The four components for the good of the patient

Dr. Edmund D. Pellegrino, one of the founders of Bioethics, identifies four

components that contribute for the good of the patient, the ultimate goal of medicine

and healthcare. It helps to prevent practicing organ centered medicine, which is

fragmented, reductionist, and unsatisfactory, and to acknowledge the whole person

approach, a core value for PRIME.

The first component is the good of the patient from a medical standpoint - the

biomedical or techno-medical good. It is directly related to the knowledge and

competence of the physician and depends on the resources provided by medical

science and technology. It aims to restore any physiological or psychological

dysfunction by applying the appropriate state-of-the-art treatment, such as

anticoagulation for deep vein thrombosis or surgery for acute appendicitis. It is the

instrumental good that patients usually desire when they seek medical advice in

order to cure or control a disease, relieve suffering and preserve life. Unfortunately,

many doctors have a restricted understanding of the patient’s good which

acknowledges only this component in the clinical encounter. This could lead to a

paternalistic and arrogant attitude of the physician towards the patient whenever

there is any physiological benefit, scientifically proven, of a certain medical procedure

(e.g. the aggressive treatment of diseases potentially reversible, like a pneumococcal

pneumonia, in terminally ill patients).

On a second level, the biomedical good is confronted with the patient's perception

of the good i.e. the patient’s opinion about what he thinks is the best for himself.

Faced with the same disease and the same therapeutic proposal, different patients

may make different choices, and therefore their preferences should be taken into

account. According to Pellegrino, ‘those choices and values are unique for each

patient and cannot be defined by the physician, family or anyone else’. Not always

what is proposed by the doctors should be done, if it collides with the risk that the

patient is willing to take to benefit from a treatment proposal. Therefore an effective

communication between the doctor and the patient is essential, which may include

listening with empathy, letting the patient express his concerns and transmitting the

diagnosis and any therapeutic proposal in an understandable way. One of the

reasons that patients usually give for suing doctors is when physicians systematically

ignore the patient’s concerns and opinions.

Another component is the good for humans i.e. the good for the patient as a human

being or person. The respect for the dignity of the person regardless of age, gender,

race, religion or social status, are included in this dimension. This would prevent

health professionals to initiate some treatments whose associated risks are either

excessive or disproportionate, even with the patient’s consent. If this component of

the good for the patient as a human being was considered, abuses in human

experimentation such as those that took place in Tuskegee, Alabama, or in

Willowbrook, New York, in the 20th century probably would not have occurred.

The highest level of this dialectical approach of seeking the good of the patient is the

spiritual good or ultimate good. It is the recognition of the spiritual dimension of the

human being i.e. what gives meaning to life beyond material well-being. A common

example of this component is the refusal of blood transfusions by Jehovah's

Witnesses, but other religious or ideological choices of the patient should be

respected as well. Sometimes in the hierarchy of values of the patient health may not

be considered the greatest good.

Edmund Pellegrino clarifies that it is not always possible to integrate these four

components for the good of the patient in every clinical decision or even establish a

hierarchy among them, particularly in emergency situations or when dealing with

minors or patients with psychiatric or cognitive disorders. In these cases at least the

‘good for humans’ component in addition to the biomedical good should be

recognized. On the other hand, Pellegrino underlines that the physician has no

obligation to obey all the choices and whims of the patient, especially those that

conflict with their own values and conscience. But even when there’s full agreement

between doctor and patient about some decision does not mean that it is an ethically

right one (e. g. a patient’s request for euthanasia).

This four-level approach of the patient’s good recognizes the whole person – physical

mental, and spiritual. It values the autonomy and dignity of the patient as a person,

and preserves his vulnerability in the face of scientific and technological advances in

medicine. This model is also patient-centered, gives the doctor a key and proactive

role in the search of the patient's good, and contributes to a more humane medicine.

Jorge Cruz, MD, PhD

References

Pellegrino, E. D. Moral Choice, The Good of the Patient, and the Patient's Good. In: Moskop, J. C.; Kopelman, L. (Eds). Ethics and Critical Care Medicine. Dordrecht, Holland: Reidel, 1985. Pellegrino, E. D. The internal morality of clinical medicine: A paradigm for the ethics of the helping and healing professions. Journal of Medicine and Philosophy, 26, 559-579, 2001.