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Abstract

The deﬁnition of the nature of the professional patient relationship in bioethics varies: some hold that it is a contractual or ﬁduciary relationship, others believe that it is a relationship based on faith in patient’s autonomy. This entry ﬁrstly analyzes the deﬁnitions and connotations of the term “profession” to help its readers to understand the nature and the core features of the professional patient relationship; then, it reveals the changes taking place in contemporary professional-patient relationship as compared to traditional relationship and the new challenges ahead through a longitudinal analysis of its evolution; and in the end, it becomes evident that today’s professional patient relationship, though much different from the traditional one, still shares the intrinsic feature – trust, the core and the foundation of professional-patient relationship – with traditional professional-patient relationship. Under the impact of market forces, the main challenge faced by modern professional-patient relationship is the ever-intensifying conﬂict of interests.

Introduction

Although the professional-patient relationship (PPR) is the most important relationship in all relationships in health care, uniformly deﬁning this term proves to be very difﬁcult. What is the nature of the professional-patient relationship? Different points of view exist in the bioethics community:

The professional-patient relationship is a contractual relationship. The contractual model presents the therapeutic interaction as grounded in “a private contract for supply of professional services” (Sieghart 1982, p. 26). That is, essentially, the relationship between professional and patient is a contractual one whereby the doctor undertakes to treat and advise the patient and to use reasonable skill and care in doing so. In modern societies, such a relationship, which covers the majority of interpersonal trades and contacts, requires both parties to take on the responsibilities to honor their commitments once the contract has been made. Generally speaking, the professional-patient relationship is more or less similar to the contractual relationship. However, the complexity of the professional patient relationship extends far beyond the normal business relationship with a contract. The contractual paradigm can’t reﬂect the obligations of ﬁdelity and veracity owed by physicians to their patients. As Beauchamp and Childress observed, it is ﬁdelity that distinguishes the practice of medicine from business practices that rest on contracts and marketplace relationship (2001, p. 312).
The professional-patient relationship is a ﬁduciary relationship. To characterize the doctor–patient relationship as ﬁduciary wherein “the law deﬁnes a ﬁduciary as a person entrusted with power or property to be used for the beneﬁt of another and legally held to the highest standard of conduct” (Rodwin 1995, p. 243). It shares the main features of ﬁduciary relationships, of which the sole purpose is to protect the interest of the clients. Although it’s justiﬁable for doctors to charge reasonable remuneration for the care they have provided for their patients, the establishment of the relationship aims at upholding the interests of the patients; moreover, with the ever increasing specialization of labor and the concentration of resources, doctors gained an authoritarian status of control over the knowledge and skills, healthcare resources, and the diseases.

When the patients come to the physicians for help, they actually stand on a completely unequal footing, and therefore become vulnerable and highly dependent. Consequently, under the laws and moral systems of most of the countries, the professional medical workers – the “ﬁduciaries” – are subject to the laws and the highest standards of ethical codes. Each judiciary may have their own regulations, but ﬁdelity and integrity of the ﬁduciaries are indispensable. A system is thus set up to ensure that the interests of the clients are prioritized.

Some scholars also suggest that contemporary professional-patient relationship is not a general commercial contractual relationship as medicine and business are different in nature, or a ﬁduciary relationship either, because the superiority of the professionals are overemphasized in the ﬁduciary relationship. As a matter of fact, modern patients do not generally subscribe to a paternalistic model of health care decision-making, nor are they content to treat the therapeutic exchange as a simple commercial transaction (May 2001). In essence, it is practiced under the framework of paternalism in which the autonomy of the individual patient is neglected and suppressed. Today’s professional-patient relationship should be a relationship of trust based on the respects for the patients’ autonomy. On one hand, patients entrust doctors to offer advice that is not just competent but also aligned with their interests; on the other hand, they reserve the right to seek a second opinion, propose their own options, or even reject advice provided based upon what they themselves determine to be in their interests (Bending 2015).

The three perspectives mentioned above, different as they seem, all reﬂect the fundamental need for trust in the professional-patient relationship despite that under different models, the contents and the boundary of trust tend to vary.

This entry begins with an analysis of the deﬁnition and connotation of profession for better understanding of the nature and the core feature of the professional-patient relationship and a discussion of the attitudes, behaviors, and moral responsibilities that should be undertaken by a medical professional – the important leading party of the professional-patient relationship – to live up to the requirements and expectations of the society and protect the image of professional patient relationship from getting stained. Secondly, this research paper also longitudinally analyzes the evolution of the professional-patient relationship and addresses the enormous changes taken place in contemporary professional patient relationship as compared to the traditional one and the new challenges faced by contemporary professional-patient relationship. In the end, we will discover that today’s professional-patient relationship, though very different from the way it was a long time ago, still shares some intrinsic characters with traditional relationship. The healthcare sector is characterized by high specialization, high risk, uncertainties, and vulnerabilities of the patients, which determined that only by building trust between patients and the professionals can we ensure the success of the medical practices. Trust is not only the essence of but also the foundation for the communication between profession and patients.

