The doctor-patient relationship under the influence of the bioethical reference point of autonomy

Objective: To analyze the influence of the bioethical reference point on the doctor-patient relationship, the effects of the Internet on this autonomy and the importance of the relationship vis-à-vis technological advance. Method: A study with a descriptive and exploratory technique, utilizing a quantitative and qualitative approach. Findings: Ten per cent consider the appearance of the reference point of autonomy to be the most important factor in the changes in the relationship; 96% consider the introduction of autonomy important or very important, making the relationship more complex (84%); and 77% consider that it has been a great advance for the patient. Fifty-six per cent affirmed that the patient takes information obtained on the Internet to the doctor’s office, 85% that this attitude increases the patient’s autonomy, and 32.2% that it interferes with the doctor’s autonomy. Conclusion: The bioethical reference point of autonomy was a great advance for the patient and has made the relationship more complex; the Internet increases the patient’s autonomy and may improve the relationship and increase his or her participation in decision making.

The physician-patient relationship, a special process of human interaction, forms the basis of clinical practice in its technical, humanistic, ethical and aesthetic dimensions. Hossne 1 deems that this process is so important that no physician's action can be referred to as "medical act" if there is no appropriate relationship between physician and their patients.
In his study "La relación médico-enfermo", Pedro Laín Entralgo 2 highlights the delicate sensitivity of this relationship in view of the changes throughout human history. The authors mentions that the continuous progress of diagnostic and therapeutic resources has a large and logical impact on progressive changes of this relationship over time. He also emphasizes that, on the other hand -perhaps the most important -, changes in the coexistence among men have changed the own fundamentals of the physician-patient relationship.
Laín Entralgo 2 considers that four periods were paradigmatic in the history of this relationship: Ancient Greece, early Christianity, the Middle Ages and the bourgeois society of the 19 th century. Whereas Lázaro and Gracia 3 classify it in three types, according to their characteristics throughout history: monarchical (relationship asymmetry), oligarchical (healthcare team) and democratic (symmetrical relationship).
According to Hossne 4 , at least six scientific revolutions occurred in the 20 th century, all with strong impact on medical practice: atomic, biological, spatial, information technology, nanotechnology and the most recent one, referred to as "pan-epistemological". In this scenario, two concepts -the bioethical principle of autonomy 5 and information technology (therefore, communication itself) -has, in recent decades, indisputable influences on medical practice in general and in the physician-patient relationship, in particular.
The concept of autonomy is associated with the progressive consolidation of human rights, especially with the fundamental contribution of the English, American and French revolutions, between the mid-17 th century and late 18 th century. From these movements, the principal of autonomy of human beings arises and is established, understood as an entitlement to self-determination, mainly based on Kant's philosophy, who formalized the principle according to which, man exists as an end in himself, and not as a means 1 . It is worth noting that the principle of autonomy, having emerged in the 18 th century, was only incorporated to the physician-patient relationship two centuries later, more precisely from the 1960s.
This study aimed to analyse the influence of the bioethical principal of autonomy in the physician-patient relationship nowadays, as well as the influence of the Internet on the autonomy of the physician and patient and the importance of this relationship in view of technological advances.

Method
The study uses the descriptive and exploratory technique. The methodology adopted was the quantitative and qualitative approach 6 . The technique used in the qualitative approach was the "categorization of answers" and the partial use of the discourse of the collective subject (DCS) 7 .
Members and former members of the Regional Council of Medicine of the State of São Paulo (Conselho Regional de Medicina de São Paulo -Cremesp) took part in the study, who served in three administration periods of the entity between 1998 and 2013. The total number of members during these three administration periods were 73 physicians. The sample choice was mainly due to the fact that the council members are active professionals -all of whom with wide experience in reflections and discussions on topics regarding professional and bioethical ethics -, as well as their performance as judges of the medical profession and continuous contact with complaints and claims filed by patients and families.
The instrument chosen for data collection was a semi-structured and self-applied questionnaire with 17 questions (Exhibit). The scale survey technique devised by Likert was used. Three questions with statements (Likert's items) were used, increasing the flexibility of the questionnaire 8 .

