An Introductory Philosophy of Medicine

Chapter 15. Patient-Physician Relationships

Even though medicine is a social enterprise and is influenced by larger social (political, economic, cultural, and religious) values and goals, its central relationship is narrowly defined in terms of the patient-physician relationship. "The encounter between patient and physician," according to Earl Shelp, "may be characterized as the focus of medicine" (1983, p. vii). It is this relationship that is one of the most important elements in defining the very nature of medicine itself, since medicine is therapeutic at its core.

In this chapter, defining the nature of medicine per se is not the focus-that is reserved for the concluding chapter-but rather the focus is on the various types of models proposed to account for the patient-physician or therapeutic relationship. The number of models seems endless and they range from the classic authoritarian models such as paternalism to the contemporary partnership models. Indeed, Danner Clouser (1983) bemoans the plethora of models but acknowledges that many more can be invented, such as the "bus driver" model or "pin-ball machine" model.

Given the sheer number of patient-physician models, Clouser raises an important, if not a skeptical, question concerning them: "why bother?" (1983, p. 94). His concern is that the models do not really help to determine or define the moral relationship between the patient and the physician. Rather than models, he prefers a list of actions that would be immoral in terms of patient-physician interactions. "The physician-patient relationship would be better served, if," according to Clouser, "instead of delineating models with all their complicated and ambiguous interrelationships, presuppositions and beliefs, we simply listed what we morally ought not to do" (1983, p. 95).

In the final analysis, Clouser fears that models do not provide the foundation needed to determine or justify the morality of actions as do normative ethical theories. Behind this concern is also a concern that models do not or cannot motivate morality. Rather, all the various models seem to be on equal footing in terms of motivating one to do what is morally right. Consequently, instead of identifying one model by which to define the patient-physician relationship, "Why not let many styles flourish`? Let patients and physicians establish the kinds of relationships which suit them. Let them find," he concluded, "each other and develop together" (Clouser, 1983, p. 96).

Robert Veatch (1983) in a response to Clouser admits that Clouser is right about the importance of normative ethics for determining or justifying an action's moral nature. However, Veatch defends the use of models in terms of metaethics: "Unless one deals with the basics of metaethics-of the meaning and justification of moral norms and the role of ethical principles in various moral choices such as professional practices-the normative ethics is likely to be muddled" (1983, p. 106).

Models allow for more imaginative analysis of the fundamental issues facing patient-physician interactions. Indeed, how one models those interactions has profound consequences not only on the ethical dimensions of medical practice but also on the outcome of that practice. For example, "It makes a great deal of difference whether you look at [the patient-physician relationship] as a healing relationship... as a contract between two persons who are on equal footing, or as a commercial transaction" (Pellegrino, 2006, p. 69). Part of the outcome of medical practice depends upon the communication between the patient and physician. Finally, "the way the doctor-patient relationship is seen can have consequences for the actual content of communication" (Ong et al., 1995, p. 914).

Models are also important for understanding and analyzing the moral character of medicine. "Medicine," according to Pellegrino, "is a moral enterprise... that is to say, it has been conducted in accordance with a definite set of beliefs about what is right and wrong medical behavior" (2006, p. 65). For the patient-physician relationship is at heart a moral relationship, and a proper understanding of it is important for a robust morality in medical practice. Any reconstruction of medical morality depends upon a patient-physician relationship that has healing as its goal and not some other goal such as commercialism or paternalism.

According to some medical commentators, the patient-physician relationship has lost its soul to cultural scientism and medicine has forfeited its moral moorings because it focuses on the physician as scientist (Pellegrino, 2006). Although science is important to medical practice, clinicians are to discharge "medicine's original moral mandate" of treating the person and not simply the disease (Tauber, 1999, p. 98). Indeed, the more authoritarian models for the patient-physician relationship are thought to be a major factor responsible for the current quality-of-care crisis (Annalandale, 1989). Thus, models of the patient-physician relationship are important tools for exploring and redressing the issues surrounding this crisis in modern medicine.

There have been a variety of typologies or classifications proposed to distinguish among the various types of models for the patient-physician relationship. For example, one classification scheme divides the models into autonomy-based or beneficence-based categories (Pellegrino and Thomasma, 1993; Loewy, 1994). The autonomy-based category includes the collegial, commercial, contract, and engineering models. "Autonomy models," for Pellegrino and Thomasma, "are largely instrumental, transactional, and procedural. They need not conform to any external set of norms. The contracting parties create their own `text' and give it the ethical meaning they choose" (1993, p. 192). The beneficence-based category includes the paternal and priestly models. These models depend upon the ends of the clinical encounter: "In the long term, the end is health; in the shorter term the end is cure, containment, amelioration, or prevention of illness, pain, and disability. The most proximate and most immediate end of this relationship is a technically correct and morally good healing decision for and with a particular patient" (Pellegrino and Thomasma, 1993, p. 193). In this chapter, the various patient-physician relationships are categorized according to the distribution of power between the patient and physician: "Physician-patient interaction is rooted in a power relationship" (Haug and Lavin, 1981, p. 212). Power is necessary for performing actions, affecting change, or accomplishing tasks.

Alvin Toffler identified three sources of power or a "power triad" of "muscle, money, and mind" (1990, pp. 12-13). "Knowledge, violence, and wealth, and the relationships among them," according to Toffler, "define power in society" (1990, p. 16). Felicity Goodyear-Smith and Stephen Buetow (2001) adapt Toffler's notion of power for categorizing patient-physician interactions. For example, medical knowledge is an important component of the power equation in patient-physician interactions, with the physician often holding the upper hand. As they note, these sources of power can also be misused, e.g. in the withholding of medical information by the physician or the patient's personal habits such as alcohol abuse.

Debra Roter (2000) provides a useful grid for patient-physician models based on whether the power possessed by the patient or physician is either high or low. This grid is utilized in this chapter to categorize the various models for patient-physician interactions into three main categories: physician-centered (high physician and low patient power), patient-centered (low physician and high patient power), and mutual (high physician and high patient power).'

15.1 Physician-Centered Models

For the physician-centered models, power is located within the role and function of the physician, with the patient remaining largely passive and powerless. In these models, "physicians dominate agenda settings, goals, and decision-making in regard to both information and services; the medical condition is defined in biological terms and the patient's voice is largely absent" (Roter, 2000, p. 7). The physician generally assumes that the patient's values are similar to his or her own, primarily the restoration of physical health. Moreover, the physician labors under the assumption that only he or she is able to make the appropriate decision, given the technical nature of medical knowledge and practice. Finally, these models for the patient-physician relationship are "asymmetrical: The patient is in a dependent, and the physician in a superordinate, position" (Haug and Lavin, 1981, p. 212).

