Medicine and Surgery

BIOETHICS - Lecture notes

Dr. Bernard Caruana

BIOMEDICAL ETHICS OF DOCTOR

AND PATIENT RELATIONSHIPS

“A doctor’s strength is in his heart.”

Paracelsus

BIOETHICAL BASES OF A DOCTOR’S PROFESSIONAL ACTIVITY

In the bioethical bases of a doctor’s professional activity we can single out

a number of principles, such as: “do not harm”, “do good”, the principle of respect
toward a patient’s autonomy, and the principle of justice. The principles of
confidentiality, truthfulness and informed consent are derivates of the above
mentioned principles.
The principles of modern bioethics have originated long before the period
of this science forming: some of them are related to the school of Hippocrates
(IV-th century B.C.) and were formulated in the famous Hippocratic Oath. The
Oath consists of two sections: dedication and the code of ethical conduct.
In the section of dedication the doctor swears by Apollo, Asclepius and
Hygieia and Panaceia and all the gods and goddesses, making them his witnesses
that he will fulfil according to his ability and judgment this oath and this
stipulation. The same section contains an obligation to honour his teacher and
respect the corporate interests.
The second part of the Hippocratic Oath contains the ethical code, which
regulates a doctor’s professional activity in the field of dietetics, pharmacological
therapy and surgery. The Oath includes a number of prohibitions, in particular
the prohibition of abortions and euthanasia. In Hippocrates’ traditions an accent
was made on the special knowledge, training and experience of a medical worker,
which had to be directly applied in the process of treatment. In accordance with
this approach a doctor gives advice, and a conscientious patient follows this
advice, because he knows that the educated and experienced specialist does his
best in the patient’s interests. In obedience to Hippocrates’ traditions a doctor
promises: “I will follow that system of regimen which, according to my ability
and judgment, I consider for the benefit of my patients, and abstain from whatever
is deleterious and mischievous”. In the language of modern bioethics the
application of every method “to the patient’s benefit” makes the principle of help
and support. “Abstaining from whatever is deleterious and mischievous”
corresponds to the modern principle of “non-harming”. The principles of help and
support and non-harming taken together in the modern bioethics are considered
as the principles of maximum: a doctor is obliged not only to “do good” and “keep
the patients from harm”, but to promote the greatest good possible and abstain
from the slightest harm.
For a long period the doctors applied the text of the Hippocratic Oath as
generalized moral wisdom. Some modern professional ethical codes adhere to the
Hippocratic traditions at least in the sense, that they confirm that a doctor’s duty
consists in rendering help and support and keeping the patients from harm. The
well known Declaration of Geneva (1948) is the most vivid example of such a
code, named “The XX-th century Hippocratic Oath”. The Declaration of Geneva
was adopted by the World Medical Association after World War II as a reaction
of the national medical associations concord to medical experiments on people
carried out in Nazi relocations centres. The Declaration is written in modern
language, the appeals to ancient gods, prohibition of abortion and surgical
limitations were excluded from its text. However, it contains the key position of
the Hippocratic tradition: “the health of my patient will be my first
consideration”. In 1949 the 3th General Assembly of the World Medical
Association had approved the International Code of Medical Ethics, the text of
which is presented in Supplement 3 in the 1983 edition.
It is interesting that in half of the USA and Canada higher medical
educational institutions the graduating students swear one of the versions of the
Hippocratic Oath, and in one of them the original version of the Oath is
pronounced. The modern “Solemn Oath of the Russian Doctor” was written
according to the traditions of Hippocrates.
The Hippocratic traditions, which express the principles of help and
support and non-harming, have occupied the dominant position in the period of
bioethics development and preserve their influence in the modern situation.
The principle of abstaining from harm is the eldest in the medical ethics.
In its Latin formulation it sounds as follows: primum non nocere, which is
translated as “foremost do not harm”, and the word “foremost” can be interpreted
in the sense that this principle is most essential in every doctor’s activity. Quite
often the principle of keeping from harm is considered the core of Hippocrates’
medical ethics. Every doctor will probably agree to W. Lambert’s statement that
“there are patients who can not be helped, but there are none who can not be
harmed”. We know that at times treatment can be harder and more painful than
illness. We mean the side effects of medication, negative effects of simultaneous
application of a large number of drugs, or the disparity between the expected
benefit and possible risk of a medical interference.
From the ethical and legal points, inadmissible harm can be caused by:
1. Inaction, refusing to render help to a patient who needs it;
2. Lack of conscientiousness, evil or mercenary motives; and
3. Incorrect, improvident or unskilled actions.

The principle of “doing good” is a supplement and continuation of the

previous one. Unlike the first principle it is not a prohibition but a norm which

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requires positive actions. Its sense is sometimes expressed in such words, as
benefaction, charity, mercy, or philanthropy.
This principle presupposes not only avoidance of harm but active operating
with the aim of its prevention and correction. This includes not only intended or
unintended harm causal by a doctor, but also any harm which a doctor can prevent
or correct, be it a patient’s pain, suffering, inability or, finally, death. There are
difficulties in the understanding and grounding of the principle of “doing good”.
For instance, in its extreme form it could be interpreted in the sense of obligatory
self-sacrifice. Acting in accordance with this principle, one could consider
himself obliged to offer his kidney or even both kidneys for transplantation to any
person, even a stranger, otherwise speaking, to sacrifice his own life. But,
obviously, it would be unreasonable and even immoral to require such a degree
of self-sacrifice of a person. Therefore sometimes the principle of “doing good”
should be understood as a moral ideal, but not a moral obligation: although
following it deserves approval, but at the same time we should not consider
amoral and reprobate a person who refuses to be actively beneficent to others.
Generally speaking, it is hard to imagine a separate doctor, and moreover
all the system of health services and medicine, which would be limited only to
the task of not harming the patients. In this case the society would simply have
no reasons to support this system. Thus, the goal of all the health system consists
not simply in abstaining from harm, but in providing the patients’ wellbeing, and
thus helping all the people and the society on the whole. For example, when the
methods of preventing such illnesses as smallpox or plague were invented,
realization of positive measures against them became natural, i.e. special
programs of prophylaxis of these dangerous diseases were actively carried out at
the national level. It would be morally irresponsible to abstain from taking these
measures. The good which the doctors and other medical professionals should
pursue consists in promoting good health of their patients. The task of the health
services is to prevent the loss of health if possible, or to recover a patient’s health,
if there is a reasonable hope for his recovery. In a number of cases the doctors
have to be satisfied with less radical results, for example, with halting the progress
of a developing disease, or — in the case of palliative medicine — with
alleviating a dying patient’s pain and sufferings.
In the traditions of Hippocrates the principles of “doing good” and
“nonharming” were realized in the course of medical paternalism. During a
historically protracted period of time paternalism was justified, but since 1960-s
it was subjected to scalene criticism, because the nature of doctor and patient
relations had changed. Firstly, the interpersonal co-operation between them
weakened in the course of the medical science complication, growth of medical
knowledge and perfection of medical technologies. Secondly, the increase of the
rate of iatrogenic diseases, caused by medical interferences generated doubt in
the infallibility of the doctors’ knowledge and actions. Thirdly, suspicions arose
that many doctors are engaged in practices, which violate the patients’ interests
and serve the interests of medical workers, pharmaceutical firms, insurance
companies and state medical programs instead.

