Richard T. Hull has argued that there are three alternative approaches to the essence of being human in our culture. He argued that these three approaches influence our views of the appropriate models for Health Care Professional/Pt. relationships. ("Models of Nurse/Patient/Physician Relations," The Kansas Nurse, Vol. 55 No. 9 (10/80))
Traditionally Religious Approach: Moral law comes from the creator. Human conduct should attempt to conform with the divine will's purposes. Each human being has value as a creature of the creator. Also, each human being has a purpose which the creator may or may not reveal. In this view, treatment decisions should be determined in light of the universal moral laws.
Individualism: Humans are creative beings who create their own moral systems and concepts of meaning. Value, meaning, and purpose are neither absolute nor universal, with the possible exception of those characteristics necessary to protect individual autonomy. Each individual makes his/her own decisions regarding what is important for him/her. In this view, treatment decisions are ultimately the responsibility of individual patients, as long as they are capable.
Communitarianism: In this view, the essence of being human comes from one's relationships with others. Individuals are seen as members of a community. The moral value of one's actions are determined by their effect on the community as a whole. In this view, treatment decisions are tempered by social considerations. What is the effect on the community as a whole?
Keeping these three approaches in mind, let's consider and compare the models for patient/professional relationships that Robert M. Veatch and Ellen W. Bernal propose. While Veatch focuses on degrees of autonomy withing the HCP-Pt. relationship, Bernal’s approach is more contextual. She is considering the role of nurses as a whole and a more holistic view of patient care. (Veatch, R. "Models for Ethical Medicine in a Revolutionary Age," Hastings Center Report, Vol. 2 (6/72) & Bernal, E. “The Nurse as Patient Advocate,” Hastings Center Report, 22:4 (1992):18-23.)
Veatch’s models are organized from greatest stress on patient autonomy to least:
The Engineering Model: In this model, the health care professional is a technical expert. He/She presents the facts to the patient without making any value judgements. The patient makes the final decision.
The Contractual Model: In this model there are obligations and benefits for both parties. Though their interests may not be identical, the parameters of the relationship allow for the interests of both to be achieve to a reasonable extent. The patient is a client and the professional is a provider. If either party decides that he/she cannot continue with the relationship due to disagreement or conscience, then the contract is either broken or not made in the first place. Both parties maintain a degree of control and individuality.
The Collegial Model: In this model, patient and professional are colleagues attempting to pursue a common goal. They treat each other as equals. They have trust and confidence in each other. Both are respected for contributing important pieces of information in an effort to agree on a specific treatment plan.
The Priestly Model: This model is paternalistic in nature. In this model, the professional knows best. The patient is like a child who needs to be encouraged to do the right thing. The professional's primary duty is to protect the patient from harm and try to promote the patient's welfare. The patient's autonomy is secondary to his/her well being. Therefore, the professional will make the final decision unless the patient's decision agrees with the professional's.
Bernal:
Advocacy Model - Bernal sees this as the model for nursing practice which was developed as nursing developed its own sense of professional identity, separate from duties to physicians and institutions. Under the advocacy model, the nurse’s primary role is to protect the patient’s rights and interests. This model recognizes that patients’ rights are undermined by institutional practices and unequal power structures. Nurses have a duty to empower patients, both directly by supporting patient autonomy and indirectly by working to changes practices that disempower patients. Bernal criticizes this model. She believes it continues the old view of nurses as the guardians of morality. It portrays nurses as adopting whatever values the patient supports and portrays relationships between patients and professionals/institutions as adversarial and manipulative. It neglects important moral considerations besides patient autonomy (i.e. just distribution of resources). Finally, the advocacy model places too much focus on patient autonomy since much of the patient’s experience involves suffering and vulnerability and requires the consideration of third party interests.
Covenant Model - Instead of focusing only on the patient-Professional relationship, the covenant model looks at the nursing profession’s duties as a whole. Nurses are indebted to society for their training and professional benefits. Society is indebted to nurses for their work. This “mutual indebtedness” creates an exchange of promises. The nurse “is given freedom to practice by the public” on the basis of the nurse’s “promise to remain faithful to the ideal of service.” (p. 22.) While advocacy is part of a nurse’s role, so is the duty to respond to the patient’s preferred view of their relationship and to the “wider variety of needs occasioned by illness and health care.” Bernal see the covenant model as more consistent with the goal of cooperation amongst all health professionals.
(Bernal, E. "The Nurse as Patient Advocate," Hastings Center Report, 22:4 (1992), pp. 18-23.)
Consider your profession. In general, which model do you believe to be most appropriate for relationships between patients and people in this profession and why? If it varies, explain why. If it does not, explain why.