Abstract
The goal of this paper is to propose a relational turn in healthcare professionalism, to improve the responsiveness of both healthcare professionals and organizations towards care of patients, but also professionals. To this end, it is important to stress the way in which difficult situations and vulnerability faced by professionals can have an impact on their performance of work. This article pursue two objectives. First, I focus on understanding and making visible shared vulnerability that arises in clinical settings from a triple perspective: patient and family, health professionals, and institutions. Second, to address this challenge for professionalism, in this paper I articulate the term "relational centered-patient professionalism", which has two main axes. The relational approach means taking into account how the relationships among professionals, patients and institutions determine the constitution and evolution of those professional values. The focus on patient centered care is indispensable, because it is the ultimate goal pursued by the development of these professional values, and must always be at the center.
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Notes
To follow in depth the publications related to the "Fifteenth Session of the International Bioethics Committee", see http://docplayer.net/19142085-Fifteenth-session-of-the-international-bioethics-committee-ibc-unesco-headquarters-paris-27-29-october-2008.html). The opening session was about "Principle of respect for human vulnerability and personal integrity: theoretical challenges and practical achievements" (http://www.unesco.org/new/fileadmin/MULTIMEDIA/HQ/SHS/pdf/Human-Vulnerability-Patrao-Neves.pdf.
As ten Have (2016) states, there are a group of philosophical perspectives emphasizing that vulnerability is a general characteristic of being human, but usually these theories are not considered to be relevant for the practical discourse of bioethics. These philosophical perspectives on vulnerability do not advocate for a vulnerable subject against an autonomous subject, but argue that vulnerability is constitutive of personal autonomy, and due to that it is preferable to use the term "anthropological" rather than "ontological" vulnerability. I will refer to this conception as universal, anthropological or shared vulnerability.
Ten Have explains why the term "ontological vulnerability" is not appropriate to express that vulnerability is the most characteristic of the human beings. Ontology states there is an essential reality prior to ethical discourse, which in the dominant bioethical discourse on the idea that the autonomous subject is prior to its context. However, philosophical perspectives on vulnerability shows that ethics and ontology cannot be separated. Those perspectives argue that vulnerability is constitutive of individual autonomy, and that autonomy can only emerge from a vulnerable subject. Vulnerability is the human condition, and autonomy a capacity that need to arise. For these reasons, ten Have propose to use the term "anthropological" rather than "ontological" vulnerability.
https://web.gs.emory.edu/vulnerability/index.html. Last accessed 11/22/2020.
For further details, visit the VHC Initiative’s website: https://web.gs.emory.edu/vulnerability/about/definitions.html (last visited 11\06\2020).
For further details about these means, see Fineman (2015).
In a systematic review about healthcare staff wellbeing, burnout and patient safety, Hall et al. (2016) found in the majority of studies reviewed poor wellbeing and burnout are associated with poor patient safety outcomes such as medical errors.
This project was initiated by the American Board of Internal Medicine Foundation, the American College of Physicians Foundation, and the European Federation of Internal Medicine.
The list of commitments includes: (a) commitment to professional competence, (b) to honesty with patients, (c) to patients’ confidentiality, (d) to maintaining appropriate relationships with patients, (e) to improving quality of care, (f) to improving access to care, (g) to a just distribution of finite resources, (h) to scientific knowledge, (i) to maintaining trust by managing conflicts of interest, and (j) to professional’s responsibilities.
The proposal of Shapiro et al. (2015) is to promote the study of Literature as a way to learn in an emotionally and critically engaging way; to learn how individuals face moral dilemmas, solve them and the consequences of those resolutions. They understand literature to be an essential element of medical education: “literature can deepen the understanding of medical professionalism, as many medical educators desire” (pp. 6–7).
Pellegrino (2012) maintains that medical ethics is primarily about caring for the good of the patients, which means each patient, and society as a whole, depends upon the physician’s formation of a good character, i.e., on the acquisition of the virtues that make for a good physician. He claims that virtue is an unavoidable element in any system of medical ethics.
Pellegrino defines the good of the patient in tangible terms connected to the phenomenology of the clinical encounter. The good of the patients is explained as a quadripartite good, a complex relationship between medical, personal, human, and spiritual good. This concept creates the duties of the clinician. As he concludes, a theory of the good of the patient has applicability for the ethics of the other healing and helping professions and the virtues and principles pertinent to their practitioners as well. See Pellegrino (2001).
In a synthesis of the literature (Molina et al. 2014) about resilience in different stages of cancer, with a patient-centered care focus, the review provided important information to consider at each stage of the continuum and offered healthcare providers and researcher different forms of resilience to incorporate in the patient care process. The authors concluded that promoting resilience is a critical element of patient-centered psychosocial care, and multidisciplinary healthcare teams can foster resilience by recognizing and improving features of resilience through the cancer continuum. A strong commitment from healthcare teams is needed in order to develop programs and interventions oriented to foster resilience in patients.
Some of these skills are: (a) sensitivity to consider the context of the person and his or her illness from his or her own perspective, (b) highlight the importance of the individual context, and not only in the context of a systematic description of the disease and its etiology, (c) narrative communication skills: exploring differences and connections, hypothesizing, strategizing, sharing power, reflection active listening, and circular questioning and (d) self-reflection.