Medicine As A Profession And Professional-Patient Relationship

To better understand the nature and core feature of the PPR and the proper attitudes, behaviors, and moral responsibilities required of a physician, as well as the requirements and aspirations from the society, it would be helpful to analyze the deﬁnition and origin of medical profession.

The term “profession” originated in the guilds (or professional associations) in the Middle Ages. As for etymology, the term actually derived from the Latin word “Prefessio” which means to declare openly. In Western culture, the interpretation of the deﬁnition varies. For example, some scholars believe that profession is a group of self-regulated people who gained a special skill through training or education and used it in the service of others. According to Pellegrino and Relman (1999) what distinguishes profession from other occupations is its core value – altruism.

As time goes by, a consensus of the basic deﬁnition of profession was gradually formed. Cruess et al. (2004) claim that a profession is an occupation whose core element is work, based on the mastery of a complex body of knowledge and skills. It is a vocation in which knowledge of some department of science or learning, or the practice of an art founded on it, is used in the service of others. Its members profess a commitment to competence, integrity, morality, altruism, and the promotion of the public good within their domain. These commitments form the basis of a social contract between a profession and society, which in return grants the profession autonomy in practice and the privilege of self-regulation. Professions and their members are accountable to those served and to society (Cruess et al. 2004).

Accordingly, medicine, as a profession, should possess the following basic characteristics: (1) having a sophisticated body of knowledge and know-how; (2) operating in the service of others and being directly accountable to the patients; (3) the members of which are governed by codes of ethics and profess a commitment to competence, integrity and morality, altruism, and the promotion of the public good within their domain during their lifetime; (4) the right to autonomy in practice and the privilege of self-regulation granted by social contract.

In medicine, physicians should be held accountable to the health of the public. However, under most circumstances, the central value of the medical profession is realized by establishing a sound rapport with a speciﬁc small group of patients and proffering care for them. The professional goal of the services provided by healthcare workers is to safeguard and improve the health of the patients. From this perspective, PPR is the core relationship in the healthcare sector and also the basic unit or the “building block” of it. In short, it is the cornerstone of the whole social system that is called medicine. Any social, political factors or economic forces that poses a threat to the PPR in any way will directly threaten the development of the entire health care profession and vice versa (Hui 2005).

A History Of The Development Of Professional-Patient Relationship

The professional-patient relationship has occurred since the birth of medicine. Medical practices always happen in the form of interactions between patients and doctors and medicine is always pushed forward by such interactions. As time passes, the professional-patient relationship has changed profoundly.

In ancient times, medical practitioners worked as individuals providing medical services for a living. There are two features in the traditional professional-patient relationship: ﬁrst, it’s simply a one-on-one relationship, because at the empirical stage of medicine, a doctor had to perform all the procedures, from analysis, diagnosis to treatment, all alone in person; second, patients in the traditional professional-patient relationship model, in essence, are passive receivers of healthcare.

Contemporary medical ethicists often criticize the traditional model for being “paternalistic.” However, under the traditional healthcare context, the “parents” and the “children” shared common and concentric fundamental interests, and the moral standards of individual doctors and the trust from the patients constitutes the two most important pillars of the professional-patient relationship. Under the present situation, in which the professional-patient relationship is facing a series of threats and challenges, we often miss and praise the traditional professional-patient relationship and even regard that period of time as the “golden age.”

In modern times, with the rapid development and extensive application of medical science, technologies and devices that became more and more sophisticated were utilized in healthcare; thus, traditional empirical medicine evolved into modern medicine that encompasses advanced technologies and equipment. Correspondingly, the traditional relationship also underwent fundamental changes.

Firstly, expanded new relationships, other than the traditional one-on-one relationship between doctors and patients, were built, transcending the realm of medicine and becoming more sophisticated. The development and clinical application of modern healthcare technologies have posed many ethical, legal, and societal problems, such as the use of life-sustaining healthcare devices, saving newborns with serious physical handicaps, and the distribution of rare donor organs and medical resources. However, the existing knowledge system, analytical methods, and problem-solving models can’t solve these problems. Therefore, since the 1950s or the 1960s, people from different disciplines and professions, including doctors, lawyers, clergies, theologians, philosophers, and artists, began working with physicians and played important roles in consultation, investigation, and even decision-making in clinical care. As a result, under such a trend of socialization and institutionalization, contemporary professional-patient relationship became more complicated and alienated, turning doctors into “the strangers at the bedside” (Rothman 1991).

Secondly, patients have become more and more involved in the clinical decision-making as their sense of autonomy strengthened and medical knowledge became more accessible to the general public. Thus, the paternalism in the professional patient relationship faded gradually and was replaced by a new relationship based on cooperation, patients’ participation, and respect for patients’ autonomy.