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 The change of the attitude toward doctors in the post-industrial society
caused discussions, directed against excessive paternalism of the traditional codes
of medical ethics. Many authors expressed moral opposition to the professional
codes which support paternalistic opinions in the medical practice. For example,
the morality of lies told for a patient’s good was called in question as a practice
which violates the patient’s right to autonomy. Not only the patients but also
medical workers, authorities, philosophers, and medical sociologists, began to
cast doubt as to the doctors’ right to make medical decisions on behalf of the
patients. This orientation of discussion was promoted by anti-paternalistic
community spirits, supported by the movements for civil laws, against the war in
Vietnam, and for the women’s rights. The doctors’ priority in determination of
what is harm or benefit for a patient was called in question. The critics of the
Hippocratic ethics pointed out that in the Hippocratic Oath there were no clauses
as to receiving a patient’s informed consent to treatment. They drew attention to
possible conflicts between the principle of “doing good” and other moral
obligations, including the respect of a patient’s autonomy. And, finally, the
traditions of Hippocrates are challenged when there is a conflict between a
patient’s interests and the interests of other people. The Hippocratic Oath, at least
in its original form, is focused exceptionally on an individual patient and does not
take into account the interests of other citizens of the society in the fields of
research medicine, the organization of health services, and in social justice.
As a result of these challenges new oaths and medical ethical codes
appeared, which were based on other than Hippocratic traditions, and some of
them had non-professional ethical systems at their background. The most
important of these documents is the Convention for the Protection of Human
Rights and Dignity of the Human Being With Regard to the Application of
Biology and Medicine: Convention on Human Rights and Biomedicine (the
Council of Europe, Oviedo, 04.IV.1997).
The development and introduction of new ethical approaches took place in
late 1960-s, in the situation when the newest achievements of biomedical science
and practice created principally new clinical situations. Artificial ventilation of
lights and other sustenance technologies not always rendered positive results.
Even when the use of such interferences as kidney dialysis or pneumo-cardial
resuscitation yielded brilliant direct results, remote outcomes remained indefinite.
There was the atmosphere of some informative opposition, lunges and
prosecutions in relation to medicine, the biomedical science, doctors and research
workers. As a result, both patients and medical workers began to feel less
comfortable than before, when doctors were in the position to decide
independently whether to use a certain medical procedure or not. The public had
certain “alerts”, it developed a feeling that the newest biomedical technologies
were risky and could cause unavoidable negative consequences, still unknown to
the doctors and scientists. The level of the people’s medical awareness and
knowledge about the state of their health and about the nature of the
recommended treatment grew. As a result they did not follow the specialists’
advice automatically any more, often tried to find out the alternative points of

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view, and required more detailed information on the possibilities and features of
the proposed treatment.
In 1960-s and 1970-s the practice of informed consent to medical
interferences and to people’s participation in medical research became an object
of judicial consideration. Despite some doctors’ opinion that complete disclosure
of all medical information and getting the patients’ informed consent were
incompatible with skilled clinical practice, the requirement as to the necessity of
granting the patients full information about every fact, which could be material
for conscious decision, legally prevailed.
The consolidation and wide spreading of the conception of informed
consent was partly related to the noticeable role of the principle of the patients’
autonomy in the bioethical analysis. This principle presupposed respect to the
choice made by a competent patient. In other words, people should be self-guided
and self-determined whenever this is possible. In this connection medical
professionals should not oppose to the wishes of a competent patient, even if the
fulfilment of these wishes exposes the patient to danger. The respect of a patient’s
autonomy may result in the failure to observe the ethical principles of help and
support or non-harming. Thus, in the conflict with other principles of bioethics
autonomy scored an advantage. This central position of the principle of autonomy
in the early period of bioethics development was consolidated on the basis of
debates as to the ethical problems of clinical tests and principle importance of
getting the human examinee’s voluntarily consent. In addition, the attention to
the problem of the patient’s choice of therapeutic methods was stimulated by the
public concern about the doctors’ paternalism in their relations with the patients.
Only an autonomous person can make a voluntary choice, and only wherein there
is such a choice it is possible to talk about responsibility and conscious
application of ethical categories. The action can be considered autonomous only
if the person who carries it out acts:
a) intentionally, i.e. in accordance with his/her own plan;
b) with precise understanding of what he/she is doing;
c) without external influence which would determine the course and result
of his/her action.

According to the first condition, a purely automatic action, which we carry

out without reflection, even if we understand its sense, should not be considered
autonomous. The second and third conditions may be realized to a different
degree in every case. If a doctor suggests a patient some serious surgical
operation, it is quite unnecessary for the patient to have all the special knowledge
about it which the doctor has. Generally speaking, to make an autonomous choice
the patient needs to understand only the main things, and not all the small details
involved in this situation. He can turn to his relations or friends for advice, and
their opinions will surely influence his choice. But if he perceives this advice not
as an order, but as additional information for decision-making, his final choice
will be autonomous. In the end the patient can consent or disagree, accept or reject
the doctor’s suggestion. If he consents, he in fact authorizes the doctor’s intention,

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i.e. makes it his own decision, — and thus the first condition of autonomous
choice is observed.
It is quite possible that taking his choice, the patient will count on the
doctor’s authority above all things. However, even in this situation the choice
which the patient makes is undoubtedly his own, and thus, autonomous decision.
The principle of respect toward autonomy is based on the idea that a human
personality is self-valuable regardless of all attendant circumstances. The
principle of autonomy grants every person’s right to noninterference with his/her
plans and actions and, accordingly, it asserts other people’s duty not to limit the
person’s autonomous actions. It certainly does not follow from this that people
never have a right to hinder someone’s autonomous actions. What is important
here, is that in every case the limitation of autonomy must be specially grounded
on other principles. It’s not the point that this principle must never and under no
circumstances be violated. It is important for a doctor to be morally aware of the
reason, why he has to limit a patient’s autonomy. And if in a concrete situation
the requirements of the principle of respect toward a patient’s autonomy
contradict to the requirements of some other principle, for example, the principle
of non-harming, one of them will be violated. A typical example of such a
situation is the case of informing an incurable patient about the diagnosis of his
disease. The revealing of the true information in this case can do him irreparable
harm and undermine his psychical and moral powers. Therefore, if the patient
does not ask the question about his diagnosis, the doctor may refrain from giving
him the information, although such an action will violate the principle of respect
toward the patient’s autonomy. We should point out that the legislation of many
countries grants the patients a right to know their diagnoses, although the laws
usually add that the information should be reported “in a delicate form”.
It should be noted that the action of the principle of respect toward
autonomy is naturally limited in regard to people who are unable to operate
autonomously — children under the age of 15 years, patients with mental
disorders, people in the state of alcohol or narcotic intoxication, etc. It is
important here that the limitation of autonomy is justified by the principle of
“doing good”, i.e. other people act with the purpose of protecting this person from
the harm he can cause to himself.
As a result of the consolidation and expansion of the principle of the
patients’ autonomy in 1960-s–1970-s a doctor’s role changed substantially. He
began to operate as a kind of “servant”, whom the patients invite when they
consider it necessary. To an ever increasing extent doctors, as well as other
professionals, turned into the service staff, which is near at hand and always at
the patients’ disposal. In accordance with this approach the relationship between
the patients and medical workers followed the model of contract relationships
which exist in other regions, for example in jurisprudence or business. Like a
lawyer or an accountant, a doctor gives his clients full information, which they
need to make an informed choice of treatment. In its extreme forms this model is
sometimes named “scientific”, “engineering” or “informative”, when a medical
worker’s responsibility consists simply in granting the patient complete
information on what is best for him from the doctor’s point of view. In this

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situation the patient’s informed consent to treatment becomes a decisive test in
the estimation of the ethical attitude toward the patient.
Today the necessity of adjusting the central position of the principle of a
patient’s autonomy in bioethics became obvious, this need is conditioned by a
number of circumstances.
Firstly, a patient’s autonomy and his ability to make independent decisions
can be limited by the disease. When a person is ill, he/she is irritable, low-spirited
and disturbed, and their judgements sometimes substantially differ from those
which are characteristic of them when they are healthy. Secondly, sometimes the
duty to respect a patient’s autonomy can result in the violation of the medical
worker’s own autonomy, when he/she is suggested to act against his/her human
or professional values. Thirdly, the observance of a patient’s autonomy can
sometimes conflict with a doctor’s responsibility in relation to the health of the
society as the whole. For example, the efficiency of modern vaccination in
decreasing the risk of infectious diseases morbidity is well known. However, any
patient may refuse to be vaccinated, declaring that the danger of disease for other
people does not interest him, or say that to his point of view the risk of disease
has already reached its minimal level, because a sufficient number of persons
were vaccinated. In this situation it should be quite ethical to overcome the
principle of the patients autonomy by carrying out programs of obligatory
immunization.
Another weak point of the patients’ autonomy model consists in the error
of the initial thesis, that an individual is completely independent and self-
sufficient in decision-making. In reality every person lives within a network of
personal and social relationships (especially with his/her family members), which
influence the nature of his/her final decisions.
And, finally, the principle of the patients’ autonomy, unfortunately, does
not offer any stimuli for the economy or just distribution of the health system
limited resources. For this reason the principle of autonomy does not always work
at the macro-level, when there is not enough facilities for the implementation of
all that every autonomous patient wishes, especially when he wants “everything
possible” to be done.
In the light of the mentioned limitations of ethics oriented at the principle
of patient autonomy, an alternative principle of social justice got understanding
and support in the system of health protection. It is based on the requirement of
social justice in the distribution of limited health system resources, so that both
advantages and economic loadings are justly distributed between different strata
of the society. It is interesting that the problem of social justice played an
important role in the origin and development of bioethics.
For instance, in the 1970-s there were many discussions in connection with
the implementation of the newest (at those times) technologies of artificial
dialysis in the clinical practice.
An ethical conflict in one of the hospitals in Seattle (the USA) got wide
publicity at that period. A practical question had to be answered urgently: which
patient was to be connected to the apparatus and, thus, his/her life would be
prolonged, and who was fated to die because of having to wait for his/her turn.

