Dr. Edmund D. Pellegrino, one of the founders of Bioethics, identifies four components that contribute for the good of the patient, the ultimate goal of medicine and healthcare. It helps to prevent practicing organ centered medicine, which is fragmented, reductionist, and unsatisfactory, and to acknowledge the whole person approach, a core value for PRIME.
The first component is the good of the patient from a medical standpoint – the biomedical or techno-medical good. It is directly related to the knowledge and competence of the physician and depends on the resources provided by medical science and technology. It aims to restore any physiological or psychological dysfunction by applying the appropriate state-of-the-art treatment, such as anticoagulation for deep vein thrombosis or surgery for acute appendicitis. It is the instrumental good that patients usually desire when they seek medical advice in order to cure or control a disease, relieve suffering and preserve life. Unfortunately, many doctors have a restricted understanding of the patient’s good which acknowledges only this component in the clinical encounter. This could lead to a paternalistic and arrogant attitude of the physician towards the patient whenever there is any physiological benefit, scientifically proven, of a certain medical procedure (e.g. the aggressive treatment of diseases potentially reversible, like a pneumococcal pneumonia, in terminally ill patients).
On a second level, the biomedical good is confronted with the patient’s perception of the good i.e. the patient’s opinion about what he thinks is the best for himself. Faced with the same disease and the same therapeutic proposal, different patients may make different choices, and therefore their preferences should be taken into account. According to Pellegrino, ‘those choices and values are unique for each patient and cannot be defined by the physician, family or anyone else’. Not always what is proposed by the doctors should be done, if it collides with the risk that the patient is willing to take to benefit from a treatment proposal. Therefore an effective communication between the doctor and the patient is essential, which may include listening with empathy, letting the patient express his concerns and transmitting the diagnosis and any therapeutic proposal in an understandable way. One of the reasons that patients usually give for suing doctors is when physicians systematically ignore the patient’s concerns and opinions.
Another component is the good for humans i.e. the good for the patient as a human being or person. The respect for the dignity of the person regardless of age, gender, race, religion or social status, are included in this dimension. This would prevent health professionals to initiate some treatments whose associated risks are either excessive or disproportionate, even with the patient’s consent. If this component of the good for the patient as a human being was considered, abuses in human experimentation such as those that took place in Tuskegee, Alabama, or in Willowbrook, New York, in the 20th century probably would not have occurred.
The highest level of this dialectical approach of seeking the good of the patient is the spiritual good or ultimate good. It is the recognition of the spiritual dimension of the human being i.e. what gives meaning to life beyond material well-being. A common example of this component is the refusal of blood transfusions by Jehovah’s Witnesses, but other religious or ideological choices of the patient should be respected as well. Sometimes in the hierarchy of values of the patient health may not be considered the greatest good.
Edmund Pellegrino clarifies that it is not always possible to integrate these four components for the good of the patient in every clinical decision or even establish a hierarchy among them, particularly in emergency situations or when dealing with minors or patients with psychiatric or cognitive disorders. In these cases at least the ‘good for humans’ component in addition to the biomedical good should be recognized. On the other hand, Pellegrino underlines that the physician has no obligation to obey all the choices and whims of the patient, especially those that conflict with their own values and conscience. But even when there’s full agreement between doctor and patient about some decision does not mean that it is an ethically right one (e. g. a patient’s request for euthanasia).
This four-level approach of the patient’s good recognizes the whole person – physical mental, and spiritual. It values the autonomy and dignity of the patient as a person, and preserves his vulnerability in the face of scientific and technological advances in medicine. This model is also patient-centered, gives the doctor a key and proactive role in the search of the patient’s good, and contributes to a more humane medicine.
Jorge Cruz, MD, PhD
Pellegrino, E. D. Moral Choice, The Good of the Patient, and the Patient’s Good. In: Moskop, J. C.; Kopelman, L. (Eds). Ethics and Critical Care Medicine. Dordrecht, Holland: Reidel, 1985.
Pellegrino, E. D. The internal morality of clinical medicine: A paradigm for the ethics of the helping and healing professions. Journal of Medicine and Philosophy, 26, 559-579, 2001.