Ethical aspects considered in doctor-patient relations: experiences of anesthesiologists

Abstracts

JUSTIFICATIVA E OBJETIVOS: Os princípios da ética orientam a forma de ser e agir do profissional, particularmente no estabelecimento da relação médico-paciente, e por isso, demandam constante reflexão. Nesse sentido, o propósito deste estudo é analisar vivências éticas de anestesiologistas em sua interação com o paciente sob seus cuidados. MÉTODO: Estudo exploratório, que envolveu 16 médicos anestesiologistas com exercício profissional em um hospital universitário de João Pessoa, Paraíba. Os dados foram coletados por meio de entrevista semiestruturada e analisados qualitativamente com o uso da técnica de análise de conteúdo. RESULTADOS: Os achados do estudo evidenciam que as vivências éticas dos participantes do estudo na relação médico-paciente foram classificadas em cinco categorias temáticas: respeito ao paciente, tratamento humanizado, tratamento igualitário, sigilo profissional e respeito à autonomia do paciente. CONCLUSÕES: Conclui-se que os entrevistados reconhecem a ética e os valores humanísticos que devem pautar a relação com seus pacientes.

ANESTESIOLOGISTA; Bioética; ÉTICA MÉDICA; Prática Profissional; Relações Médico-Paciente

JUSTIFICATIVA Y OBJETIVOS: Los principios de la ética guían la forma de ser y de actuar del profesional, particularmente en lo que se refiere al establecimiento de la relación médico-paciente y por eso, exigen una constante reflexión. En ese sentido, el propósito de este estudio, es analizar las vivencias éticas de los anestesiólogos en su interacción con el paciente que está bajo sus cuidados. MÉTODO: Estudio exploratorio, que tuvo la participación de 16 médicos anestesiólogos en el ejercicio de la profesión en un hospital universitario de João Pessoa, Paraíba. Los datos se recopilaron por medio de una entrevista semi-estructurada y fueron analizados cualitativamente con el uso de la técnica de análisis de contenido. RESULTADOS: Los hallazgos del estudio muestran que las vivencias éticas de los participantes en el estudio, en cuanto a la relación médico-paciente, se clasificaron en cinco categorías temáticas: respeto al paciente, tratamiento humanizado, tratamiento igualitario, secreto profesional y respeto a la autonomía del paciente. CONCLUSIONES: Concluimos que los entrevistados reconocen la ética y los valores humanísticos que deben guiar la relación con sus pacientes.

ANESTESIÓLOGO; Bioética; ÉTICA MÉDICA; Práctica Profesional; Relacións Médico-Paciente; ÉDICO-PACIENTE

SCIENTIFIC ARTICLE

Ethical aspects considered in doctor-patient relations: experiences of anesthesiologists

Maria de Fátima Oliveira dos Santos^{I,II,III,IV,V}; Maria das Graças Melo Fernandes^VI,VII; Eduardo Sérgio Soares Sousa^VIII; Harison José de Oliveira^IX,X; Gualter Lisboa Ramalho^XI,XII

^IBioethics and Medical Ethics Service, Faculty of Medicine, Universidade do Porto, Porto, Portugal

^IIPost-Graduation Programm in Forensic Science, Faculdade de Odontologia de Pernambuco, Recife, PE, Brazil

^IIIPost-Graduation Programm in Publich Health, Universidade Federal da Paraíba, João Pessoa, PB, Brazil

^IVFaculdade de Medicina Nova Esperança, João Pessoa, PB, Brazil

^VRegional Medical Board of Paraíba, João Pessoa, PB, Brazil

^VIDepartment of Clinical Nursing, Universidade Federal da Paraíba, João Pessoa, PB, Brazil

^VIIPost-Graduation Program in Nursing, Universidade Federal da Paraíba, João Pessoa, PB, Brazil

^VIIIDepartment of Sociology, Universidade Federal da Paraíba, João Pessoa, PB, Brazil

^IXHospital de Emergência e Trauma Senador Humberto Lucena, João Pessoa, PB, Brazil

^XHospital Santa Isabel, João Pessoa, PB, Brazil

^XIPost-Graduation Program in Anesthesiology, Universidade Estadual Paulista, São Paulo, SP, Brazil

^XIICentro de Ensino e Treinamento em Anestesiologia, Hospital do Trauma, João Pessoa, PB, Brazil

Corresponding author

ABSTRACT

BACKGROUND AND OBJECTIVE: Ethical principles guide professional conduct, particularly in establishing the doctor-patient relationship and, therefore, require constant reflection. The purpose of this study is to analyze ethical experiences of anesthesiologists in their interaction with the patient under their care.

METHOD: This was an exploratory study involving 16 active anesthesiologists at a university hospital in João Pessoa, Paraíba. We collected data through semi-structured interviews and analyzed qualitatively using the content analysis technique.