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The principle of social justice is not always directed at immediate benefaction for
the patient (as the principle of help and support requires) and does not always
provide correspondence to the patient’s autonomous choice of treatment (unlike
the principle of autonomy). The principle of social justice stresses, that medical
professionals have responsibility both before the society as the whole and before
every individual patient.
The general principle of social justice provided the grounds for the
development of related ethical principles, aimed at the regulation of the limited
resources distribution. These principles presuppose such ethical criteria as
equality, necessity, ability, efforts, social benefit and others. The standard of
necessity is usually considered the basis of the health services resources
distribution. This standard helps to estimate the patients’ need in treatment on the
basis of its probable outcome and the quality of the therapy results. A certain kind
of therapy will be prescribed first to those patients, who have the best chances for
its positive effect.
The principle of justice, as it is understood in bioethics, can be formulated
roughly as follows: everybody must get what he/she is entitled to. The word
“everybody” in this context concerns either a separate person or a group of people
selected according to certain criteria. The principle of justice, like each of the
other principles discussed above, has not an absolute, but only a relative force, it
operates prima facie. If, for example, in a situation with donor organ
transplantation it will be found that a patient, who’s turn for operation has not yet
come according to the waitlist, is in a critical condition, it would be moral to
renounce the obligations effluent from the principle justice, and to follow the
principle of non-harming. However, the failure to observe the turn in this case
can be also interpreted in a different sense; here the same principle of justice can
be used, if it is applied on the base of another criterion — the criterion of
necessity, proceeding from the degree of its urgency. The principle of justice
provides obligatory granting and equal availability of medical care. Each
community sets the rules and order of granting medical care in accordance with
its possibilities.
The discussion of the problem of justice requires decision-making
concerning the macro- and micro-distribution. The problem of macro-distribution
of goods and services is solved at the state level, it becomes the sphere of social
policy and is directly related to the economic problems. They include the
financing of the prophylactic and medical programs at different levels, as well as
other forms of health work. However, for the medical workers the problem of
micro-distribution of the health services limited resources is more urgent. In these
situations which arise daily in every doctor’s or trained nurse’s work, medical
indications should serve as the only criterion for the distribution of scarce
medications and medical services. From the moral point of view it is
impermissible to make the choice proceeding from a patient’s social status, his
connections or level of financial prosperity.
Although the principle of social justice is successfully applicable to the
ethical discussions concerning the policy of health protection, its use in the
clinical practice and in the relations between doctor and patient sometimes meets

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difficulties. The problem is that a doctor’s education and experience is initially
oriented at his patient. The doctors try to do everything possible for their patients,
and the patients expect that their doctor will do his best in their interests. The
critics of the principle of social justice assert that a doctor can not serve two
masters — the patient and the society; and if a very expensive treatment is
indicated, a doctor should do everything possible to provide it for his patient.
Another objection against the principle of social justice is the assertion that
its ethical criteria, on the base of which the distribution of health protection
resources is carried out, are hardly applicable in the real clinical practice. First of
all, the “standard of necessity” in the distribution of resources presupposes that
the rate of “necessities” is relatively permanent. However, the term “necessity”
is rather indefinite, and a real patient’s needs depend on specific circumstances.
Thus, the described principles of help and support, non-harming, the
patient’s autonomy and social justice are recognised as central in the modern
biomedical ethics. Ethical problems are solved in the modern health protection
with consideration of the content of the basic principles of bioethics, but the
chosen methodological approaches or models can be different.
The description of relationships between the doctor and patient would be
not full enough without the discussion of some conflicts of interests, which
concern a doctor’s professional activity. The medical tradition for a great period
of time considered the assistance to a patient and maintenance of his/her health
the most essential purpose of medicine. The modern formulation of this purpose
is supplemented with a phrase: “within the framework of respect toward the
patient’s autonomy”. More specific aims of medicine are traditionally
acknowledged too; they include the maintenance of life, relief from pain and
sufferings, restoration of physical and mental functions, taking care of the dying
people and some others. Along with the existence of disagreements concerning
the specific aims which should be included in the strategy of maintenance and
support of a patient’s health, there are other motivations and stimuli which
compete with a doctor’s focusing exceptionally on the problems of his patient’s
well-being. Such competitive motivations create a conflict of the doctor’s
interests, which shows up in the following variants.

1. The conflict between the doctor’s interest in providing his patient’s

well-being and his interest in the maintenance his own health. Does a
doctor have any obligations, which follow from his professional role, to
render medical help in the cases which involve risk for his own health,
for example, the risk of contacting an infectious disease?
2. The conflict between the doctor’s interest in providing a patient’s well-
being and his own financial interests. The ethical question is, whether a
legitimate competition is possible between professional and financial
interests.
3. The conflict between the interest in a patient’s well-being and the
financial interests of the society. In addition to the traditional
expectation, that a doctor must serve his patients and satisfy their
medical needs, in the last decades a new expectation appeared, that a

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 doctor should also serve the public need in the economy of medical
charges, that is, he should operate as a “double agent”. But can the
fulfilment of this social need make a legitimate goal within the limits of
the medical practice?
4. The conflict between the interest in a patient’s well-being and the
financial interests of the insurers — private companies or public
programs. Can the insurers’ financial prosperity legitimately compete
in its importance with a patient’s well-being? Is a doctor not only the
patient’s but also the insurers’ “agent” ? If an insurance company is
private, the doctor obviously can play a role of an agent of the stocks
holders, whose primary purpose consists in increasing their income.

The relationship between a doctor and patient can have specific features
related to their different cultural identification. A doctor and a patient can be
citizens of different countries, speak different languages, and belong to different
cultures (or subcultures within the limits of one country). For these reasons a
doctor and his patient can have distinctions in their cultural understanding of
acceptable ethical practice and very considerable divergences in their world view,
in particular in the question, whether the universe is ruled only by natural laws,
or the actions of spirit and magic are possible too.
A doctor and patient with different cultural views can have serious
divergences in ethical issues. For example, they can disagree on the question, who
has legitimate power in decision-making. The divergence can be caused by the
problem of veracity in medical practice, the role of the family in decision-making
concerning a patient’s management or acceptable treatment of a child.
A doctor and patient who belong to different cultures can have
disagreements on practical and metaphysical issues which influence the course of
treatment. For example, a patient can believe that the discussion of possible
complications of therapy and unfavourable outcomes of disease increases the risk
of their development. The members of some cultures can defend the necessity of
carrying out sacral actions, which cause considerable pain, with the purpose of
driving evil spirits out of a child’s organism. From the perspective of the western
culture a doctor considers such beliefs irrational and potentially dangerous,
however, from the ethical point of view the respect of cultural features and
traditions is an important component of a correct relationship between a doctor
and his patient.
Racial, ethnic or national prejudices can also cause considerable problems
in the relationship between a doctor and patient. Their overcoming is not only the
issue of biomedical ethics, but also a task of the worldwide scale.

