Catholic Medical Quarterly Volume 65(1) February 2015
DOCTOR-PATIENT RELATIONSHIP AS A REALISATION OF PERSONAL COMMUNICATION
Communication can be seen as the main ingredient in medical care. In reviewing doctor-patient communication, we are analyzing specific parameters such as: (1) the field of oncology and morality according to the Christian perspective, and (2) the doctor-patient relationship. We conclude that the relationship of doctor-patient upholds the principle of self-determination and enables patients to make treatment decisions consistent with their life goals.
Keywords: Biomedical ethics; doctor-patient communication; Christian morality; suffering.
We begin this essay by calling attention to the moral significance of the personal communication between the doctor and the patient in the contemporary practice of medicine. For cancer physicians, oncologists for terminally ill patients, the issue of interaction can be viewed as an especially important and an ethically challenging clinical problem. To understand more fully why communication between doctors and patients – cancer patients in particular – is such a powerful phenomenon, it is important to look at: (1) Oncology and morality according to the Christian perspective; and (2) The relationship of doctor-patient.
1. Oncology and ethics
The practice of oncology brings the doctor face to face with profound biological, psychological, moral, theological and philosophical questions related to the very human existence and the mystery of life. The initial diagnosis of cancer brings with it the possibility of death, and this possibility may continue to be present throughout therapy, remission, and even following the pronouncement of cure. This realization may lead to an individual and interpersonal crisis. 
Despite sustained progress and emerging treatment of neoplasms at some point in the future, these dilemmas will not be missed, because they are before and beyond oncology. In fact, they have to do with the core and the mystery of human existence, the cycle of life, the beginning and the end, as they are recorded in the whole range of nature, from the microcosm of the cell to the unexplored universe. 
According to Metropolitan J. Zizioulas, biotechnology, genetic engineering, and so on, grant us many promises but the danger of depersonalization of the human being lurks underneath these promises. It is doubtful whether bioethics can manage to halt these developments.  For this reason, while sophisticated technologies may be used for medical diagnosis and treatment, inter-personal communication is the primary tool by which the physician and patient exchange information. .
It is the argument of this paper that informing the patient is crucial. The therapist should encourage conversation and questions. It is noteworthy that respect of the personality and individuality of the patient is a key ethical principle. The patient should not be treated as a number, but as a person, that is, a being who is rational, autonomous, and in possession of a moral sense. 
Consequently, physicians might explore how better to treat the unpleasant experiences, affect, and mood associated with illness, suffering, and death. This is why at least some physicians still presume that they are to called to care for a patient even though they cannot cure, or even alleviate to any significant extent, the patient’s malady. 
However, in order to provide quality care, they must identify and accentuate the elements of care, such as personal attention, that lead to patient satisfaction. It is worth noting that other studies have identified specific characteristics of the interaction between the patient and physician or other medical staff that impact satisfaction. For example, satisfaction has been be shown to be lower when patients felt they were not ‘cared for as a person’ and when communication between patient and providers was poor. 
It is characteristic that at the final stage of the disease where the health deteriorates and the end of life is imminent, it is inevitable for someone to wonder: Why did this illness come about? Why was it me? Questions like these cause, rekindle or intensify spiritual or religious interests. In addition, suffering brings us back to the biggest and first of all puzzles: Is there any meaning to human life, the universe, our striving, our suffering, beyond what we ourselves provide?
In this frame, and in order to answer these questions, the meaning of illness can lead to a metaphysical or religious search for a deep grounding of the meaning of our lives. Religion must be understood in a more pragmatic sense and interpreted within the context of a lived, material existence. Moreover, religion is tied to a form of life and must be interpreted inside this form of life apart from its abstractness.  By recognizing the power of sickness and suffering to remind us that we will all die, Christian bioethics places the moral decisions of medical practice and health care policy within a decision to repent and free the heart from passions.
H. Tristram Engelhardt has also observed that there are cases where the medicine with its technology will attempt to engage the patient and family in a process that will absorb them entirely. A brain tumor resection may save his life, but leave him with impaired consciousness. Chemotherapy can prolong life for a few months but cause serious side effects. The inappropriate use of medical means may lead the patient, family members and caregivers to situations where euthanasia is attempted. 