There are two predominant models within the physician-centered category, depending on the role of the physician. The first are the authoritarian models, with the physician functioning as a parent or priest. The second are the mechanistic models, with the physician acting as a technician or engineer who has the necessary expertise to fight the disease for the patient.

15.1.1 Authoritarian Models

The authoritarian models are certainly the oldest and best known models of the patient-physician relationship. Of course, the basis of these models is the authority granted by patients to physicians to practice medicine. "Authority," according to Haug and Lavin, "classically is defined as the right to influence and direct behavior, such right having been accepted as valid and legitimate by others in the relationship. In the medical context," they add, "authority is defined as the patient's grant of legitimacy to the physician's exercise of power, on the assumption that it will be benevolent" (1981, p. 212).

Besides the patient directly granting the physician authority, Russell Maulitz (1988) identifies three other sources of the physician's authority. The first is legal in which the state bestows upon physicians the right to practice their trade, including prescribing pharmaceutical drugs and conducting surgical operations and procedures. The next source of authority is professional, in which the medical profession itself as a qualified and a responsible society regulates its members. The final source is cultural, especially the technological advances made in the biomedical sciences. Paternalistic Model

The paternalistic model is the traditional model of the patient-physician relationship and is the best known of the authoritarian models. It is fashioned after the parent-child relationship, in which the physician takes on the role of parent and the patient the child. "Paternalism," according to Pellegrino and Thomasma, "centers on the notion of the physician-either by virtue of his or her superior knowledge or by some impediment incidental to the patient's experience of illness-has better insight into the best interests of the patient than does the patient, or that the physician's obligations are such that he is impelled to do what is medically good, or even if it is not `good' in terms of the patient's own value system" (1988, p. 7). The physician, thereby, has the power in the therapeutic relationship to make the decisions and the patient is obligated to trust the physician implicitly and completely. In other words, the hierarchy of the paternalistic relationship is dominance on the physician's part and submission on the patient's part.

The patient's role in the paternalistic model is that of the sick child, with the physician playing the parent's role-usually that of a father. Parsons and Fox (1952) distinguished two analogies between the parent-child relationship and the patient-physician relationship. The first is between the child and patient. Just as a child is incapable of performing adult daily activities, so is the adult patient because of illness; and just as a child is dependent upon the care of "stronger, more `adequate' persons," so is the adult patient because of illness. The second analogy is between the parent and physician. "These [parents and physicians]," according to Parsons and Fox, "are the stronger and more adequate persons on whom the child and the sick person, respectively, are made to rely; they are the ones to whom he must turn to have those of his needs fulfilled which he is incapable of meeting through his own resources" (1952, p. 32). Finally, both the child and patient suffer conditions that are "conditionally legitimized social roles," i.e. both are allowed to be childish or sick temporarily but both are obligated to grow up or to be cured.

The motivation of the paternalistic model is beneficence: "In this model, the physician-patient interaction ensures that patients receive the interventions that best promote their health and well-being" (Emanuel and Emanuel, 1992, p. 2221). The obligation of the physician may also involve disciplining the patient, especially the non-compliant patient: "If patients do not live up to their sick-role obligations, if they are not cooperative and compliant, the doctor may withdraw support and legitimization of the patient's sick-role status" (Beisecker and Beisecker, 1993, p. 47). The motivation for the patient is to regain health, by complying completely and passively with the physician's therapeutic prescriptions. The patient is to trust and obey the physician without question; this is true especially for patients engaging in risky lifestyle activities, such as cigarette smoking or promiscuous sex.

Paternalism is defined in a variety of ways, especially in terms of limiting a person's freedom. A general definition, with respect to the parent-child analogy, reads: "The paternalist or parentalist interferes with (or circumvents) the liberty, autonomy, wishes, or judgment of another adult but justifies this behavior on the ground of the latter's benefit. Such interference, in effect, reduces an adult to a child, albeit for the child's own sake" (May, 2000, p. 41). Beauchamp (2004b) identifies two types of definitions for paternalism. The first is a narrow definition, in which a person is coerced to act often against his or her will. Gerald Dworkin provides the best known definition for the narrow type: "the interference with a person's liberty of action justified by reasons referring exclusively to the welfare, good, happiness, needs, interests or values of the person being coerced" (1972, p. 65).

The second type is a broad definition, in which a person's liberty and free action are not necessarily coerced.' Gert and Culver (1976, pp. 49-50) provide a comprehensive definition of such paternalistic 'margin-top:7.8pt;margin-right:0cm;margin-bottom:12.0pt; margin-left:0cm;text-align:justify;text-indent:18.95pt;line-height:normal'>A is acting paternalistically toward S if and only if A's behavior (correctly) indicates that A believes that:

(1) His action is for S's good.

(2) He is qualified to act on S's behalf.

(3) His action involves violating a moral rule (or doing that which will require him to do so) with regard to S.

(4) He is justified in acting on S's behalf independently of S's past, present, or immediately forthcoming (free, informed) consent.

(5) S believes (perhaps falsely) that he (S) generally knows what is for his own good.

Their definition of paternalism covers the acts of paternalism in which the patient is not coerced. They provide the example of a patient who refuses blood transfusion for religious reasons, only to have the attending physician administer a blood transfusion when the patient becomes unconscious. Crucial to their definition is feature (3), which prohibits breaking a moral rule. In their example then the physician, although not coercing the patient, still acts paternalistic because of breaking a moral rule that prohibits deceiving or depriving a person of an opportunity or a freedom. It must also be noted that the physician has also fulfilled other features, especially feature (4) 3

Besides the narrow and broad definitions, paternalism is also divided into either weak or strong versions. Joel Feinberg introduces these versions "to reconcile somehow our general repugnance for paternalism with the apparent necessity, or at least reasonableness, of some paternalistic regulations" (1971, p. 106). Weak paternalism refers to constraints or limitations on non-autonomous or non-voluntary activity. Childress later defines it in limited or restricted terms: weak paternalism "overrides a person's wishes, choices, and actions for that person's own good because he or she suffers from some defect, encumbrance, or limitations in decisionmaking or acting" (1982, p. 17). In other words, weak paternalism does not apparently violate a person's autonomy. Strong paternalism does. "Unlike weak paternalism," claims Beauchamp, "strong paternalism does not require any conditions of compromised ability, dysfunctional incompetence, or encumbrance as the basis of intervention" (2004b, p. 1985).