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THE PRINCIPLES OF VERACITY AND INFORMED CONSENT

The relationships between the members of different medical professions

(doctors, trained nurses, administrators, druggists and others) and the patients
form a complicated social network, through which individual, group and state
interests related to the health care issues are realized. There are norms which have
a certain role in the ethical regulation of the relations between the medical staff
and patients. The principles of truthfulness and informed consent are stated in
The Declaration on the Promotion of Patients’ Rights in Europe (Amsterdam,
1994) (Supplement 6).
The principle of veracity. This is a formal or deontological moral principle,
which asserts that the actions or rules are morally correct, if they are directed at
granting truthful information and have a goal of avoiding dishonesty in mutual
relations. To be truthful means to give the interlocutor information, which is true
from the point of view of the informer. Sometimes this rule is used in the form of
prohibition of lies, i.e. the prohibition to give information which is false from the
informer’s point of view.
Traditionally the codes of medical ethics do not give enough attention to
the veracity or deception and lies in the relationships between a doctor and
patient. At the same time, the problem of a doctor’s duty to give his patient true
information is the most discussed question in bioethics. The question is
formulated as follows: “can a doctor’s paternalistic lies and the practice of
patients deception be morally justified?” If yes, in which cases? One of the
approaches to the analysis of ethical problems consists in asking more general
questions. Is a lie always morally impermissible? Is it always correct to tell the
truth? When answering these questions, we surely need to find good grounds for
our position. If lies and intentional deception are always morally impermissible,
then all the people including doctors should never resort to them. If lies and
intentional deception are sometimes morally acceptable, it is necessary to try and
define the situations which make such actions justified. After determining these
conditions, it is possible to use specific examples of doctor and patient relations
to estimate their acceptability.
On the whole, the problem consists in the moral conflict between striving
to do the best for the patient from the perspective of good or harm concepts, and
fulfilling some commons commitments, in this case — obligations to tell the
truth.
The original approach of the Hippocratic school requires to act in a way
which would benefit the patient. According to Hippocratic ethics, a doctor should
say only those things, which can help a patient and avoid the information which
can cause harm. The following words belong to Hippocrates: “Surround a patient
with love and reasonable comfort, but mainly — leave him in ignorance
concerning his perspectives, especially the possible risks which threaten him”. A
doctor’s paternalistic lies, the so-called “holly deception”, for a great while were
considered quite acceptable in the relations between a doctor and patient.
According to D. Oken’s data (1961), 88 % of the questioned doctors in the United

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States reported that they usually do not tell the terminal oncologic patients the
truth concerning their illness, following the traditions of Hippocrates.
The principle of veracity in the doctor and patient relations is assessed
differently in different ethical systems. From the position of E. Kant’s
deontology, veracity is a duty of every person toward him/herself as a moral
creature, and to lie means to humiliate one’s own human dignity and to destroy
one’s self-esteem. Therefore E. Kant insisted that in all situations every person,
including a doctor, has a direct obligation toward himself and others to be truthful.
In W. Ross’s deontology the obligation to abstain from lies and intentional
deception is a prima facie obligation, which under cer tain circumstances can be
inferior to other conditional (prima facie) obligations. A doctor’s duty to
provide his patient’s medical well-being can be such an obligation in medicine.
From the position of the “action — utilitarianism” theory, the question of the
necessity to tell the truth is solved individually from the perspective of achieving
maximal benefit in every concrete situation. The followers of the “rule —
utilitarianism” theory in this ethical situation are confronted with a necessity to
define the expedience of formulating exceptions from the rule, which forbids a
doctor to give untruthful information to his patients. These exceptions should
probably refer to the cases when there is convincing evidence that a patient does
not want to know the truth about his/her disease, or that the information will cause
him/her a serious psychological trauma. In these cases an adherent of the “rule —
utilitarianism” theory should analyse, whether the harm done by revealing the
truth to the patient would be compensated by the positive consequences, ensuing
from the rule of prohibition of any lies in the doctor and patient relations. He will
take into account also the fact that lies have remote consequences in the form
breaking the doctor and patient relations.
In the 1970-s the attitude toward the principle of veracity began to change
sharply in connection with the criticism of Hippocrates’ paternalistic traditions
and increased accent on the principle of respect toward a patient’s autonomy.
According to the data of questioning carried out by D. Novack (1979), 98% of
doctors in the USA observed the rule of telling their patients truth about their
disease and state in the everyday practice.
For the sake of rapprochement of the Hippocratic traditions and the respect
toward the patients’ autonomy we can make another effort at analysing the
consequences of lies, remaining within the framework of Hippocrates’ principle
of non-malfeasance (non-harming). The point is that in the modern hi-tech
medicine a whole team of medical workers participates in every patient’s
treatment, and it is difficult (and sometimes impossible) for all of them to support
the same untruthful version of the patient’s disease. In other words, in the
conditions of modern medical practice there is a high probability that a lie will be
exposed, and consequences will be extremely unfavourable for the patient.
Another direction of rapprochement between the positions of Hippocratic
ethics and the principle of autonomy is the use of the “medical contraindications”
conception. In the same way as certain variants of investigation or treatment can
be contra-indicated to a patient, sometimes, for example in depression or suicidal
state, the revealing of truth can be considered medically contra-indicated.

12
 The attempts of rapprochement of different points of view in regard to the
principle of veracity can be rejected by radical supporters of the principle of
veracity. From their point of view lies destroy trustful relations between a doctor
and patient and make their coordinated actions impossible. In a number of cases
it is simply impossible to abstain from giving a patient true information about
his/her disease. For example, how can a doctor get a patient’s consent for
chemotherapy or radiotherapy without informing him that he has an oncologic
disease?
In his relationships with the patients a medical worker acts as a
representative not only of society as a whole but of his professional group too.
Permanent lies violate the trust toward the profession. If a patient is convinced
that doctors constantly hide unfavourable information from him, he will mistrust
even quite truthful assertions, like “the prognosis of your disease is favourable”,
or “this surgical operation is not dangerous for you”, or “chemotherapy will be
effective in your case”. It is possible that this circumstance can explain why many
patients after the confirmation of an oncologic diagnosis turn to various healers
and quacks even if their official treatment was effective. If patients mistrust the
doctors, it is very difficult to reach success in the struggle against serious diseases,
including tumours. Therefore both doctors, trained nurses, and medical
administrators must be truthful to maintain the attitude of trust to their
professional group in the community.
The question about the patient’s duty to know the truth is more difficult.
The discussion of this issue should be held from the patient’s position: why must
“I” as a patient know the truth? “I” must know the truth precisely in order to
preserve my “Self”, i.e. to remain an autonomous personality, to be a responsible
subject of my actions. Without the true information concerning the conditions of
one’s existence (including the information on the state of one’s health), a person
seams to shift the responsibility for his life events from himself to others (for
example, a doctor), and by doing this, to renounce his subjectivity and freedom.
Therefore the striving to know the truth is every person’s duty, even when he is
tied down by illness to a hospital bed. Surely, a sick person is naturally limited in
his freedom. These limitations vary from most insignificant ones (in transitory
colds), to most serious ones in the comatose states or changed states of
consciousness in mental disorders. Therefore the duty to know the truth can not
be imputed to every patient in an equal measure. Some people also have a
psychological predisposition to live in an inferior, dependent upon others state.
From the point of view of the autonomous personality morals, which dominates
in the modern industrial world, this self-waver of one’s own subjectivity is
harmful. However, considering that this self-refusal is voluntary, this form of
self-affirmation should also be respected. Among the representatives of different
cultures patients tend to delegate the responsibility for the decision-making
related to their disease to their close relatives or medical workers. To a certain
degree this remark is correct in regard to traditional conduct of quite a number of
patients. A doctor is obliged to take into account and respect these traditions.
It is legitimate also to discuss the question of a patient’s duty to tell the
truth. Must a physician aim at finding out the truth, and must a patient tell him