Ultimately, to care for one another when we cannot cure is one of the many ways we serve one another patiently. We might find we have something to say, not only about how illness and death can be met with faith and grace, but also about how those called to be physicians and nurses might care personally for their patients, and perhaps even about the kind of training they will need in order to become capable of this high calling.  Following Christian tradition T. Lysaught maintains that recognizing the power of sickness to ‘dis–inscribe’ bodies of their normative selfunderstanding, the Church responds with a set of liturgical practices which intends to respond to the dynamics of suffering, ‘re-inscribe’ these bodies, and assist persons in fulfilling their vocation of entering the Kingdom of God. 
2. The doctor-patient relationship
Interaction and communication between doctors and patients are especially important in cases of life threatening diseases, such as cancer. In the past two decades, descriptive and experimental research have tried to shed light on the communication process during medical consultations. However, the insight gained from these efforts is limited. This is probably due to the fact that among inter-personal relationships, the doctor-patient relation is one of the most complex ones. It involves interaction between persons in different positions, is often non- voluntary, concerns issues of vital importance, is therefore emotionally laden, and requires close cooperation. 
It should be noted that the doctor-patient relationship is not static but evolves, matures and transforms. In the center of the relationship is always the patient and all efforts should contribute to a feeling of satisfaction, security and tranquility, generally expressed as 'well-being'. It is obvious that the initiatives for a right relationship belong to the oncologist. The doctor-patient relationship must be a mutual relationship of respect and trust. 
From the patient’s point of view, two needs have to be met when visiting the doctor: firstly, the need to know and understand, in other words, to know what is the matter, where the pain comes from, and secondly, the need to feel known and understood- to know the doctor accepts him and takes him seriously. In order to fulfill the doctors’ and patients’ needs, both alternate between information-giving and information-seeking. Surely, as J.Boyle observed, double effect is important in bioethics, at least in the sense that a lot of bioethical argumentation uses, abuses, or criticizes moral reasoning in which the distinction between what one intends in acting, and what one accepts as a side effect of but does not intend marks the difference between the permissible and impermissible. 
It is the argument of this paper that the informing of the patient himself/herself is a very important chapter. And this takes time. It must be realistic but with discretion. A crucial purpose of medical communication is to enable doctors and patients to make decisions about treatment. Traditionally, the ideal doctor-patient relationship has been paternalistic: the doctor has directed care and made decisions about treatment. During the past two decades, this approach has been replaced by the ideal of ‘shared decision-making’. It appears logical that in order to make such decisions, patients need informing. Recently however, the relationship between medical decision-making and patients’ need for information has received greater attention.  Given that patients’ trust in their physician is essential for the doctor-patient relationship , and this trust implies that physicians will be honest and forthright in communicating the information needed for patients to make informed decisions consistent with their own goals, withholding prognostic information can otherwise be viewed as a form of deception.  In addition, open discussion and knowledge of prognosis is known to help many terminally ill patients and physicians better manage the death process, and has been shown to be associated with less emotional distress in some patients. 
In our understanding of patient-physician issues surrounding communication in the setting of lifethreatening disease, it is noteworthy that if a physician does not act rightly, his\her patient will quickly either lose hope in medicine, or more likely, come to believe that his\her doctor is incompetent. If there is a cardinal rule now in medicine it is that in any and every state of uncertainty, physicians must try to find something to do .
It is therefore obvious that in order to approach the cancer patient correctly the oncologist must have a range of qualifications. Absolutely necessary, of course, is clinical excellence. With the research progress in the biological sciences, it is impossible to practice oncology only with basic medical education and in an empirical way. Instead the oncologist is required to have interdisciplinary training, and classical education: biological, psychological, social and philosophical. Furthermore, a collaborative approach that is scientifically established helps clinicians to share ideas in difficult cases. Medicine rarely helps if exercised individually. 
Finally, a good inter-personal relation between doctors and patients consists of: a desire to help, honesty, encouragement, devotion, conveying interest, listening to what the patient is saying, but also to what he is unable to say, a non- judgemental attitude and a social orientation.