RESULTS: The study findings show that the classification of ethical experiences of the study participants regarding the doctor-patient relationship were classified into five categories: respect for the patient, humane treatment, equal treatment, professional secrecy, and respect for patient autonomy.

CONCLUSION: We conclude that respondents recognize the ethical and humanistic values that should guide the relationship with their patients.

Keywords: Ethics, Professional; Anesthesiology; Bioethics; Physician-Patient Relations

Introduction

Social knowledge in medicine is constantly influenced by the impersonality in medical care in private and public health facilities, means of mass communication, and the rapid and continuous diffusion of knowledge through the Internet.¹

Faced with this scenario, the anesthesiologist should base his conduct on ethical attitudes required by the profession. Anesthesiologists should also have a broad scientific knowledge, skill, punctuality, and good sense, in addition to being disciplined, particularly regarding respect for the patient. Respect for patient includes the duty to comply with the requirements and standards set for the anesthetic process, such as continuous monitoring of patient's vital functions. The anesthesiologist should not leave the operating room because, being responsible for the anesthetic technique, he should also be the one to control it with the use of monitors and instruments, enabling constant clinical evaluation of the patient.²

Anesthesiologists' ethical experiences refer especially to conflicts related to scientific and technological development and concerning the lack of equity in health care regardless of individuals economic class, among other factors.³ It is worth noting that ethics in professional relationships is determined by responsibility and commitment to work and others, as well as by respect and affection for people.⁴

The incorporation of these values influences the behavior of health professionals, spreading these values in accordance with the ethical debate, which becomes even more complex and habitual due to the nature of their work and the relationships established with patients.⁵ It is worth noting that the ethical norm that governs a person individually is not always the same as that one which a professional or their social group recommends.⁶

Thus, new issues and problems emerge, without a deeper reflection of the professional categories and without setting parameters for ethical action. Any prophylactic measure in the field of ethics involves raising awareness in an attempt to change attitudes, which is often time consuming and painful and resistances are not small. In this context, it is important that the ethical professional be aware of his actions and responsibility for the possible consequences.⁵

Ethics is not in absolute harmony with the laws that determine and/or describe exact behaviors because, in spite of its interface, it does not lay out procedures to be followed such as those contained in the so-called professional ethic codes, but just sets guiding principles of human conduct.⁷

The obligation taken on by anesthesiologists is contractual in nature and seen as the means, not the results, since the doctor undertakes the obligation to use all available resources compatible with the current "state of the art" in anesthesiology available at that time and place, and to act with expertise during the anesthetic approach. Nevertheless, few scientific studies have comprehensively addressed this issue in order to unveil the ethical experiences of anesthesiologists in the context of their professional practice. Therefore, the objective of this study is to analyze the ethical experiences of these professionals with patients during anesthesia.⁸

Method

This is a descriptive and qualitative study of the ethical experiences of anesthesiologists, conducted at a university hospital in João Pessoa, Paraíba. The sample consisted of 16 professionals who agreed to participate in the study by signing the informed consent. The study was approved by the institutional Research Ethics Committee and registered under protocol 396/10. We guaranteed participants, among other ethical topics, confidentiality and anonymity of the information as required by the then in statute of National Health Council's Resolution 196/96.⁹

From July to August 2010 we collected and recorded data through individual semi-structured interviews to answer the question: What doctor-patient relationship ethical issues do you consider in your professional practice? We scheduled time and place according to the availability of respondents. We conducted interviews around a central question to facilitate analysis, recorded them on a portable tape recorder, and transcribed them afterwards.

We analyzed the interview data using content analysis, which had the theme as the unit of meaning. Thematic content analysis means the cut-off of all interviews through a grid of categories projected on the contents that took into account the frequency of themes extracted from the speech.¹⁰

After transcribing the interviews, the next step was decomposing them into smaller units or constituent elements, also called units of analysis, which were grouped into common or proximate characteristics that generate thematic categories and obeyed the rules of exclusivity, homogeneity, and relevance.

After defining the body of categories and extracting segments and frequency of units of analysis relevant to each category, we performed data analysis using a qualitative approach, which was anchored in the specific literature. Aiming at data organization, respondents were identified by the letter "E", followed by the numeral corresponding to the order of the interviews, ranging from 1 to 16.

Results

Regarding the sample profile, data revealed that 75% of anesthesiologists surveyed were male and 25% female, 44% were active for 15 to 20 years. There was good response receptivity among participants. Everyone was interested and motivated to respond to the question. In this study, we used the method of content analysis with semi-structured interview. During the interview, the question was asked and the response recorded and transcript.

The units of analysis (themes) present in participants' speeches allowed the identification of categories shown in Table 1.

Discussion

The study findings showed that participants' ethical experiences were classified into five categories: respect for the patient, humane treatment, equal treatment, professional secrecy, and respect for patient autonomy, as shown in Table 1.