According to Iris Marion Young (1990), there are “five faces of oppression”: violence, exploitation, marginalization, powerlessness, and cultural imperialism. In these five categories, she conveys how the social constructs affect and shape the individual. Each of these forms of oppression overlaps with the other. This framework focuses on the ways in which people experience oppressive conditions in their daily lives.
Thesen explains in her article that she started thinking about the problem of oppression after conducting a study of the experience of users of psychiatric services (in this article called "Study of experience"). Users described dehumanizing experiences of being reclassified as the stigmatized "other". She explains that they presented convincing and harsh experiences of oppression, lack of love and lack of life of their own, mainly in their encounter with people from their local community, but also in health and social services. Her findings led her to think that the dominant person in a human encounter sometimes stigmatizes and harasses the other, and that doctors are no exception. After this research, she asked herself why doctors like herself assume the role of oppressor in medical encounters. She also asked herself if the reason for that is due to personal deficiencies, or if there is a more structural reason. She decided to try to explain how the oppressive process could be described. Another concern she expresses arose from this previous study is that if she recognizes that sometimes she acted as an oppressor of her patients, how could this behavior change? And finally, why this type of behavior is invisible for the clinicians.
The article published by Carel is written as a response to Sellman ́s article, confronting some of their arguments. That is why she uses the same terminology that Sellman. Sellman distinguish between ordinarily vulnerable people and more-than-ordinarily vulnerable people. While all people are vulnerable, all patients are more-than-ordinarily vulnerable and this restricts their potential to flourish. For him, nurses are well placed to contribute to the flourishing of more-than-ordinarily vulnerable persons and he claims that this ‘protective’ function is a legitimate and fundamental part of the role of nurses.
Kimberly Manning is a hospitalist at Grady Memorial Hospital in Atlanta, an associate professor of medicine at Emory, and an adviser in the Semmelweiss Society. Her interests include humanism in medicine and the use of reflective writing. She practices what she preaches by writing a blog about her experiences at Grady. “I write to share the human aspects of medicine and teaching and work-life balance,” Manning says, “and to honor the public hospital and her patients, but never at the expense of patient privacy or dignity.” She also writes about her frustrations and ways that she stays energized and optimistic in the face of daunting amounts of human tragedy. Usually, she copes very well, finding joy in the job on most days. This is not a story about one of those days. To read the whole story, visit http://www.gradydoctor.com/2017/07/heavy-on-my-soul.html. (last visited July 8, 2020).
The authors highlight that all professions in healthcare experience similar effects in relation to the stressful conditions of work. This common aspect offers an opportunity to design and implement inter-professional approaches that can enhance the capacity for resilience among teams of coworkers.
Moral distress was originally described by Andrew Jameton (1984), and occurs when a healthcare professional makes a moral judgment about a case in which he or she is involved and an external constraint makes it difficult or impossible to act on that judgment, and he or she experiences painful feelings and/or psychological disequilibrium. He developed the term in the context of the explanation of the manners through institutional policies and practices can lead professionals to act in a way that they consider morally wrong. In this relation between organization and staff, moral distress can arise when the workers cannot perform their duties in a manner according to their moral values. In many cases, the reasons may be directly related to the institution.
The relationship between burnout and clinical error is understood as bidirectional. Dyrbye et al. (2017) shown several studies in which self-perceived medical errors were associated with worsening burn out, depressive symptoms, and decreased quality of life, suggesting a cyclical relationship between medical errors and distress. In addition, they shown other studies that have found that as the average levels of burn out of physicians and nurses working in intensive care units increased, so did the standardized rates of patient mortality, while the perceived quality of work in interpersonal equipment deteriorated (Dyrbye et al. 2017). They conclude that burn out among healthcare professionals is related to quality and safety, patient satisfaction and healthcare costs.
Nancy Berlinger (2016, p. 176) has analyzed these disruptions between ideals and reality broadly: “There are limits to thinking of professional ethics in terms of virtues- being caring, being compassionate, being respectful- if healthcare professionals see few ways to put these virtues into practice. Framing professional ethics in terms of an idealized physician -patient relationship is insufficient, as this is closed off from the reality of the complex system professionals and patients have to contend with. Similarly, describing the duties of health care professionals is insufficient without acknowledging the conditions of complexity and how flawed systems can impede individual or team efforts to do good and prevent harm (…) Thinking about the complex systems as a "moral space" that must always be open to the discussion of questions of right and wrong action, of justice and injustice, may help us grapple with the continuing challenge of creating and sustaining health care systems that are safe, effective, compassionate and just”.
Triple aim refers a series of goals that the United States must follow to achieve high-value healthcare. Those goals are called the “Triple Aim”: improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations. See Berwick et al. 2008.
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Delgado, J. Vulnerability as a key concept in relational patient- centered professionalism. Med Health Care and Philos 24, 155–172 (2021). https://doi.org/10.1007/s11019-020-09995-8
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DOI: https://doi.org/10.1007/s11019-020-09995-8