Although weak paternalism is often deemed permissible, especially in emergency cases where life and death decisions must be made when the patient is not able to contribute to the decision making process, strong paternalism is generally considered so severely limited so as to be non-justifiable. For example, Heta Hayry concludes that "there cannot be standard policies requiring violations of patients' autonomy in the name of their own best interest-or, in other words, that there cannot be legitimate medical working procedures which are based on strong paternalism" (1991, p. 183). Rather, respect for the patient's autonomy to make choices about his or her health trumps such paternalism. For strong paternalism "violates the architectonic aim of medicine, which is to heal the one who is ill. To violate a person's autonomy is not to heal but to wound" (Pellegrino and Thomasma, 1988, p. 23). Priestly Model

The priestly model for the patient-physician relationship is probably the oldest of the authoritarian models. "Among pre-literature or primitive people," according to Amundsen and Ferngren, "religion and magic are usually one and the same and medicine is subsumed under them" (1983, p. 5). This close connection between religion and medicine is thought to be due to the fact that disease and illness are mysteries and of supernatural origin, i.e. demons and spirits. The priest or shaman, as the person who understands these mysteries, is responsible for confronting them and thereby providing for the patient's healing. The patient must trust the priest or shaman, a trust that is based on the patient's faith: "the patient's trust is rooted in the larger context of faith and the construction of meaning" (Barnard, 1982, p. 229). Disease, as the mystery-tobe-healed, is often situated in a supernatural structure and the priest or shaman is to provide solace and understanding for the patient. The patient's responsibility is to believe in the priest's or shaman's prayers, sacrifices, incantations, dances, etc.

The authority of the priestly model is based on two sources. The first is the patient's dependence upon the magical skills of the priest or shaman, who is often responsible not only for the welfare of the members of a community but also of the overall community itself. "One's [the patient's] dependence upon him [the priest]," according to Amundsen and Ferngren, "while in a state of specific need (illness, disease, injury), is but an extension of one's dependence upon him in the much broader spectrum of stability, prosperity, well-being and even survival, both individual and communal" (1983, p. 5). The second source is priestly charisma. James Knight labels it "charismatic authority." Charisma pertains to the "spiritual power and virtue attributed to a person who is regarded as set apart from the ordinaryset apart by reason of a special relation to that which is considered of ultimate value" (Knight, 1982, p. 100). In other words, charisma is a gift bestowed (generally by a god) upon a person to accomplish a particular task. For the priest, that gift, among others, includes the power to heal.

Although today's physicians shun the priestly mantle, because of modern secularism, physicians do function in a limited capacity as priests. David Barnard (1985) identified three "ministerial functions" of contemporary physicians. The first pertains to the physician's service and vocation. Medicine is a calling by the need of another and the physician is to respond in his or her service to that need. The next priestly function, an outcome of the first, is in terms of healing. The service is necessary therapeutic interventions to elicit healing and to sustain that healing until the patient is restored to health and wholeness. The final function is to assist the patient in clarifying his or her values, through "educative guidance" The physician is to remain loyal to the patient and not to impose his or her value judgments onto the patient.'

Barnard (1985) does caution against three possible idolatries, in which ultimate value is subscribed to something that is not ultimate in worth, including the idolatries of technology, the marketplace, and the nation-sate. Recovering these priestly functions and avoiding the idolatries are critical for "the renewal and nurture of the affective, value-conscious dimensions of professional life in a technological and bureaucratic culture" (Barnard, 1985, p. 285).

According to Veatch, the main moral principle of the priestly model is: "Benefit and do no harm to the patient" (1972, p. 6). The source of this principle is the patient's "silent plea: `Don't let me die"' (Knight, 1982, p. 101). However, the basis of this principle belies paternalism, with the physician playing the role of "Father": "It takes the locus of decision making away from the patient and places it in the hands of the professional. In doing so, it destroys or at least minimizes the other moral themes essential to a more balanced ethical system" (Veatch, 1972, p. 6). These other principles include "providing individual freedom," "preserving individual dignity," "truth-telling and promise-keeping," and "maintain and restoring justice" (Veatch, 1972, p. 6). Clouser also criticizes the "do not harm principle" in terms of the ambiguous use of harm from an authoritarian or paternalistic stance: "I would think that a person is harmed when-among other things-he is deceived, deprived of freedom, and deprived of opportunity" (Clouser, 1983, p. 92).

15.1.2 Mechanistic Models

The mechanistic models are an outgrowth of the scientific revolution, which reached its zenith for application to medicine in the mid twentieth century. For many, medicine became a science or, at least, an applied science. Because this model stresses the mechanistic nature of the patient's body and the scientific problemsolving aspect of medical practice, diagnosis and treatment of a patient's disease represent puzzles that concern the physician-scientist qua mechanic, technician, or engineer. According to Michael Bayles: "The occupation of auto mechanic has arisen in society almost simultaneously with the progress of medicine ... Despite one's initial aversion to this analogy [physician as mechanic], it soon seems a very strong and informative one for the concepts of health and illness as well as the ethical relations involved" (1981, p. 665). The physician, then, is a body mechanic and the patient is the body machine.

Interestingly, Bayles situates the analogy between auto mechanic and physician in a fiduciary relationship, rather than in a paternalistic, contractual, or agency relationship. In a fiduciary relationship, the mechanic or physician is obligated to use the expert and technical knowledge to the benefit of the customer or patient. "Physicians, like automobile mechanics," claims Bayles, "have obligations to others that do not arise from the relationship. These obligations depend on the role of the profession or occupation in society" (1981, p. 670). That role for the physician is an expert, with an expertise in treating disease. In other words, the physician's obligation stems from expert, technical knowledge. It is also this expertise that grounds the trust of the fiduciary relationship. The patient must trust the physician, because the physician is an expert. The trust is not dissimilar to that of the child in the paternalistic relationship except that the physician is a competent mechanic.

As a mechanic, the physician's "clinical gaze" is frequently myopic-focused only on the diseased body part, to the exclusion of the patient's overall experience of illness and suffering. In addition, "the `medical gaze' is directed to the inside of the body," so that the "physician in a sense renders the outer appearance of the physical object-body transparent" (Toombs, 1993, pp. 78-79). Moreover, the gaze of the machines used to diagnose and treat the patient's diseased body often accompanies the physician's gaze.

Diagnosis and treatment of patients for the mechanical model is generally from the outside in (Davis-Floyd and St. John, 1998). The role of the physician qua mechanic is to intercede on the patient's behalf and has its origins in the European barber-surgeons, who "held that the job of the healer was to intervene in the disease process" (Davis-Floyd and St. John, 1998, p. 26). Although the outside-in approach empowers the physician, it "renders invisible the personality and the experiences of the patient who must live and perhaps dies with these diseases" (Davis-Floyd and St. John, 1998, p. 28).

Physician training in technical protocols is the hallmark of the mechanical model: "Physicians quickly learn to abstract their interest in a medical case from the fateful issues that the patient and family face. A case intrigues to the degree that it challenges technical skill" (May, 2000, p. 94). Moreover, the institutional structure of medicine rewards those areas of medicine that are highly technical. For example, interventionist cardiologists are monetarily remunerated for their services at a staggering level compared to family practitioners. The economic disparity within the practice of medicine not only has an impact on the patient-physician relationship but also on the social structure of medicine itself. Physician assistants and nurse practitioners are filling the void left by physicians who pursue more lucrative specialties in medicine.