13
the truth? A medical worker’s duty to aim at obtaining maximally true
information in all situations is determined by his professional task to treat the
patients. Only complete and reliable information on the origin and course of the
disease can guarantee correct diagnostics and effective treatment. The major
condition of realizing this task is the development of trust in the patient toward
the concrete doctor and the medical profession on the whole. A patient hardly
will share the truth, if he/she is not sure that the physicians will observe
confidentiality and the details of his/her personal life, disclosed to the medical
personnel, will not be discussed with strangers. A patient’s duty to tell the truth
is firstly grounded on his/her social nature and on the necessity to consolidate the
spirit of trust in the “patient — medical staff” social unit. Veracity is everybody’s
moral duty, and illness does not diminish it at all. Besides, a patient often uses for
his treatment either state or institutional or family financial resources, which often
are limited. The feelings of solidarity with a patient and the sympathetic attitude
toward his needs are expressed in the redistribution of these limited resources to
his benefit in the forms of state health care, institutional or family support. This
circumstance creates another basis for the patient’s moral duty to co-operate with
the medical workers effectively, so that these limited resources would be used
zealously. Naturally, this is impossible without his truthfulness.
A patient’s obligation to tell the truth is grounded also on the principle of
non-malfeasance. For example, when he comes to a doctor’s consulting room, a
patient has a moral duty to report about his infectious diseases, such as AIDS,
tuberculosis, or hepatitis, which can be dangerous for the medical workers or
other patients who come in contact with him. Another ground for a patient’s duty
to tell the truth is the fact that in the process of communication with the patients
a doctor forms his experience concerning the importance of specific symptoms in
correct diagnosing and increasing the efficiency of certain treatment measures. If
a patient does not tell the doctor about wilful changes in using the prescribed
medicines or distorts the information as to his complaints, he becomes
accountable for forming the doctor’s false knowledge about the diagnostic criteria
of diseases or the efficiency or ineffectiveness of some medications. This false
information can become a source of the doctor’s erroneous actions, both in regard
to the untruthful patient and to other patients. A doctor’s right to give the patients
true information concerning the state of their health is limited by the requirement
to deliver it in an understandable form and not to cause the patient harm by this
information. A doctor’s right to know the truth is not specially regulated by law.
It is embedded in the traditions of doctoring and the administrative norms of
modern medicine. The question usually concerns not a treating doctor’s right to
know the truth, which is usually considered obvious, but rather the right of other
participants of the treatment process to have access to the information on a
concrete patient’s state of health. In the modern policlinics and hospitals medical
help is frequently rendered not by one doctor but by a group of specialists, and
each of them needs true information on the patient’s state. Their right to the access
to this information is provided by appropriate administrative norms. The question
concerning the students’ right to learn medical information on a specific patient’s
state of health is more difficult to answer, because they do not take a direct part

14
in the treatment of this patient. Teaching at the patients’ bedside is one of the
most important elements in the medical workers’ education. The traditions and
administrative order of clinics ground the students’ right to participate in the
patients examination, to implement diagnostic and medical procedures under
experienced professionals’ supervision, and consequently, to have access to the
corresponding medical information. However, from the moral point of view, as
the participation in the teaching process is not in the direct interests of a concrete
patient, the students’ right to have access to medical information and to the
treatment and diagnostic manipulations must be conditioned by a voluntarily
consent of the patient or his family members.
A patient’s right to give the doctor truthful information about the state of
his health and the circumstances of his disease development seems obvious on
the face of it. However, the “truth” which a patient knows about his disease can
concern not only him personally. For example, does a patient who is ill with a
venereal disease have a right to report the truth about his/ her sexual partner, who
probably was the source of infection? The answer to this question varies
depending on which of the two values outweighs in a specific society. If the
preference is given to the public interest in the minimization of infectious diseases
spreading, the patient not only has a right, but is even obliged (morally, and
sometimes by law) to report about the partner. If the society values the
inviolability of private life higher, the right to spread truthful information in this
case is limited by the partner’s permission to give this information to the doctor.
In the democratic societies the inviolability of private life gets all the greater
estimation and support (including its legal provision), so that the absolute priority
of public interests is preserved only in connection with the group of extra-perilous
infectious diseases. The lower is the social danger of a disease, the higher grow
the values related to the inviolability of private life. The balance of values can not
be predetermined by a certain rule. However, one should always remember that
the right to tell the truth is not absolute and the inviolability of other people’s
private life is a major legal norm and a moral value of the modern civilized
communities.
The principle of informed consent. Arguments about the veracity and lies
in the medical ethics often arise in connection with the discussions of the
requirement of informed consent. Today it is generally accepted that a competent
adult patient has a moral and legal right not to be exposed to medical interference
without his informed and voluntarily consent. It is quite clear that lies or even
concealment of information seriously undermine the possibility of valid
discussion and, consequently, the granting of informed consent. To give this
consent and realize his/her right to self-determination, a patient must have the
access to the necessary information, and doctors, as a rule, must provide it.
The requirement to get a patient’s informed consent is a relatively new
addition to the acknowledged ethical principles which regulate the doctor —
patient relations. The traditional codes of medical ethics do not acknowledge a
doctor’s duty to inform a patient about the risks and advantages of alternative
diagnostics and treatment methods. The Hippocratic ethics includes the concept
of therapeutic privilege, which consists in the concealment of information, which

15
to the doctor’s opinion is harmful for the patient and would worsen his
psychological state. The therapeutic privilege is a component part of the ethical
systems based on paternalism. The Hippocratic ethics does not exclude the
informed consent, but only in the cases when, to the doctor’s opinion, it will be
beneficial for the patient.
In the liberal political philosophy the key thesis says that full information
should be given, even if the doctor considers that it will not benefit the patient. In
1972 the doctrine and concept of informed consent were formulated and
consolidated by law, and since that time they come into special notice of the
specialists in bioethics. The pre-conditions for this doctrine were formed much
earlier in connection with the investigation into the so called “scientific” activity
of the Nazi physicians in the concentration camps during the World War II. After
the Nuremberg process in which the proofs of monstrous medical experiments
carried out in the concentration camps were shown, the issue of the subject’s
consent became one of the main topics in bioethics. It should be noted that even
before these events and in the world and domestic medical practice there was a
long-term tradition of getting a patient’s consent for surgical operations.
However, the rule of informed consent has a wider approach than just receiving
a patient’s consent for operation, primarily because this rule requires the patients’
and examinees’ consent to be voluntary and given after they receive adequate
information and make a free choice.
The principle of informed consent is designed to provide a respectful
attitude toward the patients or examinees in biomedical research as to persons,
and to minimize the threat to their health, socio-psychological wellbeing or moral
values caused by the specialists’ careless or irresponsible actions. Surgical
operations, chemotherapy, protracted hospitalization and many other types of
medical interference can have a serious impact on a person’s ability to realise
his/her life plans. The application of the rule of informed consent provides the
patient’s active participation in the choice of treatment methods, optimal not only
from the medical point of view but also from the point of the person’s values. In
obedience to this principle, every medical interference (including a person’s
participation as an examinee in biomedical research) must include as an
obligatory condition a special procedure of receiving the patient’s or examinee’s
voluntarily consent, based on their adequate informing about the aims of the
planned interference, its duration, expected positive consequences for the patient
or examinee, possible unpleasant sensations, risk for life, physical and/or socio-
psychological well-being. It is also necessary to inform a patient about the
existence of alternative treatment methods and their comparative efficiency. A
substantial element of informing consists in telling the patients and examinees
about their rights in this medical or research institution, and the methods of their
rights protection in the cases of violation. Nowadays the rule of receiving
informed consent from the patients and the people who participate in clinical tests
or medical and biological experiments became a generally accepted norm.
Medical interference fraught with the risk to the patient’s health can be
allowed as an exception in the case of urgent necessity, if the possible harm from
the application of diagnostic, preventive or treatment methods is milder than the

