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Commentary on Glannon and Ross, and McKay
  1. S A M McLean
  1. Correspondence to:
 Professor S A M McLean, Institute of Law and Ethics in Medicine, Glasgow University, Glasgow G12 8QQ, Scotland;
 S.A.M.McLean{at}law.gla.ac.uk

Abstract

The patient-doctor relationship has recently come under intense scrutiny, resulting in a re-evaluation of the basis of that relationship. The papers by Glannon and Ross, and McKay seek to identify the sources of authority in the patient-doctor relationship by evaluating it in terms of the concept of altruism. In this paper I argue that the analysis of Glannon and Ross, and of McKay is unnecessary and that the analysis offered by the latter is also flawed. I do acknowledge, however, that Glannon and Ross's description of doctors' responsibilities and patients' roles has much to commend it.

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In their paper, Are doctors altruistic?, Glannon and Ross advance the unusual, but refreshing, view that it is patients rather than doctors who are altruistic.1 This they explain by an analysis both of the nature of the doctor-patient relationship and by the definition of altruism as an act which is both optional and supererogatory. Thus, while accepting that doctors act to high moral standards and ideals, in their view this is an inevitable concommitant of their fiduciary relationship with their patients, and is thus separate from, although occasionally overlapping with, altruism. However, in supporting their conclusion that it is patients rather than doctors who are altruistic, they place themselves in what I believe is an unnecessary quandary. Their description of the doctor-patient relationship includes the notion that patients too have obligations—to tell doctors the truth, to undertake the recommended therapy, and so on. Thus, they claim, when patients go beyond these obligations by, for example, allowing medical students to examine them as apart of the educational process, they are acting beyond their own obligations and are acting altruistically.

This analysis is, I believe, flawed as well as unnecessary. To be sure, in the ideal world patients will act in the way Glannon and Ross suggest, but they do so out of self interest—not because they have an obligation so to do. Or at least, not an obligation which flows from the nature of the doctor-patient relationship. If there is such an obligation, then it is one owed to themselves. By locating the patient's relationship with the doctor on a mutually fiduciary basis, Glannon and Ross run the risk (picked up effectively in McKay's paper2) of minimising the very thing they are trying to achieve, namely a relocation of virtue in the doctor-patient relationship. In fact, it is possible to reach the same conclusion as Glannon and Ross without viewing that relationship from the perspective of the mutually fiduciary model which they advance. Whether or not patients have obligations within the relationship, it remains the case that there are certain things that they do, or may do, which do not arise out of obligation, but rather out of a true act of altruism; things such as organ donation or willing submission to medical research.

McKay, on the other hand, wishes to convince that the mere fact of choosing medicine as a profession is sufficiently supererogatory to describe what doctors do as being altruistic. He uses examples such as the fact that doctors must be prepared to devote all of their spare time if necessary to an ill patient as demonstrating the altruistic nature of what doctors do. However, although he clearly makes the case for beneficence as a descriptor of good medical practice (ironically, perhaps, the term preferred by Glannon and Ross), he does not convince this reader at least that the practice of medicine as such is altruistic. What he does achieve is evidence that in some circumstances medical practitioners go beyond the terms of their contractual or fiduciary relationship with their patients, or at least that some doctors do this some of the time.

Both papers seem to stem from a recognition that respect for medicine is currently at a low point. The revelations of the behaviour of some doctors, in high-profile media commentary, have perhaps contributed to the search for a redefinition of the morality of medicine and its practitioners. Whilst a laudable goal, it may be unnecessary. What is likely to be a temporary, or at least not immutable, response to transient incidents neither demands nor vindicates a radical reinterpretation of medicine, particularly not one which stretches the language. McKay notes that supererogation is defined as doing more than one's duty, but it is Glannon and Ross who actually explain just what that duty is; it is to act beneficently. If this is accepted, then the edifice built by McKay becomes unnecessary, albeit well constructed.

Indeed, in my view at least, it is the constraints of beneficence which are more likely to restrain the medical maverick, or maintain best practice, than any attempt to sanctify the choice to pursue a worthwhile and highly esteemed (generally) profession. It is the self respect of medical practitioners, and their concommitant respect for their patients, which will facilitate the restoration of doctors (and other health care workers) to the esteem in which they have traditionally been held. Moreover, the recognition by Glannon and Ross that altruism can indeed be a part of the patient's relationship with medicine paves the way for a radical reassessment of the doctor-patient relationship. Too often, medicine denies the opportunity for altruism—the reports of the Bristol Royal Infirmary inquiry, The Alder Hey inquiry, and the Independent Review Group on the Retention of Organs in Scotland have all pointed to the denial to parents of the opportunity to act altruistically, which has in part caused the suffering of which we are all too well aware.3 For this reason, if no other, Glannon and Ross's description of the responsibilities of doctors and the role of patients has much to commend it in current, and future, times.

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