The technical model has had a dubious effect on the moral formation of physicians: "A good deal of the moral conditioning of medical school directs itself to detaching the young physician-to-be from the vagaries of ordinary human ties" (May, 2000, pp. 100-101). The outcome of biomedical pedagogy is a physician who only connects minimally, if at all, with a patient's existential concerns and angst.

Whereas the priestly model is steeped in values, the mechanistic models are not; rather, they are constrained only by the (scientific) facts (Veatch, 1972). These facts are traditionally believed or claimed to be value-free. The physician as an applied scientist then must ignore the patient's values, in order to make an efficient and a scientifically accurate diagnosis. However, the notion of a value-free medicine and science is not possible, since values are employed daily to make choices about research problems and other important decisions. "The physician who thinks he can just present all the facts and let the patient make the choices," opines Veatch, "is fooling himself even if it is morally sound and responsible to do this as all the critical points where decisive choices are to be made. Furthermore," he concludes, "even if the physician logically could eliminate all ethical and other value considerations from his decision-making and even if he could in practice conform to the impossible value-free ideal, it would be morally outrageous for him to do so" (1972, p. 5).

15.2 Patient-Centered Models

"Nothing in medical ethics has changed so dramatically and drastically in the last quarter century," according to Pellegrino and Thomasma, "as the standards of ethical conduct governing the relationship between physicians and patients. In that time, the center of gravity of clinical decision-making has shifted almost completely from the physician to the patient" (1993, p. 54). The overthrow of physician-centered modes was the result of the advocacy for patient autonomy. In the patientcentered models, the physician's power within the authoritarian models swung to the patient: "Patients set the goal and agenda of the visit and take solo responsibility for decision-making. Patient demands for information and technical services are accommodated by a cooperating physician. Patient values are defined and fixed by the patient and unexamined by the physician" (Roter, 2000, p. 7).

There are two subcategories for patient-centered models. The first are the legal models, which include the contract and contractarian models, as well the defensive models and Baruch Brody's status model. The second are the business models, which include the commercial and consumerism models. The legal and business models may appear mutual, but against a backdrop of the physician-centered models, these models empower the patient especially in terms of negotiating a contract. The contract ensures that a physician meets the patient's needs or it allows the patient to shop around for a physician who does meet those needs. In this way, the legal and business models are patient-centered.

15.2.1 Legal Models

Besides the principle of autonomy, the legal models are also predicated upon the principle of justice, especially in terms of rights and duties. These models protect the powerless from the powerful, ensuring that the relationships between them conform to community or legal standards. Legal precedent, whether common law or statutory, ensures the protection of a person's right and the performance of another's duties. The ideal outcome is a fair and equitable distribution of goods and services that do not favor one party over another, through deception or bias. For example, contracts provide recourse to compensation when the terms are not meet by one party. They ensure "the legal enforcement of terms on both parties and thus offers each some protection and recourse under the law to make the other accountable under the contract" (May, 2000, p. 125).

Contractual models generally involve negotiations between two parties, in which both parties maximize their particular goods. "When two parties enter into a contract," according to May, "they do so because each one cuts a deal that serves his or her own advantage" (2000, p. 125). The medical or healing contract often involves a patient's rights and a physician's duties to respect those rights. "Certain rights, such as the patient's right to self-determination," observes Maureen Kelley, "and certain corresponding duties, such as the physician's duty to disclose all the information needed by the patient to make a fully informed choice, would make up the content of the contractual model" (2004, pp. 524-525).

The contract model in medicine, however, differs from common contracts for other goods and services by empowering the patient, who enjoys the upper hand in negotiating the contract. It also differs from common contracts on a number of other points (Masters, 1975). These differences include, for example, the "interest" of the patient, which is his or her life, as well as the limited knowledge of the patient concerning medical procedures.

Baruch Brody (1983) distinguishes five features of the contractual model in medicine. The first is that both the patient and physician are under no obligation to enter into a medical or healing contract. Brody notes two consequences of this feature: (1) physicians are not obligated to treat patients, sometimes even under emergency situations, and (2) patients need not seek medical treatment. The next feature is that if either party does enter into an agreement, they do so freely and without coercion or deception. The third feature is the heart of the contract, in that the contract is only binding and legal when both parties have agreed to its terms. The next two features are concerned with society's role in the contract. The fourth feature involves the social assurance that the contractual terms are either performed by both consenting parties or sanctions are levied against the non-performing party. The final feature is that the patient, and not society, reimburses the physician for rendered services.

Critics of the contractual model point out a number of problems with it. The first involves concern over the minimalization of the physician's services. "The contrac- tualist approach," warns May, "tends to reduce professional obligation to self-interested minimalism, quid pro quo" (2000, p. 126). In other words, the physician performs only the terms of the contract and is under no obligation to treat unpredicted complications. Related to this criticism is the concern that "the contract model relies too narrowly on rights and permission and overlooks other important goals and duties, such as compassion and trust" (Kelley, 2004, p. 526). Another problem is that the contractual model encourages defensive medicine, especially in terms of the physician avoiding a malpractice suit (May, 2000, p. 131). Contractual terms can at times be ambiguous and the physician may feel compelled to over perform services for fear of reprisal, if harm or damage occurs to the patient.

According to Howard Brody (1987), a contractarian model based on John Rawl's "original position" could address many of these criticisms, especially the ethical minimalism critique. Rawl's "original position" states that a group of people are born into a society without prior knowledge of their social position ("veil of ignorance"). Under this condition, goods and services are distributed equally. Brody adapts for the patient-physician relationship Rawl's position with respect to three features: description of parties, knowledge available to them, and knowledge concealed from them. For example, in terms of the description of the parties each would be "motivated to choose basic moral principles to govern the patient-physician relationship," while the knowledge available to them would be the "general nature of medicine and health care" and the knowledge concealed from them would be "one's state of health" (Brody, 1987, p. 213). Based on this modified Rawlsian "original position," the parties would not promote a minimalist position since they would certainly agree to maximize their medical goods and services equitably across social strata.

In response to the contractual model and its problems, Baruch Brody (1983) proposes a model based not on common law but on statutory Judaic law. Again, there are five features of the "status" model. The first is that both the patient and physician are, under certain conditions, obligated to enter into a medical or healing contract. The next feature is that terms are not set freely by the parties but by an outside party. The third feature is the heart of the status model, in that the relationship is binding even though one party may not consent to the terms. Again, the next two features concerns society's role in the contract. The fourth feature involves the social assurance that each person enters into the relationship and fulfills his or her respective obligations. The final feature is that society rather than the patient reimburses the physician for services rendered.