16
expected negative outcome, if no medical measures are taken, and if it is
impossible to remove the danger to the patient’s health by any other methods.
Risky methods of diagnostics, prophylaxis or treatment are allowed only
with certain reserves: they must correspond to modern scientifically grounded
requirements, be directed at the prevention of a real threat to a patient’s life and
health, be used with the patient’s consent, if he/she is well-informed about their
possible negative consequences, and the doctor is obliged to take all proper
preventive measures to diminish the threat to life and health caused by them.
If the waiver of medical interference can result in grave consequences, a
doctor is obliged to inform the patient about this. If the patient does not change
his/her decision after this, the doctor has a right to demand a written confirmation,
and if it is impossible to get it — to register the refusal by a proper document in
the presence of witnesses. If the refusal is given by the patient’s legal
representative and it can lead to grave consequences for the patient, the doctor
must inform the guardianship bodies.
Competence and voluntariness are the obligatory “threshold” elements or
condition precedents of the principle of informed consent. A patient’s or
examinee’s competence is the necessary condition precedent of the procedure of
getting his/her informed consent. The law establishes a simple enough rule, which
presupposes two states of a patient or an examinee — their competence or
incompetence. Children and persons found incompetent in accordance with an
established legal procedure, are considered incompetent. The right to give
informed consent for an incompetent patient is passed to his/her legal
representatives. The law expresses here only a generally recognised minimum of
moral norms, setting aside a number of situations, debatable and ambiguous from
the ethical point of view. In particular, a child’s rights to receive the information
concerning his/her bodily and mental health and to have some control over things
that are done to his/her body in the process of treatment, are practically not taken
into account. Certainly, a child is not mature enough to make responsible
decisions concerning the methods of his treatment without the adults’ help. But
this does not mean that the adult can fully replace him/her in the process of
decisionmaking. Can we simply ignore an under-age patient’s personality?
Probably, a differentiated approach would be more justified. Depending on the
level of individual development, the child should be given a greater or lesser
volume of rights to participate in the decision-making concerning his/her
treatment.
From the moral point of view the practice of forcing children to surgical
operations by violence or deception is incorrect. The difficulty of receiving their
consent, which indeed occurs in a number of cases, demonstrates only an insistent
need of the doctors’ education in clinical psychology and their active cooperation
with professional psychologists in solving the problems of communication
between very young patients and physicians. We should also take into account
the possibility that legal representatives can make decisions which do not
correspond with the patient’s interests. In this case the doctors’ duty is to defend
the child’s interests and take legal steps, which would limit the legal
representatives’ rights in this question. There were cases, when the parents

17
refused to grant a permission for their child’s life-saving surgical operation
because of their ignorance or religious prejudices. In such situations the interests
of incompetent patients should overweigh the rights of their legal representatives.
A patient’s competence is understood as his/her capacity for autonomous
decision-making. A patient, who’s condition is very serious is not always
competent. Competence is also decreased by the influence of considerable
emotional stress and pain. It is principally important to determine whether a
patient is competent. The determination of incompetence by a medical
commission is based on the loss of the patient’s ability to make decisions, which
would promote his/her well-being, taking into account the values and preferences
which he/she had expressed before. The bioethical practice works out the
standards of competence, which have considerable specific differences in
different fields of clinical practice. The question concerning the volume of
information, which a patient must get and understand, so that his consent could
be considered informed, is extremely important. What are the criteria of the
information sufficiency, and is it always better to get a greater volume of
information? Research shows that a patient who had got protracted and detailed
explanations of the essence and risk of a medical interference, can understand and
reproduce only a very small volume of meaningful information. At the same time,
the patients who had got less detailed information could understand and
reproduce a greater volume of important facts.
Voluntariness in giving an informed consent is no less important than
competence. The decision is considered voluntarily, if it is made in the absence
external pressure on the part of doctors, authorities, relatives or friends. There are
different forms of influence which can have a substantial impact on voluntariness.
They include direct forcing to make a certain decision by threat or authoritarian
imposing, as well as manipulation with information which, being outwardly
objective, is selected in a way, which pushes a patient or examinee toward a
decision, advantageous for physicians or researchers. A patient often supposes,
that doctors can give up treatment, if he disagrees to participate in research or to
use the method of diagnostics or treatment suggested by the doctor. Therefore
when getting an informed consent, it is necessary to draw the patient’s attention
to the fact that his refusal will not diminish his rights and availability of
alternative methods of medical interference.
Any illness, especially a grave one, has a serious impact on the patient’s
mental state and often limits his ability to make independent decisions. The
helpless state makes the patient especially subjected to direct authoritarian dictate
of the treating doctor. In these cases, even if there are no reasons to doubt the
patient’s competence, it is necessary to provide him/her a possibility to discuss
the situation with his/her relatives or friends. A doctor should also remember
about the patients’ right for the consultation of independent specialists, provided
by the existing laws. The firmest guarantees are given by the bioethical practice,
when the requests for testing and research are independently examined by the
ethics committee.
The procedural issues of informing the patient or examinee are important
in the process of getting his/her informed consent. To determine the optimal

18
volume and content of information the specialist can follow special norms, the so
called standards of informing. Several standards were proposed, and among them
“the professional standard”, “the rational person standard” and “the subjective
standard” are of the greatest practical interest. According to the first standard, the
volume and content of information is determined by the traditionally formed
practice of a specific medical community or medical institution. In the process of
training a future doctor learns from his teachers not only the doctoring techniques,
but also elementary skills of communicating with patients. This is a
spontaneously formed standard of medical practice, which is usually
involuntarily mastered by professionals. In a stable society with a well formed
health system and generally acknowledged moral norms of doctoring this
standard is effective enough. However, in a society which is in the process of
stormy social and political transformations where new codes of ethics are only
being developed, the appeal to traditional norms can have only preliminary value.
In this situation “the rational person standard” is more appropriate. This standard
proposes to imagine a kind of “average citizen” and answer the question which
information and in what volume may he/she need in order to make a grounded
decision concerning his/her consent or disagreement to a certain medical
interference or to his/her participation in biomedical research. A doctor or
scientist should be able to model in his/her imagination a patient’s or examinee’s
rational conduct and, according to the result of this mental experiment, to build
the tactics of informing.
“The subjective standard” suggests to help the patient in making a rational
decision by supplementing the information, useful for an “average patient”, with
facts corresponding to this concrete individual’s specific interests. If, for
example, this patient’s case history includes the data on a heart disease he/she had
before, the information about the risk of complications should focus on the
possibility of cardio-vascular disturbances, although they and not characteristic
for an “average patient”. “The subjective standard” proposes the tactics of
individualizing the presented information. Considering that some patients’
educational level is low, in a number of cases there is a serious doubt that they
are able to understand the presented information correctly. T. Beachamp and J.
Childress offer the following way out of this situation: “Successful informing of
ignorant in medicine patients about new and specific subjects can be attained if
analogies from their everyday life are used as explanations. For example, to
explain the risk, expressed in a numerical form, a professional can use a
comparison to the probability known to the patient from preceding experience of
risk involved in some actions, such as the risk involved in driving a car or in the
work with electric devices”.
From the practical point of view it is better not to use a lot of special terms,
which can be either not understood at all or misunderstood. It is also important to
take into account the psychological influence of the used words. The information
that the probability of survival is 50% gives more hope than the report that the
probability of death is 50%, although from the mathematical point of view the
risk is identical. When the patients learn the information that a certain medical
interference involves even a low degree of fatal risk, as a rule this sharply reduces

19
its preference, although its remote consequences can be much more favourable.
To understand the information is not the same as to accept it. A patient who has
cancer and knows his/her diagnosis well can still be convicted that really he/she
is healthy or that the tumour is benign. Therefore, proceeding from this false
conviction, he/she can give up chemotherapy or refuse the suggested surgical
treatment. As the sociological research shows, quite a lot of patients are not eager
to know the details concerning the methods of treatment and the risk they involve;
they prefer the treating doctor to make the choice for them. The number of people
not interested in learning this information reaches 50% of all the patients. A
doctor must respect his patient’s opinion and should not force the undesired
information on him/her. On the other hand, an examinee’s participation a clinical
test or biomedical experiment is impermissible without his/her knowing and
understanding the content of research and the risk it involves. Having received
the objective information about the medical interference or scientific research,
the patient or examinee must decide whether to give his/her consent or not. The
decision-making is an independent process which is only prepared by objective
informing. It requires time. Thus, a patient or examinee should not be compelled
to sign the consent form immediately after receiving the information. It is
necessary to give them some time to think, ask for their relations’ or friends’
advice or consult a specialist. It is also necessary to remember that the consent
initially given by an examinee or patient can be revised by them later. Therefore
the law provides an examinee’s right to stop his/her participation in research at
any stage, and a patient’s right to decline the treatment. The authorizing, as well
as informing, can be made both in verbal and in written form. In its essence it
means initiation, i.e. conclusion of an agreement between the patient and medical
specialists, which will bind them with certain contract relations. These relations
determine mutual legal and moral obligations of parts and establish the forms and
extent of their responsibility.
The verbal form of informing a patient or an examinee creates favourable
grounds for manipulation with their decision. Holding back some facts, incorrect
information about the comparative risk of alternative treatment methods, the
concealment of information about preceding negative experience of using certain
medical procedures, overstatement of the chances for success of the offered
investigation or medical interference — all this can violate the principle of
voluntariness. It is also necessary to take into account that a physician can resort
to such violations being unaware of what he/she is doing. A scientist carried away
with the development of a new method of treatment is naturally inclined to
exaggerate the merits of his/her innovation in comparison to the existent methods.
In this sense written filling in of a special form of informed consent creates more
possibilities for control over the objectivity of given information.
The procedure of receiving the informed consent is called to realize the
moral idea concerning the recognition of a patient or examinee as a person, who
has a right to participate together with the medical workers in decisionmaking on
the issues of his/her treatment. The rule of informed consent finds its expression
in the form of certain ethical norms, codes and declarations, adopted by the

