simply as applied biology. On this approach, the primary function of medicine is to cure, and this requires that the physician be primarily a scientist. This model still includes containment of illness, by slowing down its progress and amelioration of its symptoms, but it focuses on things to do for a particular disease that are measurably effective.
In response to this narrow definition, some advocate a broader approach that adds the sociological and psychological aspects of illness. Others would expand this further to a "holistic" approach, adding the religious and spiritual dimensions of illness to the bio-psycho-social model. These expanded concepts of medicine are limited by the impossibility that all physicians can acquire the requisite understandings and sensitivities the biopsychosocial model demands. Also, such a model tends to absorb all the health professions into medicine, expanding its pretensions beyond all reasonable hope of fulfillment.
In this essay, I wish to examine what we mean by "caring" and the necessity of a clear concept of the totality of its meaning as a basis for a reformulation of professional ethics. I will concentrate on professional medical ethics, largely to avoid the presumption, not unknown to physicians, of prescribing for other health professionals. I believe, however, that we are all joined in a common task of healing, helping, and caring and that the same moral obligations bind us all in those endeavors.
There are at least four senses in which the word care can be understood in the health professions.
The first sense is care as compassion — being concerned for another person; feeling or sharing something of his or her experience of illness and pain; being touched by the plight of another person. To care in this sense is to see the person who is ill, and at the center of our ministrations, as more than the object of our ministrations: as a fellow human whose experiences we cannot penetrate fully but which we can be touched by because we share the same humanity.
The second sense of caring is doing for others what they cannot do for themselves. This entails assisting them with all the activity of daily living that is compromised by illness: feeding, bathing, clothing, meeting personal needs — physical, social, and emotional. Physicians do little or none of this kind of care. Nurses do much more, but far less than they used to do. The large part of this kind of care is given by nurses' aides in today's "team nursing."
The third sense of caring is to take care of the medical problem — to invite the patient to transfer responsibility and anxiety about what is wrong, and what can and should be done to the physician or nurse. This implies assurance that the latter will direct all appropriate knowledge and skill to the "problem" the patient presents, to intervene in the natural history of the disease.
The fourth sense of caring is to "take care": to carry out all the necessary procedures, personal and technical, with conscientious attention to detail, with perfection. This is a corollary of the third sense of care, but its emphasis is on the craftsmanship of medicine. Together, the third and fourth senses are what most physicians subsume under the rubric of competence.
These four senses of care are not separable in optimal clinical practice. Nonetheless, in reality, they are often separated, and even placed in opposition to each other. Or all four senses are reduced to one, to the exclusion of each.
For example, the biomedical model of the physician-patient relationship places emphasis on technical competence and conscientiousness, relegating the first two senses — which are more affective than technical — to other health professionals. On the other hand, the expansionist models of medicine — the holistic or biopsychosocial — embrace all dimensions of care, blurring the distinctions between them. Partitioning or conflating the four senses of care poses dangers to patients, because it either neglects one aspect or presumes to do too much.
It is essential that each sense of caring be recognized for its contribution to the healing relationship. Each must be placed in its proper place in an order of priorities determined by the needs of a particular patient. Care is of one piece. The challenge to health professionals is to attend to each sense of care, and thus relate one to the other, so that they enhance the healing relationship for each patient.
In the ideal healing relationship (patient-physician, patient-nurse), each health professional would attend to each dimension of care in every ministration. When this is not possible, as in contemporary care, the four senses of caring must be provided by conscious partitioning of functions among members of the medical or health care team. The moment we make such divisions, we must appreciate that the unity of care is threatened. Special attention must then be exerted so that no aspect of caring is neglected, because no member of the health care team accepts the responsibility or sees it as proper to his or her professional tasks or status.
Integral care — that is to say, care that satisfies the four senses I have defined — is a moral obligation of health professionals. It is not an option they can exercise and interpret in terms of some idiosyncratic definition of professional responsibility. The moral obligation arises out of the special human relationship that binds one who is ill to one who offers to help.
To assess whether the curing or caring model is foundational for medical practice, it is necessary to examine the three fundamental elements of the physician-patient relationship. The first element is the person who is ill and needs and seeks help. The second element is the act of profession — the promise the healer makes when he or she enters into the relationship with the person who is ill. The third element is the act of medicine or the act of healing. The following discussion of these three elements should make it clear that although curing and caring are essential parts of medical practice, caring "founds" that practice.
What is the meaning of being ill? Most people regard themselves as in a state of health, but this state cannot be determined absolutely. Despite all recent attempts to define health, no better functional definition has been given than by Galen, who defined health as that state in which we feel able to do the things we wish to do with minimum pain and discomfort. This means that you can feel you are in a state of health, and not feel ill, even though you have a disease. Indeed, many of us have disease within us, yet are able to do the things we want to do with minimum discomfort and disability. When something happens that shakes us out of this feeling of being in a healthy balance, it prompts us to seek help.
