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Volume 3, Number 2

BENEFICENCE AND AUTONOMY IN HEALTH CARE

MICHEL SILBERFELD, MD

The doctor/patient relationship, like all relationships, is dynamic: it evolves within its particular social context. Today this special relationship is undergoing shifts of emphasis related to the assignment of priority to certain values; new attitudes toward communicating with patients; and implied assumptions about uncertainty. Usually the choice of priority in values is presented as a "great debate" with clear-cut, opposing positions: namely, beneficence and autonomy. These opposing positions are presented as a necessary, ongoing tension: as part of the daily travail of practicing medicine.

I believe that the conflict between beneficence and autonomy within the doctor/patient relationship is a local manifestation (within medicine) of a much broader social phenomenon: the changing perceptions within our society about the nature of personal and collective responsibility. These changing perceptions may be related to the decline in belief in all professional authority, and may well signal a change in the nature of the state in Canadian society. These and similar considerations should not be lost sight of by dismissing them as primarily a conflict between beneficence and autonomy(1).

As we shall see, the demarcation between beneficence and autonomy is not clear, nor are beneficence and autonomy truly antithetical. This paper will present definitions of beneficence and autonomy and will set out their principal areas of difference. These areas of difference include how and what to communicate to patients, as well as how to preserve certain values while involved in the treatment of patients. An area of difference relating to the understanding of uncertainty is often neglected. Such an exposition suggests that professionalism is only incidental to the determination of ethical standards. It also makes clear that, in order to have their ethical concerns heard, physicians will have to be articulate within the ethics framework.

BENEFICENCE AND AUTONOMY: The climate of ethical conduct is difficult to ascertain from such sources as widely held attitudes, debates within professional circles, proceedings before the courts, and reports in newspapers. Unfortunately, the actual discourse between people is seldom sampled and examined, because ordinary people are concerned with pragmatics more than ideals. However, for the sake of illustration we can first examine the attitudes expressed by famous teachers. Concluding his lecture on "The Care of the Patient," Francis Peabody (2) said:

The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.

Beneficence expresses the moral significance of seeking for another the greater balance of good over harm. By illustrating the proper conduct of physicians, it enjoins all practitioners to conform to that standard of ethical practice.

An alternative and more clearly contractual view of the doctor/patient relationship is based on the ideal of autonomy. In making decisions about their medical fate, autonomy takes the values and beliefs of the patient and their self-determination to be the primary moral considerations. The emphasis is on the process of decision-making and determining with whom rests the ultimate authority for those decisions. Jay Katz (3) proposes such an attitude in a fictional discourse:

Of course I shall eventually give you my recommendation, but 1 prefer not to do so yet. Since there are a number of alternatives available, each with its risks and benefits, 1 would like to hear first what your preferences are. After all, it is your body that I intend to treat and I can do so in a variety of ways. Since you will have to live with your body for a long time to come, you must have some opinions about which consequences would be easier or more difficult for you to tolerate. Once I have a better idea of your preferences and needs, I can make a recommendation that reconciles the best that medicine has to offer with the best that you envision for yourself after I have discharged you from my care.

According to the principle of autonomy, the best interest of the patient lies in the explication of the best medicine has to offer; according to that of beneficence, the best interest of the patient is served by the interpretation of a skilled, well-intentioned interpreter -the physician.

PRINCIPAL AREAS OF DIFFERENCE: Beneficence and autonomy differ in three principal areas: communication with patients (with reference to disclosure, the suggestibility of patients, and the power of authority); preservation of certain values (i.e., freedom of choice, privacy, altruism, and trust); and living with uncertainty.

COMMUNICATION WITH PATIENTS -DISCLOSURE, SUGGESTIBILITY, AND AUTHORITY: Proponents of beneficence have always held that disclosure is a matter of the physician's discretion. In his choice of what to withhold, he is motivated by the desire to protect the patient from the harmful effects of bad news. Sometimes the traumatic consequences of not protecting patients are minimized, yet ample evidence suggests that this type of disclosure may cause considerable harm. The need for patients to be protected from full disclosure was well entrenched in the Hippocratic tradition. In Decorum (4), physicians were enjoined as follows:

Perform your duties calmly and adroitly, concealing most things from the patient while you are attending to him. Give necessary orders with cheerfulness and serenity, turning his attention away from what is being done to him; sometimes reprove sharply and emphatically, and sometimes comfort with solicitude and attention, revealing nothing of the patient's future or present condition.

Such admonishments continued until recently, because the patient's protection was held to be the most cherished medical ideal. Today, largely through the influence of the courts, the proponents of autonomy are making such strong assertions as the following (5):

The duty to warn is surely a facet of due care. Therefore a lack of disclosure should be a legally cognizable injury in and of itself. All interferences with self-determination stemming from a lack of full disclosure are compensatable regardless of their impact on the patient's decisions or physical health.

The proponent of autonomy has no doubts about patients' capacities to make reasonable decisions and has no fears that meddling with faith in the physician will undermine cure. However, other than insisting on the need for a strict boundary for self-determination, it remains unclear which manner of communicating would best preserve this boundary.

The interests of the courts in these cases call for a more inquiring analysis. From one perspective their concern has been motivated primarily by a desire to find a basis for compensation for injury by assigning new definitions of responsibility (6). One vehicle by which to fulfill beneficent motives is to encourage physician disclosure to protect patient self-determination.

Suggestibility is part of the patient's vulnerability. The proponents of beneficence consider that the physician safeguards patient vulnerability as part of his general management, subject to the higher purpose of doing good. An astute physician would understand the psychology of hope and be able to protect the patient from even his own exploitation of false hopes (7, 8). Such powerful psychological influences as are exemplified by the effectiveness of placebos point to a reciprocal influence in the doctor/patient relationship.

The concept of power is often invoked to highlight the characteristics of the physician - specifically, his authority. The proponents of autonomy would say that the physician should no longer use his authority to hide uncertainty and ignorance. It is apparent that the management of hope and reassurance has to be more carefully and caringly applied to safeguard against unwitting exploitation. In the words of Waitzkin and Stoeckle: "A physician's ability to preserve his own power over the patient in the doctor/patient relationship depends largely on his ability to control the patient's uncertainty" (9). Unfortunately, many of the recommendations a physician makes are not based on an explicit and adequate psychology of hope that would enable the physician to recognize false hope and keep it from becoming a source of exploitation. An explicit psychology would also make plain to the patient the subjective risk in complying and feeling satisfied with a given course of action.

Katz (10) emphasizes the need for such knowledge:

Hope and reassurance need to become an echo, a creative act of reflecting back to patients what physicians can truly promise after they know more about their patients, their illness, and their expectations. Faith, hope, and reassurance have too often served physicians' needs to maintain authoritarian control, to hide uncertainties, and to facilitate patients'