20
international and national medical associations. A doctor and a research worker
are obliged:
1. To provide respectful attitude toward a patient or examinee in
biomedical research as an autonomous person which has a right to make
free choice and control all the procedures or manipulations with his/her
body in the process of treatment or scientific research.
2. To minimize the possibility of moral or financial damage which can be
causal to the patient by careless treatment or experimentation.
3. To create conditions which promote the responsibility in the medical
workers and researchers for the patients’ and examinees’ moral and
physical well-being.
The procedural aspects are regulated by the national laws, orders and
instructions of the health care bodies and the internal rules of the medical and
research organizations. The tradition of verbal informing has a certain advantage:
it seams less formal and more confidential. On the other hand, verbal informing
practically excludes independent control of what is really told to a patient or
examinee and reduces the doctors’ and research workers’ responsibility for the
quality of informing. Thus, it creates the conditions for the violation examinees’
rights.
Informed consent is very important for the patient’s socio-psychological
adaptation to new living conditions, which can possibly follow a medical
interference. The discussion of the treatment, its aims and possible consequences
with the doctor increases a patient’s psychological readiness to necessary changes
in his/her life mode. As a result, it promotes effective adjustment. The rule of
informed consent not only regulates certain procedural norms, which precede a
serious medical interference or participation in an experiment, but also aims at
enriching personal cooperation of doctors and patients (examinees) during the
treatment or scientific research process.
The principle of informed consent should not be considered only as a
measure undertaken in connection with the risk of doctors and researchers
causing damage to the patients or examinees. It is more justified to consider that
the prevention of this danger is a very important, but not the only or the main
task. The principle of informed consent should be understood as a norm of
cooperation of a doctor and a patient with the purpose of their joint grounding
and coordinating the optimal method of medical interference. The principle of
informed consent should be considered not as an end in itself but as a means of
providing a partner dialog of the interested parties, which are the doctor and
patient.

MODELS OF RELATIONS BETWEEN A DOCTOR AND A PATIENT

The problem of doctor and patient relationship is considered the prevailing

issue in the medical ethics, which develops together with the medical science and
practice. The contacts of doctors and patients occur every day, and every time
they are unique. In some substantial features these cooperations are well-
organized and traditional: as a rule, both parties behave in these cases in a

21
conventional way, “as they should”, often without even realizing this. In a stable
social system the course of such events is usually formed in accordance with
certain norms, the observance of which is not specially controlled, but which
people follow strictly enough. It is therefore possible to talk about the social role
of a doctor and the social role of a patient. These norms and roles organize the
behaviour of the parties: each of them from the beginning of the contact
understands well enough what it can expect from the other party and what are the
other party’s expectations. A doctor’s social role, and hereupon the social role of
a patient can be differently understood in different cultures and societies. Thus,
we have reasons to talk about different models of doctoring.
To describe different types of relationships between a doctor and a patient
we can use a number of metaphors: a parent and a child, partners, participants of
an agreement, a technician and a client, and friends. In accordance with these
metaphors, we can ground the existence of five basic models of relationships in
the field of health care: the paternalistic, collegial, contract, befriending, and
technical models (J. F. Childress, M. Siegler, 2001).
The paternalistic (pastor, paternal) model is based on centuries-old
tradition of medical practice. In this model a medical professional, in particular a
doctor, is the decision-making centre and possesses the “moral” power in the
asymmetric and hierarchical relations with a patient. We can draw an analogy
with the relations of a pastor and parishioners, parents and children. In the
paternalistic (from the Latin pater — father) approach a doctor plays the role of
a father, who not only takes care of his unwise child’s well-being, but also
determines what is good for the child. The term paternalism originates from the
language of socio-political theories and characterizes such a type of relations
between a state and its citizens or subjects, in which the state initially considers
itself the absolute representative of their well-being and their interests, i.e. makes
decisions and operates on their behalf, taking absolutely no trouble to find out
and consider their opinions. The citizens, on their part, proceed from the belief
that the state has a full authority to decide what is good for them, but at the same
time it is obliged to take care of them and be their guardian. As a result, the alien-
88 ation of the citizens’ rights and freedoms occurs, and in this case they actually
appear to be not so much citizens, in the real meaning of this word but rather the
subjects, subordinates of the state. As a phenomenon of the social and political
culture, paternalism concerns not only the relations of the state and citizens but
also all the spheres of the society life, where any kinds of authoritative relations
show up, i.e. relations of some people’s domination and submission of others.
One of such spheres is the field of health care.
Medical paternalism assumes that a doctor can trust only his own
judgements as to a patient’s needs in treatment, informing, and consulting. The
paternalistic position allows to justify the patients’ compulsion and deception, or
the concealment of information from them if it is done in the name their well-
being. Paternalistic relations are filled with subjective content and built as a kind
of interpersonal communication. It is motivated by the intention to help a
suffering person and avoid causing him harm. We can say that its moral
characteristics presuppose love toward one’s neighbour, charity, mercy and

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justice. However, the parties of this relationship are in unequal position. The
doctor acts a part of a “father” who possesses certain scientific knowledge and is
able to apply it. The patient acts a part of an ignorant child, who’s moral virtue
consists in the disciplined implementation of the orders and prescription of the
“senior”. Paternalism in the communication with patients remains a norm for
quite a number of modern physicians, and many patients perceive the paternalistic
attitude toward them as quite adequate. Paternalistic positions prevailed and were
not called in question up to the middle of the past century. The subsequent sharp
turning away from them was conditioned by the action of a number of reasons,
including the rapid increase of the educational level of the population and the
recognition of the fact that in a pluralistic society different systems of moral
values coexist. A doctor’s values, and consequently, his picture of a patient’s
wellbeing, can substantially differ from the patient’s own values and his picture
of his well-being. There are quite many people for whom a doctor’s paternalistic
attitude is psychologically most acceptable. Their personal preferences should be
respected, despite the imperfection of this model from the moral point of view.
Paternalism violates the rights of a patient as an autonomous person, who makes
vitally important decisions and controls his/her state independently and freely. As
a matter of fact, it involves an element of humiliating the patient’s personal
dignity, because the co-operation is built not “horizontally” (equally in rights),
but “vertically”, as the relations of power and submission. A patient, figuratively
speaking, is forced to “look up” at a doctor. Paternalism is a natural and most
adequate form of a doctor’s attitude towards sick children and other patients with
limited capability. The circumstance that at the moment of making a responsible
decision the child’s or mentally incapable patient’s interests can be protected by
the participation of their legal representatives (for example, parents), does not
belittle the appropriateness and moral justification of the paternalistic attitude
toward them in the context of everyday doctoring relations.
The collegial (partners) model of relations between a doctor and a patient
provides much more possibilities for the realization of an autonomous person’s
values. This model stresses that the medical professionals and their patients can
be partners or colleagues on the basis of recognising the value of health. The
recognition of common values of the involved parties unites this model with
paternalism. The principle difference consists in the accent the collegial model
makes on the equality of both parties’ rights in the interpretation of these values,
including health, along with the respect to the personal autonomy of all the
participants of the relationship. The prototype of this model are “adult-adult”
relations.
Within the framework of this model a doctor helps a patient to help himself,
while the patient uses the expert’s help to realize their common goals (his own
and the doctor’s). It is assumed that the participants have approximately identical
rights, are interdependent (i.e. one needs the other) and are engaged in the actions
which satisfy both parties to a certain extent. Moreover, this model proceeds from
the idea that the doctor does not know the best solution, and the essence of
therapeutic co-operation consists in the search for it. In the framework of this
model a patient appears to have equal rights in the cooperation with the doctor.

