Giovanni Scarafile

Feeding on the leviathan. Conflict in the doctor-patient relationship

In Filosofia, Uncategorized on 15 February 2015 at 8:39 AM

Giovanni Scarafile

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My paper is related to applied ethics with special reference to the ethics of communication. The task of this discipline is to defend otherness in the various contexts where it exists. The departure point for my paper is the observation that the physician-patient relationship, instead of being the place of therapeutic alliance, is increasingly becoming a source of conflict, as is shown by the statistics on legal actions between doctors and patients, lack of communication skills identified amongst patients, and cases of burnout amongst doctors. This situation calls on ethics to take two steps simultaneously. Firstly, it must not forego the duty of indicating the rules. Secondly, it must be capable of suggesting directions where those same rules can be applied. Succeeding in this task is decisive not only in domains where the ethical approach may be welcomed, but also for ethics as such, otherwise destined to be a disembodied specialization.

1. Did you know that on average a doctor interrupts the patient’s account of their symptoms about twenty-two seconds after the patient starts talking? This is what was discovered by major international research published in 2002 in the British Medical Journal by Wolf Langewitz, executive director of the Department of internal medicine at the University Hospital in Basle, Switzerland. The article in question, entitled Spontaneous talking time at start of consultation in outpatient clinic: cohort study, written by Langewith and five other researchers, though consisting of only two pages, is still arousing discussion today due to the topical nature of its findings. In fact, 90% of patients spontaneously conclude the story of their symptoms within the first 90 seconds (and at any rate, all the symptoms within two minutes). However, very few of the patients manage to get to the end of the description of their symptoms.

Although today there has been a dramatic increase in the doctors’ capacity to make a precise diagnosis starting from the few elements reported by the patient, it is hard to deny that twenty-two seconds is actually a very short time. Furthermore, this is all confirmed by other indicators. In an interview a few years ago, for instance, published in the daily paper La Repubblica[1], Giuseppe Remuzzi, Director of the Mario Negri pharmacological research institute in Bergamo, explained that in 2005 in the United States medical errors caused the death of 90 thousand patients. In Italy, every year about 15 thousand doctors are sued for damages and it is significant that 9,5% of these cases are due to communication problems.

In more recent years, as shown by the Health Report 2010 of the Tribunale dei diritti del Malato (Tribunal of the Rights of the Sick)(3), there has been further confirmation: the lack of attention and the essential absence of good communication are what is at the bottom of the demand for intervention made by many patients.

There is, therefore, a “communication emergency” that can transform the potential therapeutic alliance between doctor and patient into an extremely conflictual relationship with judicial aspects. Faced with this discouraging feedback, something is starting to change. The ethics of communication has not yet been introduced in the curriculum a student has to study to become a doctor. Such a result would be a reasonable solution since it would gradually introduce the future doctor to the communicative competence required in the practice of the medical profession.

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Today, faced with the problem of the communication gap between doctor and patient, an extremely practical solution is adopted. It consists of a series of supports provided to doctors and health professionals (managers, pharmaceutical consultants) to help them solve possible problems encountered in their professional practice. In such cases, the key-words are empowerment or coaching. The two terms are not exactly synonymous, but refer to the same sort of activity. Empowerment consists of making the person aware of their own potential. Coaching on the other hand consists of calling a group of experts to assist the health professional in carrying out their work, suggesting the best solutions to adopt on a specific issue. These two techniques enable doctors to find solutions that are often satisfactory without avoiding the problems. The quality of the doctor-patient relationship is therefore safeguarded. However, although the availability of ready-made solutions initially seems a great success, in the long-run it becomes a lost opportunity. In fact, the marked orientation of counseling (empowerment and/or coaching) towards practice, does not allow the doctor to gain familiarity with the criteria underlying the possible solutions. The result is that quality is confused with efficacy. The doctor-patient relationship, reduced to a standardized scenario in which certain strategies are to be used, loses the complexity of its relational dimension. This complexity is an indispensable factor in identifying solutions suited to the needs of the single patient. Without losing sight of efficacy in adopting possible solutions, it is therefore necessary to try to restore the relational aspect that is the foundation of the doctor-patient relationship. In other words, what should be done is the exact opposite of what is actually done. Is that impossible?

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2. Faced with a feat that does not seem achievable, we are saved by the Leviathan. Yes, that very same marine monster that the western tradition has been depicted in many different ways. Thomas Hobbes, for example, a 17th century English philosopher, used the title Leviathan for his book about the legitimacy and the form of the state. Hobbes himself, however, used the image of the monster taken from the biblical tradition. The book of Job says that the monster: «makes the depths churn like a boiling cauldron, and stirs up the sea like a pot of ointment. It leaves a glistening wake behind it, one would think the deep had white hair» (Job 41.23-24 31-32?). In the later biblical tradition, every other description of this frightening creature only serves to emphasise its terrifying aspects. However, in rabbinical literature, specifically in the midraš[2] Levitico rabbah, the Leviathan and Behemoth (another legendary denizen of the deep) will fight a battle to the benefit of the the righteous all over the world. At the end of the spectacle, both monsters will be killed and the flesh of the Leviathan will be used to feed the righteous. The destiny of the Leviathan has changed. No longer the bogey-man, but a source of food. This reversal suggests the possibility that a similar transformation may also take place in the context of the doctor-patient relationship. In clinical practice, is there an element universally regarded as negative which if taken can produce positive effects for everyone?

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[1] Cf. La Repubblica, 27 June 2007.

[2] In the rabbinical tradition, midrash designates firstly an activity and a method of interpreting the Scriptures which, by going beyond the literal meaning – called peshat or pashut (פשות), simple, obvious – scrutinizes the text in depth.

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