Results
Of the 73 questionnaires sent, 62 (84.9%) were duly completed upon return. Of the council members and former members, 51 were males (82.3%) and 10 were females (17.7%). The mean age was 59.6 years, the minimum age was 30 years and the maximum age was 82 years. In relation to graduation time, the minimum time was 5 years, and 46 (74.2%) had graduated for more than 31 years. Of all respondents, 51 (82.2%) have served for more than 10 years as council members and 11 (17.8%) have served in the function for less than five years.

Results of the study questions
In question 1, when asked about what was the factor that most caused changes in the physician-patient relationship in recent decades, 52% of respondents answered the emergence of the intermediary element (health insurance, public health); 11% indicated the great scientific and technological development; 10% considered the introduction to the concept of the patient's autonomy; 8% credited it to the loss of prestige of the profession; 6% to a greater access to the patient's information due to the Internet. The ratio of those who answered other was 13%.
When questioned about other factors that caused such change, the respondents who marked other answered: poor remuneration, work overload; lack of proper training in bioethics in the graduate course, which allows to situate the physician's condition in view of the social transformations caused by the other marked items; poor working conditions; low educational level of society; overwork, financial aspect that leads physicians to work in several places to have a suitable wage and, therefore, having little time to give attention to patients, as well as 'get on with work'. This last expression, used in medical jargon, refers to 'perform every service quickly, even if in large amounts'.
In question 2, on the "effect of the introduction of the concept of autonomy in the physician-patient relationship", 52% of respondents answered that it was very important; 44%, important; 2%, more or less important; 2% not important. When added, the two most frequent answers -important and very important -, we observed that 96% of respondents considered the introduction of the concept of autonomy in the physician-patient relationship as relevant.
In question 3 -which asked the opinion of the professional as to the meaning of the introduction of the concept of autonomy regarding the physician-patient relationship -, 84% of respondents stated that the relationship became more complex; 13% less complex and, for 3% this concept had no importance.
Question 4 asked the professional to what extent the introduction of the concept of autonomy was an advance or regression to the patient. For 77% of respondents, it was a significant advance, and for 16%, an average advance. No respondent indicated a regression. In this question, 7% of answers were disregarded, due to duplicity in the choices.
Whereas question 5, which asked to what extent the introduction of the concept of autonomy was an advance or regression to the physician, presented the following percentages of respondents' answers: 73%, a significant advance; 18%, an average advance; 2%, a small advance. No respondent considered it a regression. Again, in this question, 7% of answers were disregarded, due to duplicity in the choices. Question 6 had the following statement: The principle of autonomy, in a totally capable person, as to a mental point of view, should be absolute. In relation to this statement, the answer totally agree was indicated by 43% of respondents; 42% answered agree, while only 15% marked disagree. No respondent answered totally disagree.
In question 7 -Considering that the verbal consent of the patient, for diagnostic and therapeutic practices, is an ethical requirement and demonstration of respect for the bioethical principal of autonomy of the patient -, of the respondents who claimed to know such concept and to put it into practice, 75% do it frequently; 16%, sometimes; 6%, seldom. Only 3% know the concept, but do not apply it in practice. While adding the two first answersfrequently and sometimes -, we observed that 91% of respondents claimed to know the concept and to put it into practice with a certain frequency. Question 8 had the following statement: Some authors consider that the "informed consent form" (ICF), formally signed by physician and patient, is necessary in the current medical practice. In relation to it, 32% of respondents marked the answer knows the recommendation [of the ICF], but does not put it into practice; 29% seldom put it into practice; 26%, often; 11%, sometimes, while only 2% claimed to not know the recommendation.
As to question 9 -which asked the opinion of the professional on concept of paternalism, in which the medical practice was historically based (since Hippocrates to mid-20 th century) -, the following answers were given: 43% of respondents considered that this concept should be applied sometimes; 13% answered that it shall be applied often, and only 8% believe that it should be routinely applied. It is worth highlighting that 34% of respondents considered the concept of paternalism as outdated, and 2% of them did not answer the question.
