Summary of the third manuscript

Our empirical exploration of the tacit values of medical practice had caused us to describe the process of essentialising, during which the personal and human dimensions of patient suffering were systematically overlooked. In order to scrutinise this rather controversial finding, our aim in the third study was to focus on the tacit dimensions of how doctors care for their patients by analysing how this care was reflected in their actual medical practice.

It was also obvious in this study that the doctors were primarily concerned with improving their patients’ health. This is perhaps not very surprising, since this is a key and formal responsibility of the medical profession, but the extent to which this medical focus formed the consultation was still remarkable. Most doctors were very dominant in the consultations, despite an often friendly tone. With their presentation style, attitude, gestures, wording and forthright instructions, the doctors directed the consultations firmly. They often indicated when the patients could sit, when they could talk and on what subject, when they should be quiet and when they should leave. Even if the doctors started out with an open question, they would quickly answer or dismiss their patients’ questions and continue with what they regarded as the medical issue. Again, it was not the patients’ problems that seemed to be in focus of the consultations, but the doctors’ problem, i.e. the medical problem, as initiated by the patients.

Once more, we observed that the patients’ more existential needs or feelings were generally neglected. Patients often tried to raise their concerns or reflect upon how their illness was related to their personal life, but these attempts were usually brushed

aside with a smile or a shrug or were simply ignored. The doctors in this study also seemed to be primarily interested in their patients as medical objects. However, in the third study, we noticed how the doctors made small talk during these encounters, which seemed to reveal another aspect of the patient-doctor relationship. We found that conversing lightly, acting politely and maintaining a friendly tone were prominent features of the doctors’ behaviour. These are general signs of respect for another individual, and so the doctors could indeed be said to be attending to the humaneness of their patients. Accordingly, in this study, how the doctors maintained a relationship with their patients by acting courteously became clearer. This courteousness, while not reflecting any deeper concern for the life of the particular patient, displayed a general respect for the patient as a fellow human being. Patients were not treated only as medical objects or mechanical bodies; the doctors’ social interactions affirmed their human relationship with their patients. Yet, at the same time, and as noted above, the doctors neglected their patients’ more private sides. So, despite smiling, chatting and maintaining a good tone, they ignored patients’

expressed personal concerns and did not go into any existential dimension or meaning of their illnesses. This duality in the doctors’ approach was quite evident once we had discerned it. It would thus both be wrong to claim that doctors care for patients as human beings and that they do not; to clarify the issue, we need to be more specific about what we mean by “care for” and “as human beings”.

Maintaining some sort of superficial human relationship with a client is a familiar issue within many different professions. Yet clinical medicine differs in vital respects from other professional-client relationships, since it is the patient himself, or more specifically the patient’s body, that is the problem. The patient thus has to present himself for scrutiny by the doctor in order to get help. Moreover, because attending to the patient’s body as a medical object is likely to be an unavoidable part of the clinical encounter, it is perhaps of even greater importance that the doctor also emphasises the human connections with the patient. In these circumstances, doctors’

courteousness might restore the relationship with their patients, which is constantly under pressure because of the objectivation that goes on. On the other hand, it is also possible that the ways in which doctors both chat in a friendly manner to patients, at the same time as inspecting their bodily functions, confuses patients because of the mixed signals that are given out. Doctors’ courteousness may in some cases mask

their purposeful interventions and the essentialising process. When doctors appear to be friendly, fellow human beings, it might be perceived as even more surprising and offensive when they do not want to hear about patients’ personal suffering.

In our data we observed how doctors spoke in a friendly and medically correct manner to patients who were dying of cancer without ever addressing the fears that were expressed. We also saw patients who spoke of the relationship between their illness and their deceased spouses and were ignored by the doctors. We likewise observed doctors who were very friendly and forthcoming, but never got to the bottom of the patients’ enquiries because the medics paid no attention to the related existential issues.

The doctors’ care for their patients as individuals thus seems to have at least three dimensions. Firstly, there is the medical concern, which is constitutive of the patient-doctor relationship and based upon a humane and moral duty to relieve patients of their suffering and restore their health. Secondly, there is the demonstration of general courteousness, maintaining social contact with their patients and showing respect for their integrity as human beings. Thirdly, there is the existential care for patients as individuals which includes their feelings and private values. In our study, we found that all of the doctors displayed medical concern for their patients; almost all exhibited courteousness (although the amount varied); and hardly any displayed existential care. This demonstrates that the question of whether doctors care for patients as human beings is too complex for a yes or no answer. If we demand that doctors care more for their patients as individuals, we must specify in what way we want them to care. Likewise, when patients feel that they are not being cared for by the doctor, what aspect of caring is being referred to?

I suspect that many doctors often intuitively think that good communication is the same as caring for patients. Being polite, looking at patients while talking to them, and letting them formulate their own questions are indeed ways of showing respect for them as fellow human beings and is certainly positive. However, this does not nullify the existential neglect that is a part of the process of essentialising. By ignoring patients’ expressed existential concerns, doctors disregard their humanity in a way that can be morally offensive even if it may be unavoidable. While most

patients probably allow for this, those with conditions that fundamentally affect their personal lives may be particularly vulnerable.