3.3 Why ethical behaviour is central to the health care relationship
The health care relationship is basically a relationship of trust. This implies that practitioners are motivated by the users' best interests; will not exploit the therapeutic relationship to satisfy their own ends; will behave in an appropriate manner that is conducive to the healing process; and will refrain from behaviour that could harm users, including being physically or psychologically unfit to treat them. The examples in Box 2 give a clearer idea of what this means.
Box 2 Examples of ethical situations
A patient may reveal extremely personal information to a practice nurse during a family planning consultation, even though the patient knows little about the practitioner.
A dental patient who is paying for private dental treatment needs to trust that they will not be subjected to unnecessary and painful procedures simply to increase the dentist's earnings.
An osteopathic patient needs to feel confident that she has been asked to undress down to her underwear only for the purposes of her treatment, and not for the practitioner's personal gratification.
A surgical patient takes it on trust that the surgeon's skills are up to date, and that they know about all the available options that might obviate the need for surgery.
All of these examples demonstrate that people would be uncomfortable in trusting or confiding in a practitioner unless they can believe the practitioner is worthy of respect and can be relied on not to abuse their trust. Ethical behaviour is central to the health care relationship because of the inherent power disequilibrium between user and practitioner. This is based largely on the relative disparity in knowledge between health carers and the people they treat. Health professionals are consulted precisely because they have skills that lay people do not have.
People increasingly expect to be informed and involved in all aspects of decision making about their medical treatment, which is acknowledged in the development of the ‘expert patient’ (Department of Health, 2001). At the same time, many people are much more knowledgeable about health-related matters than in the past. This is hardly surprising given the attention health issues receive in the media. The internet has also helped to narrow the knowledge gap between doctors and users. In addition, television series such as Casualty, ER, Holby City and Peak Practice have made people more familiar with medical terminology and seeing health carers working through fictionalised ethical dilemmas. They also see documentaries about, for example, the ethics of assisted reproduction, separating conjoined twins and end-of-life decisions.
In contrast, many people know relatively little about CAM unless they have had personal experience. When people consult a complementary practitioner for the first time, they may not know what the therapy involves or what outcomes to expect realistically. For example, although people are increasingly aware of being asked to give their consent to conventional medical procedures, they would not necessarily expect a chiropractor to ask them to sign a consent form. They might also be unaware of the level of information they need before they can give valid consent to their first acupuncture session. In these situations, and from an ethical standpoint, it is even more important for the practitioner to openly discuss the form of treatment being offered, what it entails, and what it could achieve in the given situation, as well as to discuss alternative treatment strategies.
Another obvious inequality between practitioners and users is that most people who are ‘ill’ (loosely defined) may be frightened, in pain and vulnerable, and need to be able to rely on the practitioner. Health givers, in contrast, should be in robust psychological and physical health and in no sense reliant or dependent on the user. When people are ill, they usually look for a health practitioner who has the skill and expertise to make them better, and who may, conceivably, impose their own professional judgement when appropriate. The autonomy of people who are ill is already compromised. They may be unable to work, or their mobility may be restricted, limiting their ability to get about as they would like. They may be in too much pain or discomfort to continue with their normal business. Depending on the severity of the diagnosis, they could be anxious and possibly depressed. All of these factors compromise autonomy. To regain their health and full autonomy, many people are prepared to depend on advice and allow themselves to be cared for by others. People who are used to managing their own affairs can feel uncomfortable being dependent on others. The loss of health interferes with people's ability to enjoy their lives. They invest significant trust and hope in the belief that the person they depend on can restore them to good health. While respecting autonomy is a very important part of health care, so is the ability to care and be dependable.