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[Autonomy and practical identity. Cornerstones to ethical physician behavior].Three frequent problems of daily medical practice are analyzed: (1) a physician's perceived obligation to provide medical services regardless of whether one's health care institution provides monetary compensation for the medical act, (2) increasing pressures to obtain informed consent in a national context where paternalistic physician-patient interactions have been customary, and (3) a physician's professional responsibility to offer internationally recognized standard of care even if this means allocating expensive tertiary healthcare resources to a small number of patients in spite of one's knowledge that national governments are unable to provide primary care to millions of their citizens. These problems are discussed from the point of view of the ethical principle of respect for patient autonomy. Potential limiting factors (cultural, financial, religious or disease-related influences) on autonomy of patients and doctors are identified. The functions of patient autonomy in the framework of four different patient-doctor interaction models (paternalist, informative, interpretative and deliberatibe) are described. Physician leaders, health care institutions, and professional organizations are responsible for creating an environment in which doctors can discuss ethical issues as comfortably and as frequently as they discuss biological matters. Health care providers should do their best to recover the human side of medical practice which, undoubtedly, would create a greater likelihood that appropriate decisions will be made when facing complex ethical dilemmas.
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[Autonomy and practical identity. Cornerstones to ethical physician behavior].Three frequent problems of daily medical practice are analyzed: (1) a physician's perceived obligation to provide medical services regardless of whether one's health care institution provides monetary compensation for the medical act, (2) increasing pressures to obtain informed consent in a national context where paternalistic physician-patient interactions have been customary, and (3) a physician's professional responsibility to offer internationally recognized standard of care even if this means allocating expensive tertiary healthcare resources to a small number of patients in spite of one's knowledge that national governments are unable to provide primary care to millions of their citizens. These problems are discussed from the point of view of the ethical principle of respect for patient autonomy. Potential limiting factors (cultural, financial, religious or disease-related influences) on autonomy of patients and doctors are identified. The functions of patient autonomy in the framework of four different patient-doctor interaction models (paternalist, informative, interpretative and deliberatibe) are described. Physician leaders, health care institutions, and professional organizations are responsible for creating an environment in which doctors can discuss ethical issues as comfortably and as frequently as they discuss biological matters. Health care providers should do their best to recover the human side of medical practice which, undoubtedly, would create a greater likelihood that appropriate decisions will be made when facing complex ethical dilemmas.
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The Ideal of Shared Decision Making Between Physicians and PatientsShared treatment decision making, with its division of labor between physician and patient, is a common ideal in medical ethics for the physician-patient relationship. Most simply put, the physician's role is to use his or her training, knowledge, and experience to provide the patient with facts about the diagnosis and about the prognoses without treatment and with alternative treatments. The patient's role in this division of labor is to provide the values -- his or her own conception of the good -- with which to evaluate these alternatives, and to select the one that is best for himself or herself. As a rough guide to practice, this is a reasonable conception; most of the time it is likely to produce sound treatment decisions. However, as an ideal it is too simplistic, and is subject to several challenges that I will explore in this paper.