Patient-centricity: a new model of moral and legal improvement

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Patient-centricity: a new model of moral and legal improvement

Horielova Veronika

Candidate of Legal Sciences,

Associate Professor of Department of State Legal Sciences University of Economy and Right "KROK"

Summary

The article is devoted to the problem of the moral and legal field through the prism of such an innovation as "patient-centric". The analysis of the category "patient-centric", which in domestic medicine is interpreted as providing patients with better conditions. Researched, the domestic understanding of the moral content of the category of "patient-centric" does not always coincide with foreign experience, where it is provided as one of the mandatory and important components of the quality of care, defined as ensuring that the patient's personal values are decisive in acceptance, all medical decisions and is committed to meeting the individual preferences of patients, their needs and values. Because, in our state, there are no moral and legal prescriptions which would clearly establish legal responsibility for violation of moral bases by doctors, and "patientcentric" is characteristic mainly of the system of "paid health care", because for a person the main factor in choosing paid medical care is not only quality medical care, but also humanity, a high degree of morale of doctors. Thus, patient-centrism becomes a method of service component of medical services aimed at the consumer needs of patients. In such a situation, there is a danger of a situation where the patient is morally satisfied with his attitude, but medical control over his chronic diseases deteriorates, because it is not uncommon for patient orientation to be only a slogan or marketing tool that is far from moral precepts and rights. after all, for a person, the main factor in choosing paid medical care is not only quality medical care, but also humanity, a high degree of morale of doctors. Thus, patient-centrism becomes a method of service component of medical services aimed at the consumer needs of patients. In such a situation, there is a danger of a situation where the patient is morally satisfied with his attitude, but medical control over his chronic diseases deteriorates, because it is not uncommon for patient orientation to be only a slogan or marketing tool that is far from moral precepts and rights. after all, for a person, the main factor in choosing paid medical care is not only quality medical care, but also humanity, a high degree of morale of doctors. Thus, patient-centrism becomes a method of service component of medical services aimed at the consumer needs of patients. In such a situation, there is a danger of a situation where the patient is morally satisfied with his attitude, but medical control over his chronic diseases deteriorates, because it is not uncommon for patient orientation to be only a slogan or marketing tool that is far from moral precepts and rights.

The article analyzes foreign experience and medical reform in Ukraine on the issue of moral and legal principles of the patient-oriented model. Emphasis is placed on the need to include the category of "patient-centric" in the component of medical ethics, a list of principles of the category of "patient-centric", and an approach that artificially corrects the behaviour of the doctor. The article attempts to prove that the moral principles of the doctor should prevail over the principles of patientcentric ethics.

Key words: patient-centricity, morality, law, medical ethics, moral ideas, morality of doctors.

Анотація.

ПАЦІЄНТО-ЦЕНТРИЧНІСТЬ: НОВА МОДЕЛЬ МОРАЛЬНО-ПРАВОВОГО ВДОСКОНАЛЕННЯ

Горєлова Вероніка Юріївна кандидат юридичних наук, доцент, доцент кафедри державно-правових дисциплін Університет економіки та права "КРОК"

Стаття присвячена проблемі морально-правового поля крізь призму такого новаторства як "пацієнто-центричність". Проводиться аналіз категорії "пацієнто-центричність", яка у вітчизняній медицині інтерпретується як надання пацієнтам кращих умов. Досліджено, що, вітчизняне розуміння морального змісту категорії "пацієнто- центричність" не завжди співпадає з зарубіжним досвідом, де вона передбачена як одна з обов'язкових і значущих складових якості медичної допомоги, визначається як така, що гарантує, що особисті цінності пацієнта є визначальними в прийнятті усіх медичних рішень та зобов'язується задовольняти індивідуальні вподобання пацієнтів, їх потреби і цінності. Оскільки, в нашій державі поки що не існує морально-правових приписів, які б чітко встановлювали правову відповідальність за порушення моральних підвалин лікарями, "пацієнто-центричність" характерна в основному для системи "платної охорони здоров'я", адже для людини основним фактором вибору платної медичної допомоги є не тільки якісне медичне обслуговування, а й людяність, висока ступінь моралі лікарів. Таким чином, пацієнто-центричність стає методом сервісної складової медичних послуг, направленого на споживчу потребу пацієнтів. В такій ситуації закрадається небезпека отримання ситуації, коли пацієнт морально задоволений відношенням до нього, проте лікарський контроль за його хронічними захворюваннями погіршується, адже не поодинокі випадки, коли орієнтація на пацієнта виявляється лише лозунгом або маркетинговим засобом, які далекі від моральних приписів та права.

В статті проводиться аналіз зарубіжного досвіду та медичної реформи в Україні стосовно питання моральних та правових принципів пацієнт-орієнтованої моделі. Ставиться наголос на необхідності внесення категорії "пацієнто- центричність" до складової медичної етики, пропонується перелік принципів категорії "пацієнто-центричність", та пропонується підхід, який штучно корегує поведінку лікаря. В статті робиться спроба довести, що моральні принципи лікаря повинні переважати принципи пацієнто-центричної етики.

Ключові слова: пацієнто-центричність, мораль, право, медична етика, моральні уявлення, мораль лікарів.

Аннотация.

ПАЦИЕНТО-ЦЕНТРИЧНОСТЬ: НОВАЯ МОДЕЛЬ МОРАЛЬНО-ПРАВОВОГО УСОВЕРШЕНСТВОВАНИЯ

Горелова Вероника Юрьевна кандидат юридических наук, доцент доцент кафедры государственно-правовых дисциплин Университет экономики и права "КРОК"

Статья посвящена проблеме нравственно-правового поля сквозь призму такого новаторства как "пацієнто-центричность". Проводится анализ категории "пацієнто-центричность", которая в отечественной медицине интерпретируется как предоставление пациентам лучших условий. Исследовано то обстоятельство, что отечественное понимание нравственного содержания категории "пацієнто-центричность" не всегда совпадает с зарубежным опытом, где она предусмотрена как один из обязательных и значимых составляющих качества медицинской помощи, определяется как такая, которая гарантирует, что личные ценности пациента являются определяющими в принятии всех медицинских решений и обязуется удовлетворять индивидуальные предпочтения пациентов, их потребности и ценности. Поскольку в нашем государстве пока не существует морально-правовых предписаний, которые бы четко устанавливали правовую ответственность за нарушение моральных устоев врачами, и "пацієнто-центричность" характерна в основном для системы "платного здравоохранения", ведь для человека основным фактором выбора платной медицинской помощи является не только качественное медицинское обслуживание, но и человечность, высокая степень морали врачей. Таким образом, пацієнто-центричность становится методом сервисной составляющей медицинских услуг, направленного на потребительскую потребность пациентов. В такой ситуации закрадывается опасность наступления ситуации, когда пациент морально удовлетворен отношением к нему, однако врачебный контроль за его хроническими заболеваниями ухудшается, ведь не единичны случаи, когда ориентация на пациента оказывается лишь лозунгом или маркетинговым средством, которые далеки от моральных предписаний и права.

В статье проводится анализ зарубежного опыта и медицинской реформы в Украине относительно вопроса нравственных и правовых принципов пациент-ориентированной модели. Ставится акцент на необходимости внесения категории "пацієнто-центричность" как составляющей медицинской этики, предлагается перечень принципов категории "пацієнто-центричность", и предлагается подход, который искусственно скорректирует поведение врача. В статье делается попытка доказать, что моральные принципы врача должны преобладать над принципами пацієнто-центрической этики.

Ключевые слова: пацієнто-центричность, мораль, право, медицинская