A patient in a comatose state presents to the physician with diabetes and high blood pressure. The patient needs mechanical ventilators, dialysis machines and artificial hydration to prolong life. The doctor is informed by the patient’s wife that the patient had previously indicated that he never wanted mechanical ventilation if he fell ill. The doctor is presented with the conflict of interest on the basis of the principle of respect for patient’s autonomy. On the hand, the doctor can ascertain that it is in the best interest of the patient to put him on the life support machine to alleviate suffering and possibly cure the condition. The primary duty of a physician is to protect life.
It is incumbent on the physician to act in the best interest of the patient. On the principle of beneficence, the doctor can choose the mode of therapy that supersedes the fundamental principle of patient autonomy and maleficence. The moral dilemma can be sorted by the doctor assuming that the patient cannot make an informed consent as at that time. The physician will act based on the duty of care and good faith which is the foundation of a fiduciary relationship, to treat the patient. Clinical excellence is a blend of technical proficiency and ethical sensitivity, the doctor makes a decision that places is in the best interest of the patient above all existing ethical and professional factors.
Challenges in upholding a fiduciary relationship
There are circumstances when a doctor is unable to uphold the standards of a fiduciary relationship. A boy presents with Wilson’s disease and requires a liver transplant. The patient is from a poor social-economic background and the available health care system cannot meet the cost of the transplant. In this situation, it is in the best interest of the patient to receive a liver transplant, according to clinical assessment, yet the patient cannot afford it. The doctor may decide to recommend the most affordable yet not effective treatment because of the economic block. This is a challenge in upholding a fiduciary relationship.
Altruism is a keystone in providing quality health care. In the care of the suffering, the physician needs to sacrifice and commit his time and energy in the provision of health care. In providing quality health care, the duty of care by the doctor must take precedence to any other factors. The patient’s interest is placed first by subordinating financial matters and self-interests to achieve the central goal of medical care. A doctor should provide services to the patient without any expectation of compensation or any benefits to be derived from the service rendered. The physician will provide services without unnecessary delays and also without considering the patient's income. The doctor will sacrifice time despite being on leave or the patient comes outside the normal working hours. This act of altruism contributes to quality health care through preventing unnecessary delays in health care provision and meeting the needs and preferences of the patient with expediency. Altruism is key for clinical competence and avoiding harm to the patient by having the professional available to the patient outside their limitation of time, possession and energy.
Confidentiality is a central core in the medical profession. The information shared between the doctor and the patient is private and confidential which is essential in giving the patient confidence and faith in the doctor. Information pertaining to the patient’s illness is sometimes embarrassing and assuring the patient of confidentiality will allow for a friendly atmosphere and confidence in the doctor during history taking and medical interviews. A doctor who divulges information about the patient to other clinicians or people puts the profession in disrepute. Confidentiality is also essential since breaching it may cause harm rather than protect the patient. A breach of confidentiality disrespects autonomy and undermines trust in medical professionals.
The principle of confidentiality is not absolute. An example is when a patient is involved in crime and violent behavior that may be related to a medical condition. A judge may give an order for the medical report on the patient to be provided during court proceedings. The doctor will break the doctor-patient confidentiality since it interferes with successful execution of justice. The patient might be having a psychiatric condition which makes the patient liable to committing crime. A clinician will breach it in order to protect the patient from a harsher court sentence that will consider his medical history.
Accountability is relevant in the medical profession. The field of health care is rapidly advancing and the patient’s unique needs must be considered. The need for hospitalization and duration in a health care system that is stringent on the amount of money invested in health care is under constant review to minimize the costs and optimize on the results. Hospitalization is sponsored by governments and third parties. Doctors must account for the money spent on health care and defend the cause of hospitalization that may fall outside the average amount set aside for a certain patient.
Fauci, & Braunwald. (2006). Harrison's Principles of Internal Medicine. New York: MacGraw Hill.
Kumar, & Clark. (2006). Kumar Textbook of Medicine. New York: McGraw Hill.