From paternalism to partnership


"Doctors should comfort always, alleviate often and cure sometimes" Ambrose Pare (1510-1590). Often quoted, but still wise, words from a noted 16th century French surgeon. That they still apply to the everyday work of most doctors is a tribute to his perspicacity. However, with the advances of modern technology pushing back the frontiers of medicine, society is moving away from the primacy of care and understandably beginning to focus on cure. Whether this poses an ethical danger is one of the questions addressed in a new book by John Scally: Doctors Orders? Towards a new Medical Ethics.

In a call for the "recapture" of Ambrose Pare's insight, Scally says: "new technology holds out the prospect of great medical advances but also the danger that the patient as a person will recede into the background and that the relationship between the sick and those who care for them will be violated".

The deepest relationships which I have had with patients and indeed, their families have invariably been associated with terminal illness. Both as a doctor in a hospice, and particularly as a general practitioner, it has been one of the great privileges of my job to be trusted to look after someone during their last days and weeks.

There is no greater training ground or learning curve in medical ethics than providing palliative care.

"To comfort always and alleviate often" means providing optimal pain relief but without clouding you patients' senses with medication. It means balancing the need to be truthful with a desire to be compassionate. It requires a heightened sensitivity, ever alert to the many intricacies of holistic care.

Scally refers to patients entrusting "a greater part of themselves to the goodwill of their doctors.

They hope, justifiably, for a response to that trust that treats them with human concern and respect, as well as with professional knowledge and skill. As a norm they are not disappointed in that hope".

But I do share his concerns when he says: "the danger is that as technique becomes even more dominant, the human face of healthcare might become obscured".

Referring to the 2,400 year-old Hippocratic Oath, Scally asks whether it is time to say goodbye to the paternalistic beneficence of doctors. "The principles espoused in the Oath are particularly unfit to support the recognition of a patient's self-determination as an integral part of her or his individual civil rights", he notes.

Is it time for medical ethics to move from paternalism to partnership? The author clearly thinks so, and devotes an entire chapter reviewing the way in which the medical profession regulates its members and deals with the public.

He criticises health professions in general for expressing broad ethical principles which are attributed in the form of vague imperatives and questions the validity of a philanthropic approach to medical ethics.

"An essential weakness of the philanthropic approach is the failure to acknowledge the indebtedness of the profession to society. The symbiotic relationship of giving and receiving, which is at work in the professional relationship, needs acknowledgement to avoid what in fact occurs in most ethical codes in the medical profession: the expression of gratuitous service to humanity and an orientation to self-protection".

Hard-hitting stuff which will offend many doctors who see themselves as doing their level best in increasingly difficult circumstances. Nevertheless, it is a view which could usefully trigger a much-needed debate about the role of doctors in our society.

As a medical journalist who is closely observing the Medical Council in its current debate on the revision of professional ethical guidelines, I find myself in agreement with Scally when he writes: "Public debate needs specific information about the real situation in medical practice. Transparency, like beauty, often is in the eye of the beholder. The Irish Medical Council would claim to be fully transparent. Medical journalists would not be so sure..." It is certainly not acceptable that the current Medical Council has seen fit to effectively "gag" its members from public debate on an important issue such as professional guidelines on the termination of pregnancy.

John Scally has written a timely and incisive book, full of questions about the practice of medicine in the State, an invaluable read for anyone with an interest in health.

Doctors Orders? Towards a New Medical Ethics by John Scally, is published by Veritas, Dublin at £9. ISBN 1-85390-582-8

You can e-mail Dr Muiris Houston, Medical Correspondent, at or leave a message on 01-6707711, ext 8511. He regrets he cannot reply to individual medical problems.