- Beyond Paternalism: The Physician’s Identity in the Relational Web
This commentary examines the fiduciary obligations of physicians in a case study where terminal sedation was provided to Andrew, a dying patient in palliative care, who had earlier expressed his wish to remain “alert” till the end.
Based in Singapore, the study illustrates the complexities of decision-making in a traditional, Asian society where the authoritative position held by the physician makes trust a moral imperative of relationships between physicians, patients and their families. The physician’s fiduciary responsibilities take on challenging perspectives in a medical environment where physicians have power and are expected to have a central role in decision-making — but increasingly, patients want more involvement and control in the treatment of illness.1,2 Adding to the complexity of the situation is the role of the family in an interdependent culture where decision-making is a collective rather than an individual act.3
The narrative of the study describes the ethical concerns that arose because of the conflict between Andrew’s wish to die with comfort and dignity and his desire for some measure of control (which is implicit in his wish to stay alert), and the actual progression of a disease that relentlessly robbed him of dignity and self-control. The character of the physician acquires great importance in the end-of-life context of the narrative … there is a fine line that the physician must walk between the respect which is due to a vulnerable and incompetent patient facing imminent death, and the authority that is invested in the physician’s own person, as the central figure who will guide the course of treatment. [End Page 137]
The Cultural Nuances of the Case
In cultures with strong traditions of familial obligation, suffering is not a solitary preoccupation but a collective affair. The shared nature of illness makes decision-making a process in which the entire family engages. Concurrently, there is a shift in the role of the physician who must be more than an impersonal healthcare provider. Edmund C. Hui writes of the “relational” identity of individuals in Confucian tradition, an aspect that is common to many interdependent cultures. The physician, too, has a relational self in the “network of relations”.4 In an environment where duty and conformity often take precedence over the expression of individuality, respect for authority is a defining cultural characteristic. The physician, by virtue of his or her knowledge and skills, is imbued with authority and may even be regarded as a wise and trusted “elder”.5 Simultaneously, and somewhat paradoxically, physician-patient relationships are becoming more complex even in traditional societies, as medical environments change and patients want more active participation in their treatment.
The Issue of Trust
In Andrew’s narrative, the family was deeply engaged in the course of his illness and treatment that culminated in the final palliative measure of terminal sedation. When palliative care became futile and the only way of relieving Andrew’s distress was through the option of terminal sedation, conflict arose between family members. Different considerations influenced their opinions: a refusal to “give up” on the dying person; strong religious beliefs; a desire to end a loved one’s suffering … all these factors competed and created dissension within the family. In a striking illustration of the ultimate authority which characterises the physician’s role in traditional societies, the final decision still rested with Andrew’s physicians. Despite the interfamilial conflict, the family deferred to the physician’s knowledge and guidance. As the focus shifted from concerns of autonomy, trust became the determining value in the communication that took place between the family and the palliative care team.
In this complicated scenario, the fiduciary obligations of physicians are magnified. As central figures in the decision-making process — in whose knowledge and care the patient and the family have reposed their trust — they are required to strike a fine balance between coercion and guidance. The relationship between the patient, the family and the physician is not merely a contractual one, “where all moral truth in medicine resides in the subjectivity of the autonomous individual.”6 Rather, the relationship transcends the issues...