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Open Access 08-06-2024 | Living Will | Scientific Contribution

An “ethics of strangers”? On knowing the patient in clinical ethics

Authors: Joar Björk, Anna Hirsch

Published in: Medicine, Health Care and Philosophy

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Abstract

The shape and function of ethical imperatives may vary if the context is an interaction between strangers, or those who are well acquainted. This idea, taken up from Stephen Toulmin’s distinction between an “ethics of strangers” and an “ethics of intimacy”, can be applied to encounters in healthcare. There are situations where healthcare personnel (HCP) know their patients (corresponding to an “ethics of intimacy”) and situations where HCP do not know their patients (corresponding to “an ethics of strangers”). Does it make a difference for normative imperatives that follow from central concepts and principles in medical ethics whether HCP know their patients or not? In our view, this question has not yet been answered satisfactorily. Once we have clarified what is meant by “knowing the patient”, we will show that the distinction is particularly relevant with regard to some thorny questions of autonomy in healthcare (e.g., regarding advance directives or paternalism in the name of autonomy), whereas the differences with regard to imperatives following from the principles of justice and beneficence seem to be smaller. We provide a detailed argument for why knowing the patient is ethically valuable in encounters in healthcare. Consequently, healthcare systems should provide fertile ground for HCP to get to know their patients, and structures that foster therapeutic continuity. For this to succeed, a number of questions still need to be clarified, which is an important task for medical ethics.
Footnotes
1
We consciously use the umbrella term healthcare personnel (HCP) to move away from the focus on the physician in much abstract bioethical writing, and on the nurse in some writing within, for instance, care ethics. Our contention is that the implications of this article, if accepted, will be felt by all HCP who work closely and longitudinally with patients.
 
2
In line with Ziegelstein we do not discuss, here, situations where HCP (also) know the patient privately outside the medical relationship.
 
3
The exact proportions between the two spheres, and other empirical details pertaining to the distinction do not matter for our further discussion.
 
4
At least if the delegation itself lives up to the autonomy requirements that one proposes.
 
5
It is true that rights are waivable and that patients can therefore also waive their right to informed consent. However, it should not become common practice, as it may exacerbate the tendency to exploit patients’ trust, routinely skip informed consent and decide on their behalf (Beauchamp and Childress 2019b, p. 135–136).
 
6
Our intention is not to open a back door to paternalism here. We do not wish to give HCP the possibility of saying “this preference is not well-considered, I shall readily disregard it”. Rather we agree with the critics of advance directives that patients may sometimes provide answers which are not in line with what they really mean. If HCP have good reason to believe this is so, they also have good reason to think twice about the document’s value for autonomy.
 
7
This idea is already included in the concept of Advance Care Planning (ACP) (Bosisio and Barazzetti 2020): Within an ACP programme, patients do not write an advance directive once and possibly never look at it again. ACP initiates a continuous shared decision-making process between patients and HCP. Within some programmes, patients are accompanied by an ACP facilitator who initiates a joint review of the advance directive when special events occur in the life of the patient.
 
8
Duties of beneficence refer “to a normative statement of a moral obligation to act for the others’ benefit, helping them to further their important and legitimate interests, often by preventing or removing possible harms” (Beauchamp 2019).
 
9
Even if no one today would claim that beneficence in healthcare is geared towards a purely biological-functionalist understanding of well-being (or rather health), for example in the sense of Boorse (1975), it still underlies as a kind of basic orientation – despite new tasks and areas of medicine that go beyond the restoration of health and healing of diseases, e.g., in the field of biomedical enhancement or prevention medicine. After all, patients usually expect to be helped primarily with their health concerns when they seek medical treatment.
 
10
The “medical indication” is an important indicator in this context; a treatment that is considered medically indicated is generally aimed at improving well-being understood in the medical sense (Wiesing 2017). Treatments which are not useful to achieve a specific treatment goal or do not offer sufficient benefit for the patient from a medical point of view, are not considered medically indicated and are usually not offered to the patient (Björk et al. 2016).
 
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Metadata
Title
An “ethics of strangers”? On knowing the patient in clinical ethics
Authors
Joar Björk
Anna Hirsch
Publication date
08-06-2024
Publisher
Springer Netherlands
Keyword
Living Will
Published in
Medicine, Health Care and Philosophy
Print ISSN: 1386-7423
Electronic ISSN: 1572-8633
DOI
https://doi.org/10.1007/s11019-024-10213-y