Page 51 - Contribution To Phenomenology

44 RICHARD M ZANER

treated at all. In our times—through informed consent, patient rights, and
the like—this difference has received moral and legal support. Still, the
asymmetry of the relationship does not automatically imply that it is the
physician who should make decisions. It has thus become imperative for
physicians to develop an understanding of the relation with patients that
is quite different from that expressed in the more traditional "medical
model" ([4]; [16]; [20]; [23]; [32]). In order to develop coherent, accep-
table, and practical therapeutic plans, and to enable sound decisions,
physicians must learn the patient's (and family's, at times even the
significant others') experiences, interpretations, meanings, and values.
(ii) At the very least, this suggests that the patient's place is not, and
in many ways has never been, simple passivity—despite the typical usage
of "patient." The ability to alter a patient's condition and life thus does
not thereby signify having power-over—and that is morally significant. In
clinical encounters, power-to has most often been understood as a sort of
benign power-for (parentalism) or at times power-over or on-behalf-of
(paternalism). Increasingly, however, the physician has had to understand
the power-to-alter as power-with: decision-making requires the active
participation of the patient (often, the family and others in the patient's
circle of intimates)—indeed, decisions are the responsibility of patients or
their legal surrogates (within certain limits).^ This, I think, is surely one
reason underlying the idea that medicine is an inherently moral enter-
prise: to act on behalf of the patient, or, if nothing else to do no harm
(i.e. "beneficence"), requires acting with the patient (which suggests that
the traditional sense of beneficence needs to be rethought). The
physician's place in the relationship is a form of caring and is strictly
correlated with patient trusts
(iii) Another aspect of this was strikingly evident already in ancient
medicine, especially in the Hippocratic Oath ([5], pp. 6-10; [43], pp. 202-
223). Reflection on this covenant, along with the recognition of the
asymmetry in the ability to bring about changes in the patient, makes it
evident that the relationship itself makes it possible (even seductively

^ It has become more common to acknowledge that the physician must
recognize that the patient (family, legal surrogate) is "the true source of authority,"
not the physician (who acts solefy as "advisor" or "consultant" to the patient) ([27],
p. 199).
^ Even if, so far as doctor and patient are strangers, the best that may be
hoped for are situations where only "temporary trust" is possible ([18], p. 52).