The following statements endorsed the category Respect for the patient:

[...] I think the most important ethical aspect is respecting the human being. (E1).

[...] I try to treat the patient as ethically as possible; respecting his privacy [...] When undressing the patient, I try to explain, ask for permission, and explain the procedure [...] (E11).

[...] The time of anesthesia is, above all, a time of respect to someone in a moment of fragility (E3).

It is important to note that health professionals should respect the human being as a whole, considering his mental, psychological, emotional, social, and spiritual conditions. In this interactive process, respect for the patient should be shown in their words, way of talking, and attitudes. For such, it is necessary that anesthesiologists interact with the patient, without censorship or unkindness, showing a human attitude, which requires mutual respect between both parties.¹¹ Technical skills and reflective attitudes should be incorporated in the doctor-patient relationship, in order to consider every encounter between professional and patient as unique.¹² In this context, the anesthesiologist should seek a respectful relationship with his patient. For such, among other things, he must identify himself as an anesthesia professional, ask the patient's name, explain the procedure in detail, and try to respect the patient's privacy.

Therefore, failure to maintain the physical distance between patient and physician may mean an invasion of privacy and disregard towards his space or territory.¹³ Similarly, nudity is seen as an embarrassing situation for the patient. Embarrassment is a matter of education and upbringing built according to different sociocultural contexts. Thus, the physician must be aware of the personal value permeating the embarrassment expression of each individual, as this feeling varies according to age, sex, and social status.¹⁴

Regarding the Humane Treatment category, we can infer that anesthesiologists recognize the importance of humane treatment, which is an expression difficult to conceptualize, given its subjective, complex, and multidimensional nature, as shown in the following statements:

[...] Sometimes, the patient waits up to four months to undergo surgery, especially when it is suspended by a previous reason: the doctor is absent! Power failure! In these circumstances, the patient arrives emotionally fragile [...] Therefore, it is necessary that the anesthesiologist talk to the patient during the pre-anesthetic visit to answer his questions, easing his suffering and worry (E8).

[...] Treating people humanely, not as an object (E10).

[...] It is improving the lives of patients, trying to understand their pain, in addition to offer them good solutions for their treatment. It is standing by their side (E16).

Humanization is reflected in the attitude of professionals regarding the quality of care and requires a close doctor-patient relationship in which the subjectivity of the people involved in this interaction should be considered. In analyzing this issue, it is also noteworthy that humanization prioritizes, among other things, equal access for all patients. Thus, it presents a challenge for society and physicians,^15-17 as it demands physicians have a closer communication, elicit empathy, harmonize the technical and scientific knowledge with the patient's knowledge, and build links between the emotional actions and reason. In this sense, the humane treatment is represented by the commitment to each other and includes the likely ethical dilemmas present in this relationship.^18,19

In this perspective, humanization encompasses evaluative dimensions between health professionals, patients, and relatives, with distribution of responsibilities between the actors involved. By providing a humane care for the patient who is afraid, the physician should engage in building solidarity exchanges and take into account the views and needs of those being assisted, as each human being has specific features, such as character, personality, feelings, beliefs, and desires, which should be respected and considered.

Thus, health care humanization involves subjective and political changes in the way of seeing patients, as denying the individual subjective, cultural, and personal needs, leads the physician to provide an impersonal care aimed at the disease and not the suffering person.^20,21 Nevertheless, scientific and technical progress in health care has relegated human dignity to a second plane. In this scenario, disease has sometimes become the object of scientific knowledge, detached from the person who has it. It is worth noting that ethics, by prioritizing values, duties, rights, and how subjects present themselves in relationships, constitutes a crucial dimension for health care humanization.^22,23

The statements included in the Equal Treatment category reveal physicians' concern about implementing a treatment based on equity, as the following speeches highlight:

[...] There should be no difference in the relationship with any patient [...] everyone must be treated equally (E2).

[...] Treating everyone equally according to his/her sexual choice, color, and religion, and so on [...] I think that treating the patient as a real human being is fundamental, (E15).

[...] The patient should be treated equally regardless of race, religion, color and sexuality, [...] without distinction between a and b, whether the patient is in the public or private service or covenant [...] Treat all equally and offer them the same care (E9).

[...] In terms of ethics, you should do for the patient what you do for anyone [...] All patients should receive the same level of attention by the professional who sees them (E4).

Equal treatment is the essential attribute of a physician's ethical attitude. Thus, it involves principles and not commandments. In this context, one must be fair in his or her actions and ensure the welfare of all. Similarly, equal treatment implies valuing the person in need of care, particularly by the anesthesiologist.¹⁸

Since the teachings of Aristotle, good medical care means equal treatment to all patients. For the philosopher, the virtuous person is one who knows what he does and deliberately chooses to follow the right conduct. Accordingly, the physician should promote equal service to all without favoring or discriminating against anyone for personal reasons or otherwise; their actions must preserve the patient's rights.²⁴

In the category of Professional Secrecy, anesthesiologists' speeches reveal the following:

[...] Listening to the patient and secrecy; it is the doctor's obligation [...] The observation of medical confidentiality is a professional duty of the profession (E6).

