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Discussions of beneficence have historically been sparse in the medical literature, though one might expect otherwise. Shifting societal attitudes that apply to the practice of medicine, however, have brought about important basic changes, including emphasis on patients’ education and legal rights, patient autonomy, and self-advocacy, and despite a continued deficiency in the relevant literature, the concept of beneficence seems to have become essential to contemporary medical dialogue and thinking.
The word beneficence, which comes from Latin roots, basically connotes the doing of good and, in the genre of medical care, refers to doing what is in the best interest of the patient. Pursuance of other definitions involves generalities that all circle around this basic concept—that which improves patients’ circumstances and, ideally, leads to improvement and wellness.
Simple enough, right? It’s important, however, to realize that it is more about the intent, and, as such, is not limited to specific pathways of improvement; obviously such goals are not always achieved in medicine, especially in dealing with patients with cancer. This word play reveals a subjective distinction: the manifestation of the doctor’s intent to do a good thing, no matter the outcome.
Put another way, from an ethics standpoint, the judgment or the decisions of a physician may not always be correct, but if the planning and the intent that leads to them are based on beneficence, the action or series of actions are morally correct. Although this argument may not always provide legal immunity, the ultimate unintended outcome is at least more defendable.
The Importance of Trust
Above, I alluded to the evolution in our changing society of both the concept and the usage of the word beneficence. This is especially reflected in the attitude of contemporary physicians when compared with that of our predecessors, who tended to treat patients in a paternalistic way, often leaving them in the dark about the reality of their conditions and circumstances.
I’m convinced that past generations of physicians cared as much as we do today, and they did in fact want to do good for their patients but, in their naïveté, sometimes hedged on the truth, withheld information about potential unpleasantness or poor outcomes, and in general presumed that they knew best what the patient and the family were capable of dealing with.
Thankfully, these practices are no longer the standard, and I would venture to say that the new climate of tailored realism and forthrightness is better for both doctors and patients. In looking back in time, and judging by today’s standards, no matter how well intended, what was meant to be an act or acts of beneficence actually constituted a type of unintentional betrayal. In fairness to those doctors, this was the attitude of an era, and was not limited to the medical profession, but permeated the typical family and other social units. Obviously, patient mental competence has to be considered in making these decisions, and I have factored this into my thoughts here. It should also be noted that some doctors are poor communicators, and what they say often belies reality. Finally, it is unfortunately but true that some physicians are simply indifferent! Lest we become desensitized to the essence of ideal medicine practice, we must remember that indifferent is the antithesis of what a physician ought to be.
This discussion is colored with subjectivity, and it is largely within the hearts and minds of the doctors—in the privacy of their thoughts—that the true intent of a course of action is known. I once made a judgment error in caring for a patient that led to an unfortunate consequence. My self-revelatory misgivings did not concern the possible error in judgment (most physicians are guilty of this at one time or another), but were more about the motives and personal failing that may have led to that error. I asked myself then, and I continue years later to question, whether my motives were based on beneficence, rather than stubbornness and/or professional immaturity. I’ll never know the truth, but the question haunts me. On the other hand, if I were certain that my motives had been unselfish and beneficent, I would have long ago cast away my concerns. Such demons are one of the many things that separate us from the lay public; our responsibilities are profound!
I want to underscore the importance of truth, trust, and absolute integrity in the physician/patient interaction. Said another way, the most basic and important calculus in this interaction is the patient’s ability to trust their doctor’s unselfishness in giving only advice that is in the best interest of the patient; that is to say, it is based on a premise of beneficence, as opposed to scientific or personal convenience or curiosity. The important question to ask one’s physician, therefore, is “What would be recommended if this was a member of your immediate family?” Once that question is answered with certainty, the decisions in cancer management, for instance—radiation versus surgery or both, chemotherapy or no therapy, the prolongation of life versus acceptance of death, and so on—are far easier to make.
Responsibility to Patients
Over many years of dealing with patients, I have come to believe that physicians don’t realize how powerful their influence really is. Frightened patients are especially vulnerable, and when a trusted physician pushes, real power is in play. Essentially, enormous responsibility is bestowed on the physician by the patient.
When I noted that the true intent was within the heart and mind of the physician, it was this responsibility I was referring to, and for the patient to buy into this transference is the sine qua non of trust. At a minimum, the betrayal of such trust by a physician is a grave moral breach.
Dr. Sessions is the author of The Cancer Experience: The Doctor, the Patient, the Journey; published in 2012 by Rowman and Littlefield Publishing.