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In order to act his/her part, the patient must receive from the doctor a sufficient
volume of truthful information concerning the state of his/her health, variants of
treatment, prognosis of the development of disease, possible complications, etc.
Being to some extent equalised with the doctor in regard to possessing
information, a patient becomes able to take part in making concrete decisions
concerning his/her treatment, operating almost as an equal in rights ally of the
treating doctor. In this case he/she realizes the inalienable personal right to the
freedom of choice.
This model is rarely applied in practice and its value has a normative
nature. It demonstrates the desirable and even obligatory moral direction of
medical practice and science. As a normative model it stresses the equality of the
partners’ values and the respect towards the autonomy of both medical
professionals and other persons — patients or volunteer participants in medical
research.
The complexity in the practical application of this model depends on the
difficulties of achieving harmony of interests. The medical staff and the patient
can adhere to different value orientations. They can belong to different social
classes and ethnic groups. In the conditions of commercial medicine a doctor has
objective (conditioned not by his personal traits but by the real situation) personal
interest in minimising his own expenses and maximising his profits, while the
patient’s interests are opposite, they consist in getting the maximal available help
for minimal costs. At the same time we should take into account that there are
some regions in which the relations between a doctor and a patient can really have
collegial nature. This concerns the cases of protracted chronic diseases. The
volume of knowledge which patients acquire during many decades of their
chronic illness in certain aspects can be considerably bigger than a young and
inexperienced doctor’s. In these situations the communication of a patient and a
medical worker can approach the ideal of collegial model, reminding a
professional concilium, in which the knowledge of one party supplements the
knowledge of the other. Psychotherapy is another field of this model clinical
application; in psychotherapy both partners’ cooperation is a necessary condition
for attaining success.
The contract model. In this model the relationship between a doctor and
patient is based not only on the legal content of the “contract” (agreement)
concept but also on its general, symbolic understanding. The ideal of contract as
the most adequate form of social relations between people was formed in the
epoch of Enlightenment. Instead of the heritable and seemingly entitled by God
monarchical power, enlighteners advanced the idea of public agreement. They
considered that authority should not monopolistically belong to a group of people
by virtue of their “breed” or class privileges. The people have a right to delegate
plenary powers to a ruler by expressing their free will, but he concludes with them
a kind of a contract, which determines the general aims of his authority and the
scopes of its plenary powers. The violation of the terms of contract by the ruler
gives the people grounds for dissolution of this contract and depriving the ruler
of his power by force. In the modern society not only political relations but also
labour, family and many other social connections are built to a great extent on the

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contractual role distribution and mutual responsibility. The contract model of
relationships between a doctor and patient presupposes that medical professionals
conclude a series of specific contracts with their patients. The prototype of the
contract model were specific contracts, in accordance to which individuals
consented to exchange goods and services, and the implementation of which was
supported by state sanctions. According to R. Veatch’s opinion, the contract
model is the best compromise between the ideals of partnership with the accents
on equality and autonomy, and the realities of medical practice, when mutual trust
can not be guaranteed. In this situation the contract model is a unique possibility
to share responsibility, protect the parties’ equality and autonomy and provide the
honesty of the participants of the medical service process. The contract form of
relations allows to avoid the failings which threaten a patient’s freedom, and
which are inherent to the paternalistic and technical models. At the same time it
does not refer to the illusive possibility of a patient’s participation as the doctor’s
“colleague”. A patient voluntarily establishes relationships with a doctor on the
terms which he considers advantageous and possible. By this contract he/she can
delegate certain powers to the doctor, so that the specialist can adequately do his
professional duties. The contract model more realistic than the collegial one. It
takes into account the impossibility of a doctor’s and patient’s equality, i.e. the
inevitability of the “vertical” relations of dependence. This dependence, however,
is established on fully determined terms. If the conditions are not observed, a
patient has a right to consider the contract invalid, to deprive the doctor of those
powers which he got by virtue of agreement, and to demand for compensation.
The befriending model. The relations between a doctor and patient can be
based on friendship. This model is grounded on the proposition that a good doctor
always becomes a friend for a concrete patient and all the patients in general. In
these friendly relations the patient trusts the doctor, and the doctor’ friendship
shows up, besides other things, in his efforts to give effective help and in his
goodwill. Sure, the analogy with friendship has a relative nature, and the friendly
relations between a doctor and patient are limited by their special orientation at
achieving the goal of the patient’s healing. In addition, different factors, including
financial obligations, influence these relations. Nevertheless, the befriending
model of relations reflects the moral orientation at achieving equality, autonomy
and observing the rights of both parties. As E. Kant determined the friendship as
a union of two individuals through equality, mutual love and respect, the
befriending model contains the components of both paternalism (love or care)
and antipaternalism (equality and respect). This model reminds partnership.
Indeed, medical friendship is very close to medical partnership, but for the fact
that the first stresses the intensity, strength and depth of relations, and the second
makes an accent on restraint and limitedness of relations.
The technical (engineering) model. The relations of doctor and patient in
this case are compared to the relations between a technician (or engineer) and his
client. A patient’s body is compared to a mechanism, and the illness is interpreted
as its breakage, which a doctor, as an engineer or technician, should remove. In
this model a doctor offers or carries out technical service for the patient as a user.
The essence of doctoring comes to the manipulation with the patient’s body. The

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doctor, using certain physical influences aims at returning the patient’s
physiological mechanism to the position of equilibrium. The engineering model
is based on the understanding of medical activity as a field of applying objective
scientific knowledge about the natural mechanisms of the human organism vital
functions. The objective knowledge determines the choice of the treatment
method, which is applied as a technical procedure. The patient’s well-being is
also understood as an aggregate of objective signs: biochemical indices, values
of blood pressure, gases metabolism, the X-ray data, etc. Considering that a
patient does not possess necessary scientific knowledge about the state of his/her
health, the account of his/her opinion in the choice of medical measures is not
only useless but can even be harmful because of subjective estimations. The
patient’s personal opinion on what is good for his/her health does not deserve any
attention from a professional physician’s point of view because it is biased and
nonscientific.
The engineering model is based on an out-of-date picture of the nature of
scientific knowledge. As the modern philosophy of science shows convincingly,
the objective knowledge is “loaded” with a considerable amount of pre-
conditions unrealized by the scientists. These preconditions include personal and
group interests, as well as certain moral preferences, which act quite an important
part. The modern moral standards of medical activity most decisively demand the
avoidance of de-personalisation of relations between a doctor and patient, they
require respect towards a patient as personality. However, is the de-
personalisation always a result of a physician’s morally inadequate attitude
toward the patient? The point is that in a number of concrete situations, common
for the modern medicine, a patient objectively can not appear as a personality to
a full degree. As a result of a high degree of labour division at a modern clinic
equipped with hi-tech appliances, as a rule, a patient has personal contact only
with his/her treating doctor and a nurse. Quite a number of specialists are
occupied with the implementation of special procedures, which practically
eliminate the elements of personal contact with patients. The de-personalisation
of relations with patients in this case is not a result of amoral attitude, but is a
consequence of the modern medical practice technisation.
The technical model of relations between a doctor and patient can not be
considered desirable or possible. It is hard to imagine that a medical, professional
would operate like a technician only with “factual” material which does not have
any value or ethical characteristics. The point is that the basic medical concepts,
such as health and illness, are considered from the position of their intrinsic
values. However, if a “technician” works at an organization or has direct relations
with patients, he also serves certain values. The technical model offers autonomy
to the patient, whose values become dominant due to the morality and purity of
medical professionals. In other models, such as contract, partner and befriending,
moral responsibility is distributed among all participants, because they, in a
certain sense, have equal rights.

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