Humane Judment - Chapter 3
This chapter on "humane judgement" examines the relationship between doctor and patient.
A doctor-patient relationship is a "professional" relationship. It is not a friendship relationship.
• In the Oxford English Dictionary, "professional" means... Undertaken or engaged in for money;
engaged in by professional as distint from an amateur.
•the first characteristic (engaged in for money) describes many occupations (carpentrer
musician, airline pilot, cashier...)
• the second characteristic (professional vs amateur) describes standard of quality.
• To be "professional" involves advanced knowledge or skills obtained through specialized
In a "regulated" health proffessions, the sale address the issue of quality by setting legal
requirements for qualification in the professional. (different of other professions that there is no
regulations. e.g., proffessor and mechanic.
The state also establishes the legal rights and responsabilities that govern health prefessions.
In Ontario, there are 26 regulated health professions; these include:
• physician, pharmacist, optmetrist, ...
• Dental hygienist, pharmacy technicians, acupuncturists, ...
Downie and Macnaghton explain that formal conditions (requirements, rights, responsabilities)
are important in health professions because..
• practitioners intervene in "existentially crucial ways"
• practitioners often cunduct physical examination and ask about personal details.
These formal conditions provide "emotional insultation" to both parties, and also provide legal
protection to both parties.
According to Downie and Macnaughton, these formal conditions are the "technical" part of the
According to Downie and Macnaughton, the techinical part of clinical practice is rooted in
specialized knowledge and skills obtained through medical education.
• the knowledge consists if the generalized knowledge of medical research (that must be
• the skills consist of:
• Practical skills (e.g. administring an injection), communication skills (explaining things in a
easy way that fits the patients) and negotiating consent.
According to Downie and Mcnaughton, the other important part of the doctor-patient relationship
is "humane attitude".
• a patient's "medical good" reflects the technical part of the clinical practice - a "technical
attitude", so to speak.
•A humane attitude is to realize that a patient's "medical good" is only part of their "total good".
A technical attitude is exemplified by viewing a patient as a set of symptoms.
• "the fracture in bed three"
• "the teth case of flu this week"
Downie and Mcnaughton argue that it is useful to view patients in terms of symptoms... - it is these symptoms that bring her or him to consult the doctor.
Some other ways of viewing a patient...
• in terms of the patient's case history - by considering a broader range of medical factors. (e.g.,
about pressure, family history....)
• in terms, of the patient's discomfort and vulerability. (we have to take care here to not become
• in terms of the patien's right to medical care. (individual factor, the fact that he/she is comfort,
the fact they have rights.)
Possible ways to think of patient rights to medical care...
• consumer model - authorizing consent. (patients know what have to be doing and authorize)
• contractual model - specific outcomes rather than open-ended. (check my pressure)
•partnership model - mutual trust, shared responsabilities, equal power. (both have rights.
These one is more open)
• but patient-doctor relationship is unequal in terms of power. (the doctor does know more
than the patient. The doctor has more power, but this model is still better than the other
• Relationship needn't be reciprocal - patient may be angry or mistrustful of doctor.
In summary, a patient can be a viwed as:
• a set of symptoms (technical attitude)
• an individual case history (technical attitude)
• someone who is in discomfort (compassionte attitude)
• Somenoe who has a right to medical care (transactional attitude) ->interaction between the
person and ...
But, neither separetely nor in combination are these views a pictures of a full person.
Moreover Downie and Macnaghton argue that the doctor-patient relationship cannot become a
As they write:
"the doctor must deal with the patients, or in others words, with persons in certain restricted of
their total existence" (p.86)
There is a tendency for doctors, and other health practioner, to medicate a situation by viewing
a "medical good" as the "total good".
• a practitioner holds a humane attitude by recognizing a patient's total good rests in a larger
context - a larger contex know patient only.
Downie and Macnaughton suggest that a practitioner should show an awareness that a patient
has a wider life.
• This can be done with a simple comment or two about matters unconnected with the
A short conversation can show an awareness that the patient has:
• a history - a before and after medical relationship, and
• Geograpgy - areas of life that have nothing to do with the meical relationship
Lets draw things together...
Downie and Macnaughton describe the doctor-patient relationship in terms two parts.
• Technical attitude - recognize the form requirements, rights, responsabilities involved in the
doctor-patient relationship. •
Involve "technical judgements" based on generalized knowledge individualized thorugh
clinical skills and negotiated consent.
• Humane attitude- recognize that a patient's "medical good" is only part of their "total good".
• Involves humane judgements based on practioner's humanity
Downie and Macnaughton discuss two threats(ameaças) to humane attitude...
1 "medical Affectation" (section3.5)
• The placing of medicine on a pedestal, over extending the range of its role in society.
• As Downie and Macnaughton write, "medicine is not a panacea" (p. 93)
2 Consumerism (Section 3.6)
• Consumerism is one way of thinking of patient self-determination
• but, Downie and Macnaughton argue that a patient-doctor relationship should not be a
• a suppl