That balance is upset by a symptom: a pain in the chest, finding a lump, loss of appetite, morning nausea, dizziness on bending over — you name it. When such symptoms are perceived as a change in the function of our whole organism, they become sufficient to lead us to seek help. We become patients when we need help bearing a problem, a pain, a concern, an anxiety. It makes no difference whether a problem is emotional or physical; when we seek professional help, we become patients, and in becoming patients we enter a new existential state, of dependency and vulnerability. In this state, called illness, the body becomes the center of our concern because it is an impediment to, rather than a willing instrument for, the things we want to do.
The second element in the patient-physician relationship is the act of profession. When a patient enters a physician's office, the physician will say "What can I do for you?" or "How can I help you?" This is an act of profession, rather than a greeting, because within our social structure the physician is "ordained" as the one to whom the ill come for help. The physician's offer to help contains two implicit promises. First, the physician is competent and possesses the knowledge you need; second, he or she promises to use that knowledge in your interest.
The relationship of a vulnerable human (in the state of illness) with another human who has declared and professed that he or she is competent to heal is different from a commercial or legal relationship. A commercial relationship is based on mutual self-interest; a legal relationship is based on contract. A patient-physician relationship is based on profession and trust. Patients must trust the physician because illness has disabled them, has forced them to face the fragility of personal existence and placed them in a vulnerable state where they are dependent on another human being. This extreme vulnerability requires that the physician's relationship to the patient be based not on mutual self-interest, or contract, but on profession.
The gap between the patient's illness and the physician's profession is closed in the act of medicine, the third element. This moment of clinical truth is the decision on what to do. Medicine does not come into existence until a decision is made about a particular human being in a particular life-context, here and now. Medicine, science, the biological sciences are preparatory for the moment of clinical truth, in which the physician and patient, together, decide what ought to be done.
What ought to be done has two elements: the right decision and the good decision. By "right" decision I mean that it must be technically correct, must use the best scientific knowledge. Therefore science is fundamental to all kinds of medicine. Medical science can determine what is physically wrong, what can be done about it, and what is likely to be the outcome; but it cannot tell what ought to be done for the good of a particular patient. If you follow the cure model, the biomedical model, then what is medically good — what is medically indicated, what is scientifically correct — becomes what is good for the patient.
But reflect for a moment and you'll see that the two are not the same. The good decision must also fit the particular person's concept of the good life and the way he or she wants to live. The good decision must fit the patient's value systems, belief systems, and (if present) religious and spiritual convictions. In short, a good decision, to the extent that is humanly possible, must take into account how the scientifically indicated fits into the particular values, beliefs, and convictions which define the patient as person.
All physicians face the conflict between a technically right curing decision and the patient's conception of the good decision. For example, this conflict often arises in treatment of a Jehovah's Witness, who can be cured of certain acute situations with a blood transfusion; but the Jehovah's Witness has religious convictions which, for him or her, preclude that possibility. The right decision technically is not the good decision, because it violates the promise that the physician will use his competence for the good of the person who is ill and vulnerable. A person in a vulnerable state is in an unequal relationship, in which another has control of his or her life at that moment. Obligations are greatest on the one who has this power in the healing relationship, because he or she has voluntarily professed to work for the good of this particular patient.
Cure, in the radical sense, is not the only aim of medicine. The end of medicine, in the philosophical sense, is a right and good healing decision for a particular human being. A medically right decision might be to resuscitate a critically ill patient in hope that time would eventually lead to cure. Or if a patient had said no ("I'm not willing to pay the price of continuing to suffer; I am ready to face death; I am ready to begin the day of my dying"), the right decision and the good decision would be in conflict. What we have, then, at the moment of clinical truth, is an intersection of value systems which is the central and focal problem of medical ethics.
Excerpted from Caring, Curing, Coping by Anne H. Bishop, John R. Scudder Jr.. Copyright © 1985 The University of Alabama Press. Excerpted by permission of The University of Alabama Press.
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Table of Contents
1. The Caring Ethic: The Relation of Physician to Patient Edmund D. Pellegrino,
2. Nurse and Patient: The Caring Relationship Sally A. Gadow,
3. Ethical Relationships between Nurses and Physicians: Goals and Realities — A Nursing Perspective Mila Ann Aroskar,
4. Physicians, Patients, Health Care Institutions — and the People in Between: Nurses H. Tristram Engelhardt, Jr.,
5. "How the Hell Did I Get Here?" Reflections on Being a Patient Richard M. Zaner,
6. Further Considerations,