Question 10 asked the respondent's opinion regarding the phrase "The biggest cause of claims (ethical and legal) against physicians is the inadequate physician-patient relationship or the inadequate relationship of the physician with the patient's family", in relation to which, 64% of respondents stated that they totally agree; 29% agree moderately; 2% slightly agree, 3% of respondents moderately disagree with the statement, and only 2% totally disagree. None of them answered slightly disagrees.
Question 11 asked: In your daily practice, is it common for a patient to arrive for consultation or return for medical review with information obtained from the Internet? We observed that 56% of respondents answered generally and 42% indicated that the situation sometimes occurs. Only 2% of respondents did not answer the question.
Question 12 -which asked the professional's opinion on the fact that the patient searches for information on the Internet about their own diseases -was subdivided into two parts: the first part asked if this fact increases the patient's autonomy, and the second part, if it interferes in the physician's autonomy, also with the alternative no opinion. As to the first part, 85.5% of respondents answered yes (i.e., the fact that when the patient searches for information on the Internet about their own diseases, it increases their autonomy), whereas 12.9% marked no. On the second part of the questionnaire, 66.1% of respondents stated no (i.e., internet search for information, by the patient, does not interfere in the physician's autonomy), while 32.2% answered yes. Only 1.6% of respondents have no opinion on the topic.
Question 13 asked the professional on their approval or not as to the fact of the patient brings, for consultation or return for medical review, several information from the Internet. In response, 68% of respondents stated that they approve the fact; 24% stated that they do not consider it relevant; 5% do not approve it, and 3% did not answer the question. Those who do not approve this patient's attitude justified their answer as follows: "The anguish increases with information that is not interpreted correctly"; "It is rarely applicable"; "I do not approve it because most of time information is wrongly interpreted". The respondents' answers that approve the patient's attitude could be classified in three categories: 1) right and autonomy of the patient; 2) increase of the patient's involvement; 3) improvement of the physician-patient relationship.
Regarding the first of these categories -right and autonomy of the patient -, the following answers were obtained: "It is a proof of the patient's autonomy"; "I respect the patient's right. I keep my conduct and my rights"; "Search for knowledge". Regarding the second category -increased patient's involvement -, it was reported: "It increases the patient's involvement and responsibility in the treatment"; "It demonstrates the patient's interest in their own care and adherence to therapeutics"; "It is a sign that the patient is assuming their responsibilities". As to the third category, concerning the improvement of the physician-patient relationship, the respondents informed: "It provides the patient with the opportunity for clarifications and reinforces the patient's confidence in the relationship with their physician"; "The dialogue during the consultation flows better and the discussion and conduct to be indicated by the physician becomes more transparent"; "It helps the physician-patient relationship".
In question 14, healthcare professionals were asked how they see the importance of the physician-patient relationship nowadays, in view of the extraordinary advances in the diagnostic and therapeutic areas. For 74% of respondents, the physician-patient relationship has a great relevance nowadays; 26% believe it is reasonably relevant, and no respondent answered that it is slightly or not relevant.
Question 15 listed some factors deemed as relevant for competent medical care, and asked the professional to indicate that which they considered predominant. For 37% of respondents, the most important factor for competent medical care is the proper physician-patient relationship. Then, next to it the scientific development of the professional, the most important factor for 23% of respondents. Good conditions for professional practice is the most important factor for 16% of respondents, while 18% believe that all factors mentioned contribute to improve medical care. In this question, 3% of respondents answered other, and, when asked about what would be this factor considered by them as the most important, we had the following answers: "Good ethical, moral and professional values (character)"; "Development and proper physician-patient relationship". Due to their lack of clarity, 3% of answers were deemed invalid.
Question 16 asked healthcare professionals on the future importance of the face-to-face relationship between physician and patient, in view of technological advances in the diagnostic and therapeutic areas. We observed that, for 90% of respondents, this relationship will always be essential and indispensable, regardless of technological advances, whereas 10% believe that face-to-face relationship will be less and less important, but will always occur. None of them considers that this relationship will be less and less important, until be no longer necessary in the future. practice, going from Hippocrates's proposition according to which the physician should have a feeling of love for the patient, not an erotic kind of lovebut one defined as philia -, and such friendship for the patient being fundamental in the therapeutic relationship. The respondents were asked whether such proposition would be acceptable, in the current techno-science age. We observed that, for 87% of respondents, the concept of philia is current and very important in the physician-patient relationship; 10% considered that it may be important in certain cases and 3% deemed the concept as completely outdated.

