SLA pg 43-58: Foundations of the Health Professional–Patient Relationship

Traditional Hippocratic ethic: provider judges and pursues the patient’s physical health; patient largely passive
Paternalism justified truth-withholding if disclosure might harm care
Mid-twentieth-century critiques (e.g., Alan Goldman) stress:
- Welfare ≠ mere physical survival; quality of life & values matter
- Self-determination has independent moral worth; deception blocks informed choice
Respect for autonomy now the cornerstone of contemporary bioethics, yet balanced with beneficence & non-maleficence

Paternalistic (Hippocratic): physician decides; limited disclosure
Informative: physician supplies facts; patient chooses; sharp fact-value split
Interpretive: shared exploration of patient’s values to identify best option
Deliberative: physician also recommends “most admirable” health-related values; teacher-guide role
Contractual / covenant imagery underlies informative & interpretive versions; moral equality but challenged by illness-induced vulnerability (Terrence Ackerman)

Ethical drivers: promote well-being, honor autonomy
Legal grounding: Schloendorff decision (“right to determine what shall be done with one’s own body”)
Cobbs v. Grant replaces professional-standard disclosure with reasonable-patient standard: divulge material risks relevant to a rational choice
Practical tensions: small-risk side effects (impotence case), medical errors (Françoise Baylis), cultural norms (Blackhall study on disclosure preferences)

Confidentiality sustains privacy, trust, and care-seeking
Conflict cases:
- Tarasoff: duty to warn potential victim overrides confidentiality when threat is specific & grave
- HIV home-care case: debate over informing caregiver sister about patient’s status (Fleck vs. Angell)
- Misattributed paternity in genetic testing: dual confidentiality duties; potential relational harms (Lainie Ross)

Health workers often “double agents” (institutions, insurers, military, prisons)
Obligations may collide with duties to family, employers, public safety, or personal conscience

Pharmacists refusing emergency contraception: Cantor & Baum favor middle path
- Allow refusal if: prior disclosure, timely referral, no undue hardship on patient
- Absolute refusal or absolute compulsion both reject fiduciary & liberty concerns

Historical ambivalence: AIDS, potential bioterror, pandemic threats (SARS)
Surveys: sizable minority of physicians unwilling to treat under uncertain danger
Emanuel argues social trust & professional mission require willingness to serve, tempered by reciprocal protections (training, equipment, compensation)

AMA & ANA codes forbid involvement; assert incompatibility with life-preserving mission
Atul Gawande: medical presence sanitizes killing; undermines public trust
Kenneth Baum: core duty to relieve suffering mandates involvement to ensure humane death (“to comfort always”); analogous to terminal oncology care
Broader implications for medical roles in interrogation and state violence

Patient autonomy, while central, is not absolute; must be integrated with welfare, justice, cultural context, and professional integrity
Ethical analysis of health-care relationships uses competing models; choice of model shapes duties
Law (informed consent, duty to warn) codifies but does not settle moral debate
Professional roles carry fiduciary duties that can clash with personal morals or societal demands; navigating these conflicts defines modern bioethics