1. What Are the Three Forms of the Patient-Provider Relationship

Children vs. Weis. In this Texas case, the court found that Dr. Weis had no established relationship with Daisy Childs, who was 7 months pregnant, who came to the emergency room with bleeding and pain at work [3]. The doctor had never seen or treated Daisy Childs. When she was called by the nurse, Dr. Weis told the patient that she needed to see her own doctor in Dallas. During the trip, she lost the baby.[3] The court noted that « a doctor cannot be held responsible for the arbitrary refusal to respond to a call from a person who also needs urgent medical care. Assistance if the relationship between doctor and patient does not exist » [3].

A technical model of the supplier-patient relationship provides that the provider provides the patient with only technical-medical expertise. Different versions of this type of model are called « informative », « scientific », « technical », « consumer », etc. The doctor diagnoses the disease, explains the treatment options to the patient as well as the expected benefits and potential risks, and gives the likely favorable results with each option, including discussing those that are most popular in the patient`s situation, but no significant time is spent discussing the goals and values of the patient`s life or health, and the patient is free to decide for himself what to do. The patient needs to think about what they want from life, the risks they are willing to take, etc., and then decide what to do. The type of technical model avoids accusations of paternalism because it does not assume that the provider has to hide information from the patient or decide for him, and the provider does not claim to know what is best for the patient. But reviews of the tech models claim that while they represent what we expect from an auto mechanic or travel agent, it`s probably not what most of us expect from a healthcare provider. While people may not want the provider to automatically make the important decisions, they often want to discuss treatment options with the provider as part of a discussion about their health and their life goals and values. Many patients would welcome a provider-patient discussion about what they want from life and how to get there. They want the provider to evaluate options in light of the provider`s knowledge of the patient`s goals and values for health and life. Patients may not want the provider to make the decisions, but they do want advice and recommendations. They do not want coercion, but many would welcome dialogue. So many critics see technical models as too extreme a reaction to paternalism.

Obligations to third parties. A closely related question is the extent to which physicians owe obligations to third parties arising from their patient-physician relationship. In one famous case, it was found that a psychiatrist had a duty to warn an easily identifiable victim who was then murdered by his patient [13]. In another case, a physician who had treated the applicant`s father for colorectal cancer was ordered to warn the patient`s daughter of the risk of genetic transmissibility of the disease [14]. However, in one case in Texas, it was found that a physician had no obligation to third parties when he wrongly concluded that a patient child had been sexually abused by the pursuing father. The court pointed out that, in some cases, there may be an obligation to third parties (in this case the father), depending on the nature and predictability of the risk, as well as the extent and consequences of the burden on a doctor [15]. Doctors on call. In Mead, the on-call physician formed a patient-physician relationship because he performed the positive act of recommending treatment [4]. In a similar case in Texas, it was believed that a physician had not established a patient-physician relationship when he or she was the physician on call supervising residents during an emergency caesarean section [7]. In another case, a patient-physician relationship was not established until a physician saw the patient during the shift [8, 9]. In contrast, a recent Ohio Supreme Court decision concluded that a patient-physician relationship can be established between a physician who « contracts, accepts, assumes, or otherwise assumes the duty to supervise in a teaching hospital, and a hospital patient with whom the physician has had no direct or indirect contact » [9, 10]. The question was whether and to what extent the physician was expected to play an active role in patient care and whether the physician was considered to be the patient`s attending physician [9].

The issue is still a developing area in law, with different state courts coming to different conclusions about the duty of the doctor on duty. The safe course of action is for on-call physicians to consider anyone whose patient they supervise. The practice of medicine and its embodiment in the clinical encounter between a patient and a doctor is fundamentally a moral activity that results from the imperative to care for patients and relieve suffering. The relationship between a patient and a physician is based on trust, which establishes physicians` ethical responsibility to place the patient`s well-being above one`s own self-interest or obligations to others, to use good medical judgment on behalf of patients, and to advocate for the well-being of their patients. It is inevitable that providers will act paternalistically in a sense that is harmless to much of what happens in health care. For example, a surgeon performing surgery on a patient will use the techniques that they think are best suited to the situation, rather than seeking advice from the patient or presenting decisions about the technique to the patient throughout the surgery. Or when deciding on drugs to treat an infection, the provider will narrow down the range of options to those who, at their professional discretion, are likely to disable the particular type of infection, rather than providing the patient with long lists of antibiotics to choose from. Or when deciding what kind of training conferences to attend or specialized literature to read, the provider will not ask for advice from patients, but will make their own judgment about what new knowledge and training will best benefit their patients. The paternalism critic might argue that when a provider makes critical decisions for a patient or retains important information to influence a patient`s decisions without involving the patient in the process, the provider seems to implicitly assume everything about the type of life people should live in general and want to get out of life.

But to know all this, controversial philosophical and religious issues that do not fall within the scope of medical expertise should be clarified. The provider may know what they want from life, but they may not know what the patient wants to get out of life, and the provider is most likely unable to know what the patient wants to get out of life. For example, the provider should not simply assume that the patient does not want to be aware of an incurable disease because the patient may want to have that knowledge so that he can take the time to put his economic, personal and spiritual affairs in order before death. The second assumption of paternalism in health care mentioned above is that the provider actually knows what is best for the patient. There are several possible interpretations of it. In the United States, what is considered the ideal model for the relationship between healthcare providers and patients has changed in recent decades. Paternalistic models have been replaced by models that place greater emphasis on respect for patient freedom and joint decision-making. Paternalism occurs outside the health care system. Typical parenting decisions in a family are paternal in this way – parents choose what they want to say to their children, present only the alternatives they prefer, and make the important decisions. When the government requires a motorcyclist to wear a seat belt or helmet, it is acting paternalistically. The government believes in such cases that it is acting in the best interests of citizens, but what makes it paternalistic is that the individual is not free to control the decision (without breaking the law). In health care, « paternalism » occurs when a physician or other health professional makes decisions for a patient without the patient`s explicit consent.

The physician believes that decisions are in the best interests of the patient. But control in the relationship belongs to the doctor and not to the patient, just as control in a family belongs to the parents and not to the children. In the traditional paternalistic model, it was considered acceptable for the doctor to decide what to say to the patient about the actual diagnosis, and in cases of incurable disease, sometimes the patient was not informed of the true nature of the disease (perhaps the family was informed instead). Or if the patient has been informed of the diagnosis, the doctor might be the only one presenting the recommended treatment plan instead of mentioning alternatives that might be considered. Or if the patient has been informed of the alternatives, the doctor could clearly prioritize the recommended treatment plan so that it can be selected. According to the critic, the provider should instead stick to learning from the patient what the patient wants from life and advise the patient on health goals and practices that are likely to achieve the patient`s life goals.