Discussion
We had a return of 84.9% of questionnaires sent to members and former members of Cremesp, and such fact makes this study sample very consistent. It is worth highlighting that 84% of respondents are aged between 51 and 70 years, and 96% had been medical graduates for more than 21 years and 82.2% have served as member of Cremesp for more than 10 years.
In Brazil and, possibly in South-American countries, several authors, among which, we are included 1,9,10 , consider that the physician-patient relationship is still fundamentally important in the medical care provided to our patients. To Hossne 1 , the principle of autonomy is one of the most significant bioethical achievements of the last century.
Due to the relevance of the physician-patient relationship in our culture, we could question if, among us, the impact of the bioethical principle of autonomy in this relationship was not greater than in other countries. Possibly yes, but the data obtained by us do not favor this hypothesis. Only 10% of respondents viewed autonomy as the factor that most caused changes in the physician-patient relationship, whereas 52% considered the introduction of the intermediary element (health insurance, public health system), the most important factor.
Another aspect highlighted by three respondents as the one which caused most changes in this relationship was "poor medical working conditions", characterized by work overload and low wages in this professional category.
Our data demonstrate that, for most respondents, the introduction of the concept of autonomy in the physician-patient relationship was important or very important (96%) and made this relationship more complex (84%).
The introduction of the principle of autonomy was viewed as a great advance for the patient by most respondents (77%), while 73% considered it a significant advance for the physician. Hossne 1 also views the introduction of autonomy in the clinical relationship as a great advance, but draws attention to the emergence of new ethical conflicts and the increased complexity of this relationship.
Only 15% of respondents disagreed with the phrase "The bioethical principle of autonomy, in a totally capable person, as to a mental point of view, should be absolute". The vast majority (85%) agreed with this statement, showing the strong impact of the bioethical principle of autonomy in the medical practice, mainly in the view of a specific group of physicians, responsible for assessing the professional practice.
Such view is not supported by the literature. Several authors, among which Engelhardt Jr. 11 and Rothman 12 , consider that the current reflection about the bioethical principle of autonomy includes the right of having the self-determination of people respected in the context of broader issues, such as social reality, distribution of funds for health, compliance with laws in force, fair cause, etc.
In relation to the necessary consent of the patient for diagnostic and therapeutic practices as an ethical requirement and a sign of respect towards the self-determination of people, our results widely confirm literature data 13,14 . Almost all respondents (96.7%) know, agree and put into practice this requirement, duly contemplated not only in bioethical reflections, but also in practically all professional codes of ethics of western medicine.
As to the informed consent form (ICF), formally signed by patient and physician for diagnostic or therapeutic procedures, out of the study protocols, there is no consensus, nor in the literature nor in our results, and there are no legal, deontological or ethical devices in Brazil, as in the case of research with human beings. Only 26% of respondents know the recommendation and often put it into practice, and approximately one third of them knows the recommendation, however they do not put it into practice.
We consider that the signature of the ICF, in itself, is not a guarantee that the patient was duly clarified, in addition, the obligation of presenting this document may lead to the "bureaucratisation" of the physician-patient relationship 10 . The consent should be, above all, a constructive process of consensus in a relationship of trust, and not only a simple contract signed at a certain moment. As to the current practice of paternalism, approximately one third of respondents (34%) deemed this concept as outdated, while 64% believe it is necessary to use it. These data are in accordance with the current literature trend of rediscussing the role of the paternalist action of the physician in the relationship with their patients.
According to Cohen and Marcolino 15 , in the physician-patient relationship, autonomy and paternalism are complementary, and the figure that best represents it, would be a pendulum in which, at one end, we would have a radically autonomous relationship, and, on the other end, we would have a centre with absolute predominance of paternalism. And both -physician and patient -would have to find the ideal point of this pendulum movement.