The difference between the common law contractual model and Brody's statutory status model is that the former is based on autonomy while the latter on responsibility. "From the point of view of physicians," claims Brody, "this [status] model emphasizes their [physicians'] responsibility to treat patients in an appropriate fashion for a reasonable fee. From the point of view of patients," he adds, "this model emphasizes their responsibility to seek the best medical treatment required to maintain the highest level of health possible" (1983, p. 128).

15.2.2 Business Models

Modern medicine is big business. In the United States, the healthcare industry represents a significant portion of the Gross National Product. And its economic impact and commercialization are going to continue to escalate in the future (Heffler et al., 2005). Today, hospitals, physicians, clinics, and pharmaceutical companies advertise their goods and services in the media, to attract and educate patients.

Business models of medicine have certainly been a part of medicine's history, but their impact on the patient-physician relationship is a recent phenomenon that began with the consumerism movement in the 1960s. With the passage of a consumer bill of rights in the United States, consumers are now protected from and empowered against victimization by big business. "During the decade of the sixties," according to Leo Reeder, "a new concept came into prominence in this country. This was the concept of the person as a consumer rather than as a patient" (1972, p. 408). While the patient became the buyer of healthcare goods and services, the physician became the provider or seller.

With the consumer model of the patient-physician relationship in which the patient becomes the buyer and the physician seller, the switch in labels also reflects a shift in power. "In simple terms," claim Haug and Lavin, "consumerism in medicine means challenging the physician's ability to make unilateral decisionsdemanding a share in reaching closure on diagnosis and working out treatment plans" (1983, pp. 16-17). If the patient believes that the physician is not providing the best service or goods or that patient feels his or her voice is not being heard, then the patient is free to shop around for another physician with whom he or she is satisfied. With the business model, "consumerist patients should be expected to engage in `doctor shopping' in order to find a physician who best meets their health, economic, and personal needs" (Beisecker and Beisecker, 1993, p. 52). Of course, the patient as buyer of healthcare goods and services must be wary of the physician. Instead of trust that under girds most models, business models operate on distrust. The guiding principle for the patient-consumer is caveat emptor-buyer beware (Reeder, 1972).

Whereas autonomous rights and duties are the foundation for the legal models of the patient-physician relationship and are also important for the business models, the market is the foundation for the business models. "In the consumer model," according to Pellegrino and Thomasma, "health care is view[ed] as a commodity or service, like any other commodity, to be purchased in the marketplace on the consumer's terms, that is, in terms of his or her personal assessment of alternative models of treatment, their cost, benefits, and risks" (1993, p. 56).

The assumption behind the business models is a free market in which all parties come to the bargaining table as equals. Importantly, the free market guarantees a fair exchange between parties. "Participants are assumed to be bargaining equals," claims Loewy, "in that the consumers know what they want and buy it from the producer offering the best deal-the implication being that this state of affairs is most likely to serve the best interests of all parties concerned and, for this reason, is the most apt to be just and equitable" (1994, p. 28).

The main feature of the business models is an exchange relationship. "The consumerist doctor-patient relationship," according to Beisecker and Beisecker, "is conceptualized as an exchange relationship from which both parties expect to receive something of value and in which economic concerns are central" (1993, p. 50). The motivation for the patient is to find the best healthcare possible, at the best price. The motivation for the physician can be either monetary or prestige (Beisecker and Beisecker, 1993). For example, the crisis of primary healthcare providers is based on the economic disparity with specialists, such as interventionist cardiologists. For Lois Pratt, the business models are founded "on an exchange between two problem-solving participants working together in an egalitarian relationship" (Haug and Lavin, 1983, p. 26). The patient as consumer is obligated to manage his or her healthcare through the expert input from healthcare providers. Ultimately, the patient as consumer is responsible for demanding and ensuring quality healthcare.

There are a number of criticisms of the business models. The assumption that the two parties are equal is at best questionable. Certainly the patient is knowledgeable about the personal dimensions of his or her ailment but it is highly unlikely that the same patient, especially from lower socio-economic classes, is sufficiently knowledgeable about the technicalities of contemporary medicine in order to shop effectively for the best medical care.

Another problem is the competitive nature of the business models, which often brings out the worst in human nature. "In the heat of marketplace competition," warns Loewy, "trust, commitment, and loyalty can actually become dysfunctional as regulative ideals; cynicism, strategic alliance, and shrewd bargaining become more valued attitudes of the day" (1994, p. 29). Patients, especially with debilitating diseases, may not fair well under the business models. As May cautions, "the crises under which many patients press for medical services do not always provide them with the leisure or calm required for discretionary judgment. Thus," he concludes, "normal marketplace controls will never wholly protect the consumer in dealing with the physician" (2000, p. 132).

15.3 Mutual Models

Whereas the power of the physician-centered and patient-centered models is located with the physician and patient, respectively, the power associated with the mutual models is equitably distributed between the patient and physician in their interactions. "Inasmuch as power in the relationship is balanced," according to Roter, "the goals, agenda and decisions related to the visit are the result of negotiation between partners; both the patient and the physician become part of a joint adventure. The medical dialogue," she argues, "is the vehicle through which patient values are explicitly articulated and explored. Throughout this process the physician acts as a counselor or advisor" (2000, p. 7). While the patient-centered models are based on the principle of patient autonomy, the mutual models are based on the principle of informed consent (Katz, 2002). Informed consent, a product of the 1970s, is instrumental in empowering the patient with the information needed to participate in the decision making process.

There are a variety of mutual models, with the predominate being the partnership models. Another well known mutual model is May's covenant model and its associated role of the physician as teacher. The final two models include the friendship model, in which the patient and physician are intimate with one another in terms of desires and fears, and Kathryn Montgomery's neighbor model, which she proposes to curb the intimacy of the friendship model.

15.3.1 Partnership Models

In 1982, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research published its report, Making Health Care Decisions, in which the committee members examined the impact of the principle or doctrine of informed consent on the patient-physician relationship. The main question the members of the commission addressed is: "how can a fuller, shared understanding by patient and professional of their common enterprise be promoted, so that patients can participate, on an informed basis and to the extent that they care to do so, in making decisions about their health care?" (President's Commission, 1982, p. 31). In answering the question, the members of the commission rejected two predominant patient-physician models: "medical paternalism" and "patient sovereignty" Rather, they proposed a model that cultivates "a relationship between patients and professional characterized by mutual participation and respect and by shared decision-making" (President's Commission, 1982, p. 36).

The partnership models are composed of a family of models that have been given a variety of names within the literature. For example, in 1956 Thomas Szasz and Marc Hollender discussed three models for patient-physician relationship. Two of the models are variants of the physician-centered models while the third is the "model of mutual participation." Szasz and Hollender identified three key features of the model: "the participants (1) have approximately equal power, (2) be mutually interdependent (i.e., need each other), and (3) engage in activity that will be in some ways satisfying to both" (1956, p. 587).

