Still Searching for Moral Certainty? The Physician-Patient Accommodation after 40 Years
Farr Curlin, MD, Josiah Trent Professor of Medical Humanities and Co-Director of the Theology, Medicine and Culture Initiative, Duke University; Lydia Dugdale, MD, Columbia University; and Mark Siegler, MD, University of Chicago
More than 40 years ago, an ambitious young physician at the University of Chicago published a paper titled, “Searching for Moral Certainty in Medicine: A Proposal for a New Model of the Doctor-Patient Encounter.” In that paper, based upon a 1979 lecture he presented to the New York Academy of Medicine, the physician observed a “deterioration of social consensus concerning the proper limits, means, and ends of medicine,” and he criticized the new principlism and its focus on autonomy, which he argued “fails to provide sufficient practical guidance to morally conscientious physicians and patients.” In response, he proposed the “physician-patient accommodation,” a new model of the doctor-patient relationship that ostensibly “avoids the unilateral, static notions of either a physician-dominated, paternalistic model or a patient-dominated, consumerist-libertarian model of medicine.”
This panel will consider the “physician-patient accommodation” and its influence on “shared decision-making” forty years later and in light of the conference theme. The theme asks us to consider the boundaries of medicine—how we discern what ought (not) to be done. The young physician had argued: if moral certainty exists in medicine (that is, if it is possible to determine which actions taken in a medical context are moral and ethical, which are right and wrong), such moral certainty will be discovered not by recourse to formal laws, moral rules, or moral principles, but rather in the context of the particularities of the physician-patient relationship itself. Participants will evaluate this proposal and how it has fared in light of what the sociologist John Evans calls “the crisis of bioethics.”
Participants will also consider how physician-patient accommodation’s bilateral model for the clinical encounter has held up. In the physician-patient accommodation, how the physician and patient will work together is “determined mutually, voluntarily, and autonomously by both patient and physician.” In 1982, the President’s Commission repeatedly cited the “Searching for Moral Certainty” paper as a basis for their recommendation of shared decision-making – a concept the Commission seemed to see as interchangeable with the physician-patient accommodation. In its landmark 1982 report, “Making Health Care Decisions,” he Commission stated, “The Commission’s view is intended to encompass a multitude of different realities, each one shaped by the particular medical encounter and each one subject to change, as the participants move toward patient-physician accommodation through the process of shared decision-making.” Meanwhile the University of Chicago physician founded a center for what he called “clinical medical ethics,” training hundreds of clinicians who have gone on to lead and direct scores of ethics centers around the world. Notwithstanding initial support for his model and the influence of the hundreds of clinician-ethicists he has trained, however, both principlism and an emphasis on patient autonomy have dominated professional understanding of the doctor-patient relationship over the subsequent decades and to the present. This panel will consider why, and to what effect.
Finally, the conference also asks us to follow “the central theme of how medicine seeks to care for souls.” The panel will consider how the care of souls might fit within a physician-patient accommodation model vs. within a model that emphasizes patient autonomy. Seeing humans as “souls” has been more at home in religious traditions than in secular discourse, and the physician-patient accommodation allows the physician to practice according to “his own conscientious standards of what it means to be a good and responsible physician and human being,” which sounds like it might welcome physicians being motivated and directed by a religious vision of the care of souls—including the boundaries that vision would establish. The model’s author, however, acknowledged at the outset that his proposal might be controversial, and “particularly the notion that a physician may be obligated not to enter a physician-patient accommodation if doing so would violate the physician's conscientious sense of professional and personal responsibility.” The panelists will consider the care of souls in light of growing calls for physicians to set aside their “personal” values and judgments.
Panelists are the author of the “physician-patient accommodation,” now professor emeritus, along with two of his former students, both of whom teach medical ethics in prominent academic medical centers, and both of whom have written about the intersection of religion and medicine.
This panel will consider the “physician-patient accommodation” and its influence on “shared decision-making” forty years later and in light of the conference theme. The theme asks us to consider the boundaries of medicine—how we discern what ought (not) to be done. The young physician had argued: if moral certainty exists in medicine (that is, if it is possible to determine which actions taken in a medical context are moral and ethical, which are right and wrong), such moral certainty will be discovered not by recourse to formal laws, moral rules, or moral principles, but rather in the context of the particularities of the physician-patient relationship itself. Participants will evaluate this proposal and how it has fared in light of what the sociologist John Evans calls “the crisis of bioethics.”
Participants will also consider how physician-patient accommodation’s bilateral model for the clinical encounter has held up. In the physician-patient accommodation, how the physician and patient will work together is “determined mutually, voluntarily, and autonomously by both patient and physician.” In 1982, the President’s Commission repeatedly cited the “Searching for Moral Certainty” paper as a basis for their recommendation of shared decision-making – a concept the Commission seemed to see as interchangeable with the physician-patient accommodation. In its landmark 1982 report, “Making Health Care Decisions,” he Commission stated, “The Commission’s view is intended to encompass a multitude of different realities, each one shaped by the particular medical encounter and each one subject to change, as the participants move toward patient-physician accommodation through the process of shared decision-making.” Meanwhile the University of Chicago physician founded a center for what he called “clinical medical ethics,” training hundreds of clinicians who have gone on to lead and direct scores of ethics centers around the world. Notwithstanding initial support for his model and the influence of the hundreds of clinician-ethicists he has trained, however, both principlism and an emphasis on patient autonomy have dominated professional understanding of the doctor-patient relationship over the subsequent decades and to the present. This panel will consider why, and to what effect.
Finally, the conference also asks us to follow “the central theme of how medicine seeks to care for souls.” The panel will consider how the care of souls might fit within a physician-patient accommodation model vs. within a model that emphasizes patient autonomy. Seeing humans as “souls” has been more at home in religious traditions than in secular discourse, and the physician-patient accommodation allows the physician to practice according to “his own conscientious standards of what it means to be a good and responsible physician and human being,” which sounds like it might welcome physicians being motivated and directed by a religious vision of the care of souls—including the boundaries that vision would establish. The model’s author, however, acknowledged at the outset that his proposal might be controversial, and “particularly the notion that a physician may be obligated not to enter a physician-patient accommodation if doing so would violate the physician's conscientious sense of professional and personal responsibility.” The panelists will consider the care of souls in light of growing calls for physicians to set aside their “personal” values and judgments.
Panelists are the author of the “physician-patient accommodation,” now professor emeritus, along with two of his former students, both of whom teach medical ethics in prominent academic medical centers, and both of whom have written about the intersection of religion and medicine.