Therapeutic Relationship Models by shimeiyan3

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									        Lecture 4

Professional Responsibility
      To the Client
(Therapeutic Relationship)
    Therapeutic Relationship
    Conflict in any relationship
   What to expect when you enter
    into a relationship?
   Therapeutic relationship as an
    instance of professional-client
   Who decides what?
    Medical decision involves
         value choices

 Case 1: blood transfusion for Jehovah
  Witness patients
 Case 2: Brian Clark, Whose Life is It,
  Anyway (1978)
 Case 3: DNR and anticipated QOL
 5 Models of Therapeutic
 Paternal model
 Consumer model
 Model of Partnership
 Model of Friendship
 Fiduciary model
   Just like parents treat their small
    children, the professional treat the
    client in such a way that s/he would
    not allow the client free choice, for
    the sake of benefiting the client.

   medical paternalism – For the sake of
    restoring the health or saving the life
    of the patient, the healthcare
    professional would make all the
    therapeutic decisions for the patients
     2 important instances
 Treatment; e.g., surgery or not? overriding
  refusals of treatment, overriding requests
  for treatment
 Information; nondisclosure or partial
  disclosure of information
  e.g., disclosure of bad news, withholding
  truth to a terminally ill patients
Reasons to support medical
1. superior knowledge of the professional
2. client is incapable of giving sufficiently
  voluntary and informed consent
3. agreement in retrospect
disclosing of information is
 like transfusion of blood
1. Doctor knows best only in scientific
  knowledge; a patient is a person, not a bodily
  object in need of repair; persons have values;
  medical judgement is to be made in a
  nonmedical context, in which health is only
  ONE of the treasured values.
 “Is this kind of life worth living?”
 “Is it better off dead than to be in this
    “Will life become too degrading to go on
QOL is not a medical
judgement, but a value
judgment on the basis of
a statement of empirical
2. Since doctors deal with persons, not bodies,
  they have the responsibility to be skillful
  communicators as well as skillful healers.
  (Cf. TCM !!!)
      Illustration for the 5 models
   Cosmetic surgery – not a matter of life or
    death, not even a matter of physical health,
    but a matter of psychological well-being,
    self-esteem, aesthetic need, and/or career
What stuff should I put inside?
                  Silicone gel
   Merit: looks and feels more
   Disadvantage: long term safety
    not assured
       Silicone injected to skin
fill wrinkles, add volume to lips & cheeks
                Saline gel
 Merit: safe
 Disadvantage: looks and feels less
    Breast Implant & Paternal Model
   Doctors have the responsibility to safeguard patients’
   When the long-term effect of a procedure is not assured
    of safety, doctors should not perform the procedure for
   “You want silicone gel breast implant?       No way !!!”
   “Doctors know best. You cannot choose. I’ll give you
    only saline gel implant.”
   US Government restriction of silicone-gel breast
    implants, 1992 – present (Reading 2, pp.1918b-1919a)

 private practice in free market economy
 consumer sovereignty
 patients’ rights as consumers’ rights
 self-determination and a person’s values
 Brian Clark, Whose Life is it Anyway? 1978
Difficulties to be a
prudent and intelligent
consumer in healthcare
1. medical decision involves highly technical
  and complex knowledge
2. consumer intelligence presupposes
  emotional calmness
    Breast Implant & Consumer Model
   Sovereignty of consumer choice
   Each consumer should weigh the benefits and risks of
    each treatment and decide for herself
   A woman should have the freedom to take a little risk
    and get a more satisfactory breast augmentation. “It’s
    my body!”
   “You want silicone gel? Yes, no problem.”
   “You want saline gel? Yes, I’ll do it for you.”
    Partnership in what sense?
   Patient participation, not in decision making,
    but in self-care or discipline in lifestyle

   equal partners?
Typical model of other joint
 partners in business, dancing, bridge, tennis
 Such partnership requires:
    1.   equality (approximate, not strict),
    2.   cooperation,
    3.   shared rights and responsibilities,
    4.   shared decision-making,
    5.   shared benefits and risks
       However, therapeutic
     relationship is essentially
1. medical knowledge; emotional stability;
2. risk is largely unilateral
Breast Implant & Partnership Model

   No true partnership can be obtained
   mutual understanding, mutual trust,
    genuine care
   decision-making: sometimes mutual;
    sometimes the doctor is entrusted to do it
    unilaterally, in light of the values of the
   admit that therapeutic relationship is
    unequal, doctor has to do most of the
    decisions, trust the doctor like trust a friend;
   family doctor (cf. euthanasia in Holland)
   shop around

1. not much choice in public hospitals and
2. referral to specialist; rush to A and E (ER)
3. hospital – face many strangers

   Hence, limited applicability – primary care
    in private practice
Breast Implant & Friendship Model
    This model cannot apply because there is no
     history of friendship between the patient
     and the surgeon.
Two important considerations
  for a satisfactory model
 consideration 1: unequal relationship,
  leading role of professionals
 consideration 2: a patient to retain a certain
  degree of self-determination because of
  one’s own values.
 model in law
 beneficiary (受惠者 )– entrust some property
  or delegate some power to the fiduciary
 Fiduciary (受託人) – to promote the interests
  of the beneficiary
 stock-holders and company managers
 defendants and lawyers
 investors and investment company
 patients are beneficiary, healthcare
  professionals are the fiduciary
 entrust one’s health to the professionals for
  them to promote one’s health interest
    Yet, we should not trust
    strangers open-endedly

 No blank check
 retain the right of some key decisions
 patients do not decide, but consent; passive,
  yet involved
Informed Consent !!
    Breast Implant & Fiduciary Model
   Informed consent as a corner stone
   The doctor provides the recommendation on medical
    ground (active), and seeks the patient’s authorization
   “1st choice: saline; 2nd choice: silicone”
   “You refuse the 1st choice? Okay, I’ll give you 2nd choice;
    but you need to consent to accept the possible side
   “You refuse the 1st choice? Too bad, I can’t recommend
    another treatment. Try another doctor, if you want.”
  To be worthy of patients’
1. honesty
2. candor
3. competence
4. diligence
5. loyalty
6. fairness
7. discretion

   「現在欺騙老師, 將來極可能會
    欺騙病人. 這是浸會大學及香港
    的悲哀 !! 」

   Moral virtues are necessary for good
    medical practice!
The practice of traditional Chinese medicine in
  modern society – which model of therapeutic
  relationship should we adopt?

Which model of therapeutic
relationship do these tracts
            Mid-term Test
 March 15 (Wednesday)
 Short questions and one-page answers
 Choices: 5 out of 6

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