Recently, Emanuel and Emanuel proposed a "deliberative" model of patientphysician interaction in which the patient and physician engage in "moral deliberation, the physician and patient judge the worthiness and importance of the health-related values" (1992, p. 2222). Based on these deliberations the physician and patient make a mutual decision as to how best to proceed in terms of treatment. Loewy (1994) proffered a "consensus" model, in which patient and physician reach a mutual agreement over the best means for proceeding in the face of significant differences. "Its goal," according to Loewy, "is not to persuade (coerce?) everyone to adopt the same position for the same reasons but to preserve the maximum interests and values possible of each and every particular and unique individual-as opposed to a homogeneous, generalized other-involved in and affected by the resolution of specific, concrete problems" (1994, p. 35).

Besides the engineering and priestly models, Veatch also proposed a collegial model for the patient-physician relationship. According to Veatch, in this model the "physician is the patient's pal... [with] an equality of dignity and respect, an equality of value contributions" (1972, p. 7). However, he faults this model as naive, since there is no means to regulate such equality. Rather, he then proposed a contractual model.

Veatch's contractual model is not a legal contract per se, but is more like a marriage covenant, although there are "social sanctions" for non-compliance of the terms. "With the contractual model," according to Veatch, "there is a sharing in which the patient has legitimate grounds for trusting that once the basic value framework for medical decision-making is established on the basis of the patient's own values, the myriads of minute medical decisions which must be made day in and day out in the care of the patient will be made by the physician within that frame of reference" (1972, p. 7).

Later, Veatch (1981, 1991) expanded the contractual model to a "triple contract" model. This model is composed of a "basic social contract" that specifies the basic ethical principles for members of a society, a "lay-professional contract" that specifies the basic ethical principles for the lay-professional relationship, and a "personal patient-physician contract" that specifies the personal ethical principles of the unique patient and physician.

Based on the "triple contract," Veatch (1991) then developed a "partnership" model for the patient-physician relationship: "the patient-physician relation ought to be one in which both parties are active moral agents articulating their expectations of the interaction, their moral frameworks, and their moral commitments. The result," according to him, "should be a partnership grounded in a complex contractual relation of mutual promising and commitment" (1991, p. 3). His partnership model is a moral contract in which both parties, although not maximizing benefits, do meet substantial needs of each other.

For Veatch (1991), in contrast to the patient-centered models, patients have duties and physicians have rights. The first duty of the patient is to fidelity, in terms of veracity and confidentiality, as well as for paying bills and keeping appointments. The second duty is to justice, in terms of not abusing malpractice and of stepping aside in the face of another patient with greater or more urgent need. The physician's rights parallel the patient's duties: "physicians have a right to expect fidelity of patients to the commitments they make, including keeping appointments, paying bills, and maintaining confidences. They have a right to expect truthful disclosures and to be treated justly" (Veatch, 1991, p. 150). Finally, physicians have the right for patients to respect their autonomy.

Indeed, one on the problems with the patient-centered models is that they "encouraged people to make demands but failed to emphasize reciprocal responsibilities" (Coulter, 1999, p. 719). The partnership models rectify this problem by stressing not only sharing information and decision-making but also sharing responsibilities, especially on the patient's part.

Besides Veatch's duties for the patient, Michael Meyer distinguished three "duties" that are incumbent upon the patient in the partnership models. The first is that the patient must be honest and open about the illness experience and why the patient is seeking healthcare. For example, an important duty is "to give as good a medical history as possible" (Meyer, 1992, p. 550). The next duty is to comply with procedures upon which the patient and physician agree. However, the patient does have the right to forego the agreement if he or she feels is it not meeting the agreed upon healthcare goals and needs. The final duty is "to avoid regarding the health care professional as infallible" (Meyer, 1992, p. 552). The patient has a responsibility to recognize that physicians are limited in terms of their technical abilities.

Finally, empirical studies demonstrate that mutual partnership between patient and physician results in positive benefits for the patient's overall recovery and illness experience. In a review of the literature, Deborah Ballard-Reisch identifies around a half-dozen benefits. The first is that patients who participate in the decision-making process are more likely to accept the decision and to be satisfied with it. Another benefit is that patients are more committed to the decision and are more compliant in terms of engaging it. "Shared decision making," according to Ballard-Reisch, "also leads to increased satisfaction with physician-patient communication" (1990, p. 94). Studies show that patients are anxious to discuss their health-related problems with a physician and that a major source of concern and dissatisfaction is poor communication between the patient and the physician. Finally, patients who participate in the decision making process are often in better health after therapy in which they share the process with the physician. "Structured, participative decision making," concludes Ballard-Reisch, "offers advantages to both members of the doctorpatient dyad, including higher quality decisions, greater commitment to decisions, increased satisfaction with interaction, and increased compliance with treatment regimens" (1990, p. 94).

15.3.2 Covenant Model

Another mutual model for the patient-physician relationship is the covenant model. William May is the best known champion of this model, which he discussed in his classic book, The Physician's Covenant, first published in 1983. May set the tone for his classic in an earlier article, in which he contrasts the covenant model with codes, contracts, and philanthropy. The central question for May was: "is covenant simply another name for a contract in which two parties calculate their own best interests and agree upon some joint project in which both derive roughly equivalent benefits for goods contributed by each`?" (1975, p. 33). His initial answer appeared to be yes.

May distinguished three components of a covenant: "(1) an original experience of gift between the soon-to-be covenanted partners; (2) a covenant promise based on this original or anticipated exchange of gifts, labors, or services; and (3) the shaping of subsequent life for each partner by the promissory event" (1975, p. 31). Each of these components is also a component of a contractual relationship. For a contract to be binding, there must be consideration (usually in the form of money) on the part of one of the parties and promises exchanged between freely consenting agents. This bond then guarantees the performance of the promises.

Although a covenant appears to be similar to a contract or at least a variation of it, May (1975) differentiated among several features that distinguish it from a contract. The first is indebtedness. The physician is indebted not simply by consideration but also by several gifts. The first gift is the training the physician receives from the professional community. Many more resources are made available to the medical student than covered by tuition. But the most important gift is that of the patient, who comes to the physician in need. The patient is under no obligation to do so, but given the severity of the need seeks out the physician for relief. Without the patient there is no need for the physician. The relationship begins with the simple act of the patient seeking help and ends with the physician offering help. "A covenantal ethics," for May, "helps acknowledge this full context of need and indebtedness in which professional duties are undertaken and discharged" (1975, p. 33).

The physician's indebtedness also grounds the next component of the covenant model: "fidelity and fidelity to promise" (May, 1975, p. 37). A physician must be faithful to the patient and to the promises made to the patient not simply because of a contractual obligation but because it is the best thing morally. Thomasma locates the source of the morality as a "general benevolence or loving charity" (1994, p. 15). In terms provided by Clouser, May promoted a covenant model because it is more concerned with motivation and a philosophy of life.' In other words, a covenant better captures the patient-physician relationship because "the relationship is so complicated, there are so many variables, so many different contexts and situations, that we could never spell out explicitly all that a physician should or should not do" (Clouser, 1983, p. 99).