In this sense, the application of the Greek concept of philia in the physician-patient relationship nowadays, continues to be viewed by most respondents (87%) as very current and essential. To Hossne 1 , philia presupposes equality of the parties, the search for symmetry in the physician-patient relationship and, evidently, a greater respect for the autonomy of the patient and healthcare professional, in the broadest possible sense.
Our understanding is that a proper physician-patient relationship is impossible without the presence of emotional involvement and the relationship of trust and partnership between those who seek the physician to treat their health issues and the professional itself, technically trained and oriented to take care of this person.
Regarding the introduction of the Internet use by the patient in order to search for information about their health, our data evidence the strong influence of this tool in the relationship between patient and physician. More than half of respondents (56%) answered that in general, patients come to the consultation with information from the Internet. For the vast majority (85%) this action increases the patient's autonomy and, for 32% of them, it interferes in the physician's autonomy.
The results of our study, as well as of other published studies 16 , not only show the considerable impact caused by the Internet in the physician-patient relationship, but also in the indisputable reality of the use of this resource in the healthcare area. Thus, the principle of autonomy led to increased ethical conflicts in this relationship, the Internet made it more complex, and it may facilitate or hinder the respect for the autonomy of the patient and physician, which essentially depends on the quality of the relationship established at each meeting.
Regarding the fact of the patient having used the Internet to know more about their disease, most of them (68%) approve such attitude and 5% do not approve. Among those who approve it, the justifications are that this procedure increases the autonomy and engagement of the patient in decision-making processes and improves the physician-patient relationship. However, our data corroborate the findings of Broom 16 , who states that the Internet use can improve the treatment of patients, but that part of the physicians still finds it difficult to deal with this inevitable reality.
In our view, the fact that patients refer to the Internet may lead, on one hand, to an improved dialogue with the physician, to an easier building of "bridges" and greater attention of the professional regarding their patients. Conversely, it may create resistances and difficulties, if the physician feels that they are being "checked" by the patient as to their knowledge and update, which may generate a situation of mutual distrust.
Regarding the importance of the physician-patient relationship nowadays, in the current techno-science age, a significant part of respondents (74%) considers it very important, and for the vast majority (90%) it will always be fundamental and indispensable. It is worth emphasizing that, for 35% of respondents, the most important factor for competent medical care is the suitable physician-patient relationship and that, for 18%, factors such as due scientific development, proper physician-patient relationship and good conditions for professional practice are necessary for competent medical carehowever it is impossible to point out which of them is more important.
Nor can we fail to mention the fact that most respondents (93%) agree with the statement according to which, the greatest cause for ethical and legal claims against physicians is the inadequate relationship between physician and their patients or their family members, confirming the assumption advocated by Hossne 17 . The importance of the physician-patient relationship nowadays is a topic for reflection, now under the bioethical view, reliving paradigms consolidated by Balint 18 and Tähkä 19 . To Godolphin 20 , we are definitively in the age of "shared decisions", where physician and patient should assume the respective responsibilities for their choices.
Obviously, we do not aim to generalize the results obtained here. The findings are valid, in last analysis, for the studied group. Future studies should be conducted with patients and physician assistants, for a more global view of the topics discussed here.

Final considerations
Finally, our data, as well as the literature review, signal to aspects such as the fundamental relevance of the introduction of the bioethical principle of autonomy in the physician-patient relationship, the difficulties of its introduction in clinical practice, the remarkable philosophical importance that it acquired in recent years, without forgetting the considerable and welcome ethical conflicts arising thereof -a result of philosophical and technological advances of our time.
They also point to the urgent need of rescuing, as fundamental factors of the physician-patient relationship, the emotional engagement of the physician in the care for their patients and the benevolent paternalist attitude, adapted to nowadays.
In short, this study allowed us to reach three important conclusions, which we believe may contribute to future discussions in the bioethics field: (1) the introduction of the bioethical principle of autonomy in the physician-patient relationship was a great advance for the patient and increased the complexity of the relationship; (2) the Internet use in healthcare increases the patient's autonomy and can improve the physician-patient relationship and increase the patient's participation in decision-making processes; (3) the physician-patient relationship is very important nowadays and will always be essential and indispensable.