To sum up, communication can be seen as the main ingredient in medical care. This is the first and foremost step in order to build a good relationship between doctors and patients characterized by mutual respect and appreciation. The ideal type of patient, according to the above, is characterized by the perception of freedom of choice. This ideal view of the patient perpetuates the pervasive understanding within Bioethics that individuals have the capacity for self-determination. Before we end our essay, we ought finally to point out that according to Christian bioethics suffering, illness and death evoke moral and metaphysical reflections which are part of the history of salvation.
Kapsimalakou Christina1*, Papaloucas Christos 2, Kouloulias Vassilis1
1. 2nd Dept Radiology Unit, ATTIKON, University Hospital, Athens,
2. Anatomy Laboratory, Medical School, Trace University,
* Corresponding author. Dr. Vassilis Kouloulias (MS, PhD)
ATTIKO University Hospital, Rimini 1, Chaidari Athens,
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- See Issues in Bioethics, Life, Society and Nature in the face of challenges of BioSciences (2013), Edited by S. K. Tsinorema-Louis, University Press of Crete, 152-153.
- Zizioulas J.D., Communion & Otherness, ed. Paul McPartlan, 2006, 95.
- The relevant bibliography is rich. See as indicative of the topic of communication, Ong L.M.,De Haes J.C.J.M., Hoos A.M. and Lammes F.B., Doctor- patient communication: A review of the literature, Soc. Sci. Med. Vol. 40, No.7, 903.
- See Issues in Bioethics, Life, Society and Nature in the face of challenges of BioSciences (2013), Edited by S. K. Tsinorema-Louis, University Press of Crete, 137.
- For a more extended discussion of these issues see Hauerwas’s, Suffering Presence: Theological Reflections on Medicine, the Mentally Handicapped and the Church, 1986.
- Walker M.,Ristvedt S. and Haughey B., Patient Care in Multidisciplinary Cancer Clinics: Does Attention to Psychosocial Needs Predict Patient Satisfaction? Psycho-Oncology 12, 2003, 291-292.
- Carter JK. Race, A theological account, Oxford University Press.
- Engelhard, T., H., (2007), The Foundation of Christian Bioethics, Τα Θεμέλια της Βιοηθηκής, Μιά χριστιανική θεώρηση, translated by P. Tsaliki - Kiosoglou, Armos Publications, 384-385.
- For a fuller discussion of this perspective, especially as it relates to biomedical ethics, see Hauervas S. and Pinches C. (1996), Practicing Patient: How Christians Should Be Sick, Christian Bioethics Vol. 2, No. 2, 213.
- On Christian bioethics see Lysaught T. (1996), Suffering, Ethics, and the Body of the Christ: Anointing as a Strategic Alternative Practice, Christian Bioethics Vol. 2, No. 2, 172-201.
- Ong L.M.,De Haes J.C.J.M., Hoos A.M. and Lammes F.B., Doctor- patient communication: A review of the literature, Soc. Sci. Med. Vol. 40, No.7, 903. 13.
- See Issues in Bioethics, Life, Society and Nature in the face of challenges of BioSciences (2013), Edited by S. K. Tsinorema-Louis, University Press of Crete, 139.
- Boyle J.(1997), Intentions, Christian Morality, and Bioethics : Puzzles of Double Effect, Christian Bioethics Vol.3, No. 2, 87-88.
- Ong L.M.,De Haes J.C.J.M., Hoos A.M. and Lammes F.B., Doctor- patient communication: A review of the literature, Soc. Sci. Med. Vol. 40, No.7, 905.
- Bok S.(1995), Shading the Truth in Seeking Informed Consent for Research Purpose, Kennedy Institute of Ethics Journal; 5, 1-17.
- Gordon E. and Daugherty C.( 2003), ‘Hitting you over the head’: Oncologists’ disclosure of prognosis to advanced cancer patients, Bioethics, Vol.17,143.
- See, for example, Christakis N.(1999), Death Foretold: Prophecy and Prognosis in Medical Care, Chicago, IL. University of Chicago Press.
- Hauervas S. and Pinches C. (1996), Practicing Patient: How Christians Should Be Sick, Christian Bioethics Vol. 2, No. 2, 205-206.
- See Issues in Bioethics, Life, Society and Nature in the face of challenges of BioSciences (2013), Edited by S. K. Tsinorema-Louis, University Press of Crete, 140.