A covenantal relationship is more fluid in terms of meeting the exigencies that are part of the normal course of patient-physician interactions. "Covenants," according to May, "have a gratuitous, growing edge to them that nourishes rather than limits relationships" (1975, p. 34). Thomasma also makes a similar point: "The covenant model is capable of suggesting a wider range of healthcare commitments to individuals who are sick than can the contract model" (1994, p. 16). This is possible because of cultural and religious values shared by the patient and physician and a richer notion of personhood than simply the notion of autonomy.

The main role of the physician in a covenantal relationship, with respect to the patient, is teacher. "The covenantal image," for May, "...demands that healers teach their patients" (2000, p. 155). Of course with the explosion of knowledge within the biomedical sciences, physicians often struggle to keep up with advances in their own specialties. And yet, patients need to know preciously what they are suffering from and the consequences.

A major function of physician as covenanter is to teach the patient not only about the illness and its consequences but also about alterations in habits and lifestyles, if appropriate, needed to live a healthful life. In other words, physicians must work to assist their patients to transform their lives so as to be healed and to remain healed. "Good teachers," warns May, "do not attempt to transform their students by bending them against their will, or by charming them out of their faculties, or managing them behind their backs. Rather, they help them see their lives and their habits in a new light and thereby aid them in unlocking a freedom to perform in new ways" (2000, p. 161). To achieve that level of life-changing teaching, a physician-teacher must be able to understand the patient-student and the blocks that constrain the patientstudent from learning what is needed to be transformed in terms of healing.

In the mid 1990s a group of physicians made a clarion call in a statement published in JAMA, for implementing the covenant model in contemporary medicine (Crawshaw et al., 1995). Specifically, these physicians believed that a covenant of trust is at the core of medical practice: "Medicine is, at its center, a moral enterprise grounded in a covenant of trust" (Crawshaw et al., 1995, p. 1553). Jing Jih Chin made a similar claim with respect to the patient-physician relationship and a covenant of trust: "Trust is fundamental to the physician-patient relationship" (2001, p. 580). The reason it is fundamental to medicine, especially for the patient-physician relationship, is that it stems from the patient's vulnerability and need for competent and compassionate care on the physician's part. Without trust the patient-physician relationship dissolves into an ineffectual or dysfunctional relationship, with the patient being harmed further.'

The covenant of trust has eroded over the last several decades, especially due to medicine's commercialization. "Accepting the `business' paradigm, especially in a profit-center corporate setting," remarked Christine Cassel in comments on the original JAMA statement, "turns the physician away from concern for the patient and toward concern for the bottom line" (1996, p. 605). The JAMA covenant statement was endorsed by a number of medical societies (Cassel, 1996). "Only by restoring the element of trust in this ageless patient-physician covenant," according to Chin, "can the soul of the medical profession be restored and preserved regardless of technological and social changes in society" (2001, p. 581).

15.3.3 Friendship Model

The friendship model of the patient-physician relationship has a long tradition in medicine, beginning with the ancient Greeks and Romans, and is second historically only to the priestly model. "In Greco-Roman writings," observes Stephen Post, "friendship came to define the ideal patient-physician relationship, at least according to Plato, who refers to physicians as friends of their patients" (1994, p. 26). In general, friendship or philia is the ideal for the ancients in terms of relationships because it promotes freedom, in which both parties enter into a relationship as equals for the mutual good of each other, even though the goods are not identical. For the patient the good is health. For the physician, however, it is the patient's appreciation for restoring the good of health.

As Aristotle (2001) noted in the Nicomachean Ethics, friendship involves not simply seeking one's own good in a relationship but the good of a friend. Although the friendship model has a long tradition, there has been relatively little philosophical exposition on it-especially in modem times. A possible reason for such dearth of interest is that "the friendship model is taken for granted as the preferred model and hence requires no further justification or elaboration" (Illingworth, 1988, p. 26).

Although there is no extensive analysis of the friendship model, there is adequate exposition of it within recent literature. For example, Patricia Illingworth defines it best as "a strong personal bond between physician and patient and which emphasizes the physician's qualifications as trustworthy, wise, good-willed, and with unqualified integrity" (1988, p. 24). Other definitions focus on a patient's need to confide his or her deepest concerns to a physician as a friend, or on the need to motivate the patient in terms of compliance. Pedro Lain Entralgo, a well known advocate of the friendship model, claims that a patient befriends a physician not because of the latter's technical skill but because of "kind and friendly goodwill" (Montgomery, 2006, p. 178).'

Based on the various definitions, Illingworth distinguishes two types of friendship models in medicine. The first is where "friendship is prescribed for primarily moral reasons" (Illingworth, 1988, p. 27). The reasons for the morally motivated friendship model include beneficence or patient autonomy. In other words, the physician befriends the patient for the patient's good, i.e. to relieve pain and suffering. In the other type of model, "friendship is required because it will generate patient compliance and satisfaction" (Illingworth, 1988, p. 27). A friendly physician is more likely to elicit patient compliance than an unfriendly one.

Advocates of the friendship model view it as normative, in that all patients should desire to be friends with their physician. This view is problematic, since most patients are looking for a competent physician to treat them rather than for a friend. Illingworth cites Veatch's notion of the "protean personality"-one who compartmentalizes life in non-overlapping categories-to support the view that, although some patients might want the physician as a friend, most probably do not.

The normative claim for the friendship model by its advocates is also problematic in terms of patient autonomy: "To saddle patients with a friendship which they do not desire violates their autonomy because in doing so physicians fail to respect patient claims of self-determination" (Illingworth, 1988, p. 28). In other words, the imposition of a relationship that a patient does not want would oblige conditions through which the patient could be coerced into a decision that he or she might not want-thereby compromising patient autonomy. Rather than desire for friendship, patients truly desire that "physicians behave in a neutral manner that is respectful of patients as self-determining agents" (Illingworth, 1988, p. 34).

In defense of the friendship model, David James (1989) agrees that most patients probably do not desire friendship with their physician; however, he argues that this fact does not vitiate the model's normative element per se. Rather, he claims that it is possible to have it without it being prescriptive. "The normative element," according to James, "need not consist of obligations. `Friendship' points towards and helps to organize important moral goods and ideals which physicians and patients may strive to attain, without specifying rights and duties which must be obeyed" (1989, p. 144).