[...] In relating to the patient, the important thing is preserving the patient's privacy; the disease belongs to the patient. Finally, ethical issues should be considered with all patients (E12).

Professional secrecy is one of the most important ethical aspects of the doctor-patient relationship, as it establishes and ensures the trust that must exist between them. By considering professional secrecy, the doctor keeps to himself the confidences reported by the patient during treatment.^25,26 It is noteworthy that there are situations in which there is need for a breach of confidentiality, such as when the patient's secret endangers his health or that of others. For such, the patient should be informed and the reasons for this attitude must be justified.

The physician is only the depository of a secret that must be kept confidential, with the ultimate goal of protecting patients, their relatives, and society in general. However, although the secret belongs to the patient, professionals have the duty of keeping the information, not by requirement of whom has a secret, but by conditions established as duty for the person who is entrusted to it.^27,28

The confidentiality of medical information is tacitly established as an informal agreement between the health professional and patient. It is based on the assumption that the information discussed during the consultation or interview and afterwards cannot be disclosed without the patient's explicit permission. This commitment is based on the rules of medical ethics, underpinned by the principles of autonomy and morality and by laws established to ensure the patient's right to privacy.^23,30] Therefore, in order to avoid that the physician is considered a person unauthorized to disclose the known information, it is up to the patient to determine what information may or may not be disclosed. Therefore, it refers to obligations and duties of both parties and requires flexibility and respect for each other's limits.³¹

In the Respect for Patient Autonomy category, the interviewees' statements reveal:

[...] One should ask the patient if he wants to undergo that procedure. The patient is the one to authorize [...] Authorization is also part of humanization (E 7).

[...] In my patient care, I cannot attack my moral, ethical, and religious conscience. For example, abortion, I do not apply anesthesia, even with a court decision, because it hurts my ethical and religious conscience (E 12).

[...] We should explain to the patient the type of anesthesia in a language that he understands [...] I make a point of explaining, starting in pre-anesthetic evaluation, I explain step-by-step everything that will happen [...] Always ask if the patient has any doubts [...] if he wants to ask something about anesthesia [...] So, I try to resolve his doubts; this to me is now a routine. [...] The more well informed the patient, the more at ease you become (E 5).

[...] I try to give attention and explanation [...] that's what I try to do in my day to day practice of anesthesia [...] I respect the patient's embarrassment, [...] We talk; I apply a sedative, [...] so that patients are not embarrassed to be exposed before the doctor (E14).

Respect for patient autonomy is an important theme in contemporary ethical debate and produces substantial changes in medical ethics. Regarding this phenomenon, a person can only exist if he/she meets the condition of being aware of him/herself and others. Human maturity is mainly achieved in the ethical stage or in the condition in which the autonomous and free man acts according to values that are appropriate to his way of living.

An autonomous person can make his/her own choices, achieve goals, and always seek the respect of peers without harming others.^32,33 Regarding health care, patient autonomy is considered in the informed consent, which is the agreement to submit to a procedure or treatment suggested by the physician. For an ideal exercise of autonomy, the physician should have a good relationship with his patient and provide complete and understandable information necessary for him or his relatives to decide on the treatment or care.³⁴

The principle of autonomy refers to respecting each person's rights to self-determination, making decisions that affect his/her live, health, physical and mental integrity, and social relations. In this context, the individual should be treated as an autonomous agent.³⁵

This study presents a reflection on ethical experiences of anesthesiologists, particularly the doctor-patient relationship. This reflection was revealed in the statements of respondents through five thematic categories that summarize the study participants' thought on the subject, namely: respect for the patient, humane treatment, equal treatment, professional secrecy, and respect for patient autonomy.

The data reported here allow us to confirm that ethical issues are subjective, essential, and significant. Another key aspect is that the ethical issues experienced by the study participants assume prominent importance in medical practice, in which principles and values are questioned in the profession of those who perform such practice.

Finally, it is worth noting that anesthesiologists' statements, in addition to revealing their perception of the attitude that health professionals must have to best serve the patient, also somehow signal conflicts of contemporary society that must be overcome. For such, the starting point should be to overcome the theoretical-ethical-philosophical discourse, generally empty, and exert a health care practice that produces change in society.

Conflicts of interest

The authors declare no conflicts of interest.

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Publication Dates

• Publication in this collection
  13 Nov 2013
• Date of issue
  Oct 2013

History

• Received
  20 Apr 2012
• Accepted
  30 July 2012