Health is a fundamental good valued across many contexts, including personal, social and economic life, related to the maintenance and well-being of the whole person. Without health personal plans cannot be made, projects pursued, or identities created without restrictions imposed by a physical, mental or social ailment. Health is therefore a prerequisite for the realisation of other human goods.

Broadly speaking, the end of medicine is to guarantee the health of a society and individuals within it. Despite the difficulties of defining health and illness as concepts, medicine is broadly recognised as a practice to promote health, thereby working towards a fundamental good. A lack of agreement on a ‘correct’ definition of health, reflected in debate on the topic, does not undermine the fundamental value of health to human life. The ends of medicine are achieved through ‘good’ medical encounters with individual patients. In pursuing these ends in the doctor-patient relationship, moral and technical capacities must work together in the interests of the patient because medical activity affects individuals with moral worth and interests.

As discussed in the section entitled “The Oviedo Convention and human rights principles regarding health”, the Oviedo Convention prescribes the following values:

  • Human dignity
  • Primacy of patient interests over societal and scientific interests
  • Right to life
  • Physical integrity
  • Privacy and identity
  • Informed consent
  • Right to know and right not to know
  • Prohibition of discrimination and inequality in access to healthcare
  • Quality of care standards

These values, and the different goals of medicine as a practice, can be realised through different types of doctor-patient relationships. Models of the (ideal) doctor-patient relationship have adapted over time in recognition of the growing importance of patient autonomy and its appropriate balance with other ethical obligations of the doctor towards beneficence, non-maleficence, and justice. An influential paper from Emanuel and Emanuel (1992) proposed four models for the doctor-patient relationship:

Paternalistic Model

This model vests the vast majority of decision-making power in the doctor. It assumes the existence of shared, objective values or criteria to define the best course of action to promote the patient’s health and well-being. The doctor’s role is expert, skilled practitioner tasked with “promoting the patient’s well-being independent of the patient’s current preferences.” The doctor acts as “the patient’s guardian, articulating and implementing what is best for the patient.” Autonomy is realised only through patient assent to the doctor’s determination of the best course of action.

Informative Model

In contrast, this model vests the vast majority of decision-making power in the patient. The objective of clinical interactions “is for the doctor to provide the patient with all relevant information, for the patient to select the medical interventions he or she wants, and for the doctor to executive the selected interventions.” Objectives values are not assumed; rather, the patient’s values and interests are taken as known or fixed to the patient but not the doctor. The doctor’s role is to provide facts to facilitate the patient making a decision that bests matches their interests.

Interpretive Model

This model closely follows the informative model but provides a greater role for the doctor to assist the patient in understanding her values and interests, and the possible impact of different interventions in these terms. The doctor acts as an advisor to help the patient “elucidate and make coherent” their values but does not pass judgement on these values or attempt to prioritize them on behalf of the patient. The ultimate choice of intervention still rests with the patient in the interpretive model, but the doctor plays a more active role in shaping this choice than the informative model.

Deliberative Model

This model closely follows the interpretive model but gives the doctor a greater role in judging and prioritizing patient values. It is the doctor’s role to “elucidate the types of values embodied in the available options…suggesting why certain health-related values are more worthy and should be aspired to.” Deliberation between the doctor and patient remains limited to “health-related values, that is, values that affect or are affected by the patient’s disease and treatments; he or she recognizes that many elements of morality are unrelated to the patient’s disease or treatment and beyond the scope of their professional relationship.” The aim of the deliberation is moral persuasion, but not coercion, with the patient ultimately deciding on the appropriate validity and priority of these values in their life. Whereas the doctor is an advisor or counsellor in the interpretive model, in the deliberative model they serve as “a teacher or friend, engaging the patient in dialogue on what course of action would be best.” The doctor indicates both what the patient could do and, in the context of their understanding of the patient’s life and values, what he thinks the patient should do in terms of choice of intervention. The final decision still remains with the patient but is subject to greater persuasion and normative argumentation on the part of the doctor. This model conceives of patient autonomy as a tool for moral self-development; “the patient is empowered not simply to follow unexamined preferences or examined values, but to consider, through dialogue, alternative health-related values, their worthiness, and their implications for treatment.”

Read more

A fifth model is mentioned in Emanuel and Emanuel’s treatment of the doctor-patient relationship, the ‘instrumental model’, but quickly discarded on moral grounds. In the instrumental model the patient’s values are given no importance; rather, the doctor takes a decision or convinces the patient to choose a particular course of treatment on the basis of external values such as social or scientific good. While rightly condemned on moral grounds, it should be noted that this model remains potentially relevant as a warning for the deployment of AI. In cases where AI is pursued not for the good of the patient, but rather for the sake of efficiency or cost savings, one could argue the doctor-patient relationship is instrumentalized. The influence of such external values on the doctor-patient relationship are elaborated below.

Each of these models of the doctor-patient relationship show varying degrees of respect to patient autonomy and moral self-development. The rights and values embedded in the Oviedo Convention provide some indication of the general acceptability of these models of the doctor-patient relationship. A paternalistic model would appear prone to violating the informed consent requirement set out in Article 5. A deliberative model would likewise appear to violate a specific aspect of the consent requirement expanded on in the Convention’s Explanatory Report: a patient’s consent should be based on “objective information” provided “in the absence of any pressure from anyone.” The difficulty of providing objective information will be picked up again in the section entitled “Potential impact of AI on the doctor-patient relationship” in discussing transparency in AI-mediated clinical care.