Thirdly, with the increasingly advanced and highly effective healthcare technologies rendering medicine extremely powerful and authoritative, doctors became more and more relied on and addicted to pursuit of those technologies. Inch by inch the professional-patient relationship is replaced by a relationship between doctors and those technologies. For many doctors, they cannot see the patients but only the diseases and methods and equipment to treat them (Dugdale et al. 2008).

Besides, the healthcare service sector and the pharmaceutical industry, equipped with the innovative and advanced technologies, are no longer traditional empirical medical practice or individualistic care, but an important building block of social capital. Furthermore, with the full development of the proﬁt-oriented market economy, the humanitarian tradition in the professional-patient relationship has been seriously compromised. In the end, the professional-patient relationship could risk degrading into a relationship between the providers and customers of healthcare.

Trust Is The Core Of The Professional-patient Relationship

Although we have seen signiﬁcant changes in the professional-patient relationship in the history of social development, trust has been and will always remain the core of the relationship as long as medicine as a profession exists.

Trust is created when people engage in interactions of mutual beneﬁts, dependence, and reliance. In those interactions, when one party makes a commitment and holds on to it for certain interests, the other party would trust and depend on him and hold expectations for his commitment. Healthcare is characterized by high specialization, high risk, uncertainties, and vulnerabilities of the patients, which determined that only by building trust between patients and doctors can we ensure the success of the medical practices.

Under most circumstances, the health of the patients is in the hands of the doctors, and this is especially true today when medical specialties have been further divided and the patients rely on their doctors even more desperately. Moreover, doctors are in an absolute superior position in terms of medical knowledge and the control of resources in the relationship. In clinical practices, patients have to not only describe their conditions truthfully but also communicate intimate information and the fear and anxiety hidden in their hearts. In certain cases, they may have to handover all the autonomy to the doctor. Under these circumstances, trust (or to become trustworthy) is of great importance. Patients must believe that doctors will, from the beginning to the end, honor the commitment that the health of their patients comes ﬁrst and believe that doctors will do no harm to them or make use of their vulnerabilities to acquire power, money, and career success. Only in this way can real professional-patient relationship be established and medical practices carried out uneventfully.

Trust, the core feature of the professional patient relationship, is of great ethical signiﬁcance. It requires the professional, as the leading party of the relationship, to bear principal responsibility for building and maintaining the professional rapport with the patients. In other words, doctors should make themselves trustworthy and reliable in the ﬁrst place. To this end, doctors should become professionally competent in research and in clinical care, and keep honing their skills; at the meantime, they must be committed to safeguarding and improving the health of patients and upholding the primacy of patient’s well-being. Although there is no certain answer to how much sacriﬁce should a doctor make in order to be proved “professional,” consensus is that doctors should uphold the primacy of patients’ health and well-being and avoid any conﬂicts of interest with the patients (Pellegrino 1987).

The conﬂicts of interest become increasingly ﬁercer under the impact of market economy. In certain western countries, doctors who are in possession of healthcare facilities may overuse those facilities for proﬁts; or, may try to earn a gatekeeper’s bonus from the insurance companies by blocking access to medical care; or, may accept various kinds of gifts and cash gifts from pharmaceutical companies. These misconducts all contribute to the potential conﬂicts between doctors and patients and directly undermine the professional obligations of doctors to prioritize patients’ interest (Wazana 2000; Blumenthal 2004; Dana and Loewenstein 2003). When there is a shortage of healthcare resources, certain countries, including China, have adopted a healthcare system rather different from that of the western countries. However, the opportunities and ideas of turning medicine into business, driven by the free-market ideology, are more prevalent and prosperous. If we regard traditional medicine before the 1950s, which hew to the principle of upholding the primacy of patients’ beneﬁts, as benevolent, the negative impacts of the healthcare market have fundamentally jeopardized medical professionalism and have become the biggest challenge faced by contemporary professional-patient relationship in a global scale.

Conclusion

This entry started with breaking down the fundamental term of the professional-patient relationship. As a profession, medicine must be based on the mastery of a complex body of knowledge and skills; its members must profess a commitment to maintenance of competence, integrity and morality, codes of conduct, altruism, and upholding the health and well-being of the patients. Altruism of the physicians constitutes the basis of the professional-patient relationship.

Furthermore, the article discussed the evolution of the professional-patient relationship and addressed the profound changes taken place in the relationship. However, the core element of both the traditional and contemporary professional-patient relationship, the trust placed in medical profession, remains the same. Nowadays, the professional-patient relationship is faced with a trust crisis and multiple challenges in almost every country. Although medicine is a profession that is deeply connected with local cultures and national traditions, and thus shows great differences in clinical practices, the greatest challenges of contemporary professional-patient relationship, generally speaking, are the intensiﬁed conﬂicts of interest under the impact of market force and medical corruption. In addition, with the extensive application of high-tech, especially the rapid development of the Internet and telemedicine, a new type of professional-patient relationship may emerge in the future.

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