Escrevi o seguinte texto para uma publicação da PRIME – Partnerships in
International Medical Education. Relata os quatro aspetos que se podem
identificar na procura do bem do paciente, de acordo com o modelo de
beneficência fiduciária proposto por Edmund Pellegrino:
Dr. Edmund D.
Pellegrino, one of the founders of Bioethics, identifies four components that
contribute for the good of the patient, the ultimate goal of medicine and
healthcare. It helps to prevent practicing organ centered medicine, which is
fragmented, reductionist, and unsatisfactory, and to acknowledge the whole
person approach, a core value for PRIME.
The first component is
the good of the patient from a medical standpoint – the biomedical or
techno-medical good. It is directly related to the knowledge and competence of
the physician and depends on the resources provided by medical science and
technology. It aims to restore any physiological or psychological dysfunction
by applying the appropriate state-of-the-art treatment, such as anticoagulation
for deep vein thrombosis or surgery for acute appendicitis. It is the
instrumental good that patients usually desire when they seek medical advice in
order to cure or control a disease, relieve suffering and preserve life.
Unfortunately, many doctors have a restricted understanding of the patient’s
good which acknowledges only this component in the clinical encounter. This
could lead to a paternalistic and arrogant attitude of the physician towards
the patient whenever there is any physiological benefit, scientifically proven,
of a certain medical procedure (e.g. the aggressive treatment of diseases
potentially reversible, like a pneumococcal pneumonia, in terminally ill
patients).
On a second level, the
biomedical good is confronted with the patient’s perception of the good i.e.
the patient’s opinion about what he thinks is the best for himself. Faced with
the same disease and the same therapeutic proposal, different patients may make
different choices, and therefore their preferences should be taken into
account. According to Pellegrino, ‘those choices and values are unique for
each patient and cannot be defined by the physician, family or anyone else’.
Not always what is proposed by the doctors should be done, if it collides with
the risk that the patient is willing to take to benefit from a treatment
proposal. Therefore an effective communication between the doctor and the
patient is essential, which may include listening with empathy, letting the
patient express his concerns and transmitting the diagnosis and any therapeutic
proposal in an understandable way. One of the reasons that patients usually
give for suing doctors is when physicians systematically ignore the patient’s
concerns and opinions.
Another component is
the good for humans i.e. the good for the patient as a human being or person.
The respect for the dignity of the person regardless of age, gender, race,
religion or social status, are included in this dimension. This would prevent
health professionals to initiate some treatments whose associated risks are
either excessive or disproportionate, even with the patient’s consent. If this
component of the good for the patient as a human being was considered, abuses
in human experimentation such as those that took place in Tuskegee, Alabama, or
in Willowbrook, New York, in the 20th century probably would not have occurred.
The highest level of
this dialectical approach of seeking the good of the patient is the spiritual
good or ultimate good. It is the recognition of the spiritual dimension of the
human being i.e. what gives meaning to life beyond material well-being. A
common example of this component is the refusal of blood transfusions by
Jehovah’s Witnesses, but other religious or ideological choices of the patient
should be respected as well. Sometimes in the hierarchy of values of the
patient health may not be considered the greatest good.
Edmund Pellegrino
clarifies that it is not always possible to integrate these four components for
the good of the patient in every clinical decision or even establish a
hierarchy among them, particularly in emergency situations or when dealing with
minors or patients with psychiatric or cognitive disorders. In these cases at
least the ‘good for humans’ component in addition to the biomedical good should
be recognized. On the other hand, Pellegrino underlines that the physician has
no obligation to obey all the choices and whims of the patient, especially
those that conflict with their own values and conscience. But even when
there’s full agreement between doctor and patient about some decision does not
mean that it is an ethically right one (e. g. a patient’s request for
euthanasia).
This four-level
approach of the patient’s good recognizes the whole person – physical mental,
and spiritual. It values the autonomy and dignity of the patient as a person,
and preserves his vulnerability in the face of scientific and technological
advances in medicine. This model is also patient-centered, gives the doctor a
key and proactive role in the search of the patient’s good, and contributes to
a more humane medicine.
References
Pellegrino, E. D. Moral Choice, The Good of the
Patient, and the Patient’s Good. In: Moskop, J. C.; Kopelman, L. (Eds). Ethics
and Critical Care Medicine. Dordrecht, Holland: Reidel, 1985.
Pellegrino, E. D. The internal morality of
clinical medicine: A paradigm for the ethics of the helping and healing
professions. Journal
of Medicine and Philosophy, 26, 559-579, 2001.