Post concurs with James, in his defense of the model, and lists several of the goods or advantages of the friendship model: "expanded dialogue, shared uncertainty, better patient education and understanding, better compliance, fewer unwanted malpractice suits, and mutual respect for moral conscience" (1994, p. 25). For James the friendship model is "aspirational" rather than "conscriptural" vis-a-vis behavior. "What defenders of a friendship model are trying to talk about is value, not conduct;" claims James, "the Good, not the Right" (1989, p. 144).

Both James and Post also defend the friendship model against Illingworth's charge that it violates the patient's autonomy, in terms of trust. According to Post, friendship depends on trust, especially in terms of the notion of "discerning entrustment," in which decisions are best made in the context of friendship. Such decisions are more conducive to self-determination, than those made in isolation. Friendship provides a cooperative rather than an adversarial environment for patient care, in which patient and physician discuss with mutual respect what is best. Finally, and most importantly, "caring that is associated with compassionate friendship is a significant value" (Post, 1994, p. 28).

Although Montgomery claims that the traditional relationship of the patient and physician in terms of science's detached concern or the "care of strangers" is obviously inadequate, since there is no attachment or bond between the patient and physician so that the patient does not feel cared for, she argues that the friendship model of medicine is equally inadequate. "It directly conflicts with medicine's ideal of openness to all in need," opines Montgomery, "or if it does not, it is impractical; friendship with every patient would be emotionally exhausting, even perilous" (2006, p. 180). Rather, she proposes a "medicine of neighbors."

According to Montgomery, patients want a physician who is both competent and caring and that the neighbor model delivers on both. Rather than the physician as friend, which is too intimate, the physician as neighbor provides a "safe distance" so that the physician can be attentive and respectful but still remain nonjudgmental. "Above all," concludes Montgomery, "the physician as neighbor entails a relation to community that itself is caring. Because," she explains, "it offers both sure footing in intimate human contact and a goal of service" (2006, p. 187). In other words, the neighbor model is a median position between the detachment of the traditional model and the intimacy of the friendship model.

15.4 Summary

The patient-physician relationship has undergone significant changes within the last several decades, from the physician-centered models associated with the biomedical model of medicine to the mutual models espoused by humanistic or humane practitioners. Cassell (1991) has identified several factors involved in that change. An important factor is the association of medicine with science in the biomedical model. The effect is to displace the patient for the disease. According to Cassell, "physicians came to believe that to know the disease and its treatment is to know the illness and the treatment of the ill person" (1991, p. 20). But as he points out, physicians treat patients not diseases.

Another important factor in the change of the patient-physician relationship is technology, which often intervenes between the needs of the patient and the role of the physician. Physicians rely too much on their technology, often to the detriment of their relationship with patients (Cassell, 1991). Probably the most important factor in the changing relationship is the decline of medical paternalism with the enlightenment of the public concerning medical knowledge. Patients became co-participants in their treatment, in that they "frequently believe themselves to be active partners in their care. They want to take part in decisions formerly reserved for the doctor; they demand choice in therapy and have high expectations as to outcome" (Cassell, 1991, p. 25). The result is elevation of patient autonomy as one of the chief values in medicine.

Cassell sets out to reclaim part of the wholeness that typifies the patient-physician relationship, which, besides the professional relationship, also includes the personal, private, economic, social, and other relationships. Importantly, he dismisses the notion that the patient-physician relationship is either a transference or parentchild relationship. At its essence the relationship is a healing one, in that the patient must be more than simply cured: "It has been one of the most basic errors of the modern era of medicine to believe that patients cured of their diseases... are also healed; are whole again" (Cassell, 1991, p. 69).

The role of the physician in a healthful patient-physician relationship is to assist in the patient's healing and the basis of that relationship is the trust a patient places within a physician. The physician must be both competent and caring. "To be effective," according to Cassell, "physicians must be adept at working with patients-taking histories, establishing rapport, achieving compliance with regimens that may be extremely unpleasant, being sensitive to unspoken needs, providing empathetic support, and communicating effectively" (1991, pp. 76-77). The various humanistic modifications of the patient-physician relationship have gone a long way in alleviating the current quality-of-care crisis.

Finally, in stories from his own experience in medicine Tauber provides an in depth glance at the problems associated with the patient-physician relationship. In the first story, he recounts one of his mother's countless asthmatic attacks. Although he was always afraid during these attacks, his mother always reassured him as her "little man" From this story Tauber informs the reader that his medical career began at age four and that his goal in life was "to find a cure for asthma" (1999, p. 71). He continues the story with his introduction to medicine by accompanying his father, a general surgeon, as he visited patients on house calls. What struck Tauber was his father's "commanding authority" and ability to dictate the medical interview. Although Tauber considered his father's practice of medicine "paternalistic," he also witnessed the concern his father had for his patients such as crying over a patient's death. The outcome of these experiences for the young Tauber was the "fun" of practicing medicine, which continued through medical school even given its demanding curriculum.

But during Tauber's medical education, he experienced the frustration associated with the biomedical model's treatment of patients with chronic diseases. The first was as a medical student. His father secured for him a clerkship at the Mayo Clinic. While making rounds with an attending physician with a British accent, Tauber witnessed a woman with pancreatic cancer summarily discharged accordingly:

"My dear lady," intoned Dr. English, "I am sorry to say that you have cancer of the pancreas. There is nothing we can do for you. You will simply have to get used to the idea that you will die soon. I'm not sure when, but if I were you, I would put my things in order. You will be discharged tomorrow." And with that, he turned abruptly and his entourage followed (1999, pp. 119-120).

The second was as a resident. The patient was a young woman suffering from an asthmatic attack. After assessing her condition, he realized that no pharmaceutical drug would help and so he summoned a resident anesthesiologist to intubate her. Around an hour later, he returned to find the anesthesiologist chatting with the patient, and around two hours later he left with the patient breathing easily. No intubation was needed. Later while glancing at the patient sleeping comfortably, "I," Tauber informs the reader, "felt ashamed" (1999, p. 76).

What lessons do these powerful stories teach us about the patient-physician relationship and the practice of medicine, especially with respect to the biomedical or humanistic model? The first lesson is that physicians are persons with a history that shapes who they are not only personally but more importantly professionally. Tauber's family history provides the motivation and foundation for a career in medicine. While his father is instrumental in introducing Tauber to the professional dimension of medicine in terms of competence, his mother introduces him to the human dimension in terms of caring. As for many physicians these two dimensions are generally separate, and often in conflict with one another, and require joining.

Another lesson from Tauber's confessions is that patients are vulnerable and therefore require protection from overly dominating and abusive physicians. The patient with pancreatic cancer was certainly traumatized not only by her fatal illness but also by the careless and inhumane treatment of the attending physician. One can only imagine that physicians and often medical professions as a whole cause patients greater suffering than their illnesses. A final lesson is that the technical aspects of medicine are often ineffectual for treating chronic illness. As the anesthesiologist demonstrates all that was needed to stabilize the patient was being present in a caring manner, not intubation.

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