Principle of Primacy of Patient Welfare – The Fundamental Principle in Medical Professionalism and Practice

Date:
01/03/2015

This paper was originally delivered as a National University Hospital grand round presentation on 17 October 2014.

The commitment to the primacy of patient welfare is a longstanding historical and fundamental principle held across all healthcare professionals. It embodies the internal core of clinical medicine, that is: a fellow human, who is distressed by disease and unable to resolve the distress (both physical and psychological), decides to seek the help of another human who professes to have the knowledge, skill and motivation to help. Medicine is basically an enterprise rooted in human welfare, relieving of suffering and healing traditions. Medicine has, in its foundation, an overwhelming social and ethical dimension in its goals.

The principle demands acceptance of holding the interest of the patient above that of the clinician’s. Market forces, societal pressures, and administrative exigencies must not compromise this principle. Today’s medicine is marked by for-profit medicine, medical entrepreneurship, investment in and ownership of medical facilities by clinicians. This brings altruism and the patient’s welfare in direct conflict with the financial interests of clinicians and hospitals.

The principle underlines the fiduciary nature of the professional relationship and the virtue of altruism in developing trust and confidence which is essential in achieving the goals of medicine. It alludes to the inherent imbalance of power in the doctor-patient relationship. It recognises the vulnerability and dependency of the patient when undergoing the illness experience. Illness can be viewed as an assault on the patient’s autonomy to move, choose, carry out her vocation and pursue her life’s goals. The assaults are of the threat or actuality of death, permanent disability, pain, shame, discomfort and limitations of a chronic illness. The patient is thus vulnerable to exploitation and abuse, which this principle aims to protect her from.

Scope of the principle

In upholding this principle, the clinician is committed to maintain and improve his clinical competence. Without clinical competence, the goals of improving the patient’s welfare would not be reached, and the patient potentially harmed in the process of care. The scope of this principle also encompasses the principle of fidelity and non-abandonment. The virtue of altruism and fidelity marks the clinician’s commitment to provide care beyond the contractual model with acceptance of reasonable risk and inconveniences to him.

It is a commitment to maintaining trust by appropriately managing conflicts of interest. The scope of the principle requires a commitment to preserve the professional boundaries and not violate them by the clinician’s interest. This principle also embodies the legal duty of care owed to the patient based on due diligence, care, skill, knowledge and sound judgement.

What is necessary to effect this principle is the develop-ment of capacity for compassion, humility, conscientiousness, wisdom (discernment) and integrity on the part of the clinician and the healthcare profession and organisation.

In fact, this principle alone renders the clinician to be committed to maintaining all professional responsibilities and guard against any abuse of professional privileges (see Table). The scope is wide and so is the challenge for the clinician to uphold this principle.

Professional autonomy and judgement

The practice of medicine is complex, full of uncertainties and demands a high level of commitment and effort on the practitioner. Developing appropriate responses to the challenges, complexities and uncertainties in medicine calls for good professional judgement, which includes clinical and ethical competence. Professional judgement would require the clinician to make things black or white, when many areas of medical practice are grey, so the treatment plan can be executed. Inappropriate delays or indecision can harm the patient’s welfare.

The clinician needs discretionary space, time, support and resources to enable the exercise of good clinical and ethical decisions and judgement in serving the principle of primacy of patient welfare. Professional autonomy is about meeting the professional standard of care and the ethical and legal duty of care.1

Healthcare organisations can support or destroy the development of good professional judgement by their policies, protocols and ethics. Healthcare financiers can support or destroy professional discretion in upholding the principle of primacy of the patient welfare.2 Professional regulators can support or destroy professional autonomy in upholding this principle. Overregulation, legalisation of medical practice, bureaucratisation of healthcare services and its financing can all compromise the development of good medical judgement in the clinic and at the bedside.

Do the regulations and the ethical codes facilitate or restrict the professional autonomy and the exercise of responsible professional discretion? Are the regulations and the ethical code guiding or dictating medical practice? These are questions that the profession must be engaged in regularly, to create the discretionary space and to protect professional autonomy, in order to uphold the principle of primacy of patient welfare.

Counter-instinctive nature of professional obligations

Essential factors for enabling the clinician to uphold the principle of primacy of patient welfare includes lifelong professional education, clinical training and experience. Placing another person’s interest above one’s own is counter-instinctive. Demonstrating calmness and professional demeanour in an overbooked clinic, crowded hospital ward or highly provoked emotional situations is counter-instinctive. Displaying compassion and empathy when one is deprived of sleep and food, and when physically and emotionally exhausted, is counter-instinctive.

Self-interest and self-preservation are instinctive. Fight, fright and flight responses in stressful situations are instinctive. Denial, discounting and distancing are common behaviours of all humans when unexpected adverse outcomes arise. Liking and being compassionate to people who are like ourselves is a naturally instinctive behaviour. Upholding the principle of primacy of patient welfare does not come naturally to the human predicament. Learning counter-instinctive behaviours and habits requires a transformative learning process.

Transformative learning journey

Acquiring the skills and demonstrating professionalism is achieved by incremental development in a transformative learning journey, shaped over a lifetime of care. It involves a process of modelling and remodelling by knowledge, experience, reflection and metacognition. It is a process of redefining our beliefs and learning new skills. Time is required for internalising and imbibing values. The clinician needs to be mentored, coached, and where necessary, counselled.

Transformative learning comprises a multistage and multistep cognitive, emotional and intuitive learning process. It involves a psychological transformation by developing self-awareness, self-examination, skills in situational awareness, and critical reflection on experience and oneself. It also involves a convictional change and paradigm shifts of personal beliefs and values to professional values and habits. Additionally, it involves a behavioural transformation of conscious change of unhelpful behaviours to developing new habits and behaviours. Role modelling is an essential component of transformative learning.

The professional education requires the development of self-awareness and training in self-management. Self-awareness involves recognising the warning signs of stress (somatic, emotional and cognitive) and responding appropriately to them. At the same time, there is a need to develop social and cultural awareness of others. Mindfulness or mindful practice comprises an acceptance of one’s own imperfections and a willingness to audit and improve one’s own ideas, behaviour and performance. Becoming a medical professional requires the acquisition of skills in building therapeutic relationships and appropriate dispute resolution.

Acquiring the skills and demonstrating professional behaviour necessary to uphold the principle of primacy of patient welfare needs a transformative learning process. Transformative learning must be supported by a community of self-motivated lifelong learners. Becoming an effective professional requires a professional collegial enterprise and effort.

Conclusion

Upholding this principle of primacy of patient welfare is essential to preserve the humanistic core and the healing nature of medicine. As medicine is a complex system, the upholding of this fundamental principle is a function of the entire medical community. There has to be a willing assumption of ownership of this principle by all stakeholders in medicine, namely the medical profession, the public, the press and media, policy makers, regulators, healthcare organisations, politicians and patients.


References

  1. Fryar C. Doctors can depart from guidelines in patients’ best interests. BMJ 2015; 345:h841.
  2. Boyd CM, Darer J, Boult C, et al. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases. JAMA 2005; 294(6):716-24.