Defining The Covenant Relationship and Informed Consent
In recent years, the physician-patient dynamic has become more of a business transaction rather than a trusting relationship. Several medical ethicists state that “medical care has become more of a contractual, legalistic, rights based agreement which greatly diminished the trust that marked the old relationship between doctor and patient, the covenant” [1]. Many physicians wish to maintain the covenant relationship with their patients because they believe that “medicine is, and its sender, a moral enterprise grounded in a covenant of trust”[2]. This covenant, defined as a “mutual agreement between persons to do or refrain from certain acts” charges physicians to be “competent and to use their competence in the patient’s best interest” and to “serve the good of those persons who seek help”[2-3]. The covenant relationship also refrains physicians from becoming “commercial entrepreneurs, gate-closers, or agents of fiscal policy that run counter to trust”[2].
The covenant relationship is the solid foundation upon which the process of informed consent is built. Informed consent is the process of “disclosure of appropriate information to a competent patient who is permitted to make a voluntary choice”[4]. During this process, the physician determines the amount of disclosure that will enable the patient to make an informed medical decision. When determining proper disclosure, the physician views the consenting process through a particular ethical lens. The covenant relationship between physician and patient is best cultivated when the physician views informed consent through a deontologist perspective rather than a consequentialist perspective.
Deontologism vs. Consequentialism
When embracing the covenant relationship during the process of informed consent, deontologism trumps the opposing consequentialism viewpoint because it better emphasizes the physician’s obligations in a covenant relationship.
Deontologists favor “obligation and rightness-wrongness” in opposition to consequentialists, who favor the final result, or the “empirical value of consequences”[5]. The purely consequentialist physician is not held to any method of providing information, as long as the end result is a patient able to give informed consent. For example, the consequentialist orthopaedic surgeon may simply give informative brochures to a patient considering an elective arthroplasty. While this physician may achieve the end result of appropriate informed consent, one might question if he fully embraces the covenant role of “healer, carer, helper and advocate” in providing consent [2].
In contrast, a physician appealing to pure deontologism embraces the “obligation and rightness-wrongness” of the consenting process, which naturally supports a covenant-type relationship with the patient [5]. An example of this would be the orthopaedic surgeon who discusses various options, provides informative brochures, and helps interpret the risks and benefits for a patient considering an elective arthroplasty. This physician is focused on the methods and process of the informed consent more than the absolute, “empirical consequence”[5]. Granted, absolute pure deontologism is not ethically viable for giving informed consent because the end result must still be achieved. Even so, one could argue that the deontologist’s emphasis on virtue would automatically ensure that the patient was properly educated to provide informed consent. To maintain the covenant relationship when providing informed consent, deontologist ethics trumps consequentialist ethics because consequentialism enforces the end result, but deontologism emphasizes the physician’s methodological obligations necessary to arrive at the result.
Conclusion
Establishing a covenant relationship between patient and physician is critical for cultivating trust and practicing virtue ethics in medicine[6]. The process of obtaining informed consent is one of the most important exercises of patient autonomy and thus should be viewed through a carefully selected ethical lens. While consequentialist ethics places the end result above the process, deontologist ethics favors the virtuous obligations of the process, which are necessary in establishing a covenant of trust with the patient. A physician employing deontologist ethics properly emphasizes the obligations of a covenant relationship in the process of providing informed consent.
References
- Beyda D. Curing or Caring: The Physician’s Dilemma. September 2014.
- Crawshaw R, Rogers D, Pellegrino E. Patient physician covenant. JAMA 1995;(273):150-53.
- covenant, n. In: Oxford English Dictionary. Vol Oxford University Press.
- Appelbaum P. Assessment of Patients’ Competence to Consent to Treatment. N. Engl. J. Med. 2007;357:1834-40.
- Schuh S. Hard and soft deontologism. J. Value Inq. 1992;26(2):281-85.
- Pellegrino E. The Virtuous Physician and the Ethics of Medicine. In: Virtue and Medicine: Exploration in the Character of Medicine. Vol Philosophy and Medicine. D Reidel Publishing Co.; 1985:243-55.
Matthew DiLizia is a medical student at the University of Arizona College of Medicine - Phoenix, Class of 2018. He is a graduate of Arizona State University with a degree in Biochemistry. He plans to pursue a career in a surgical specialty. He may be reached by email at emdilizia1@email.arizona.edu with any questions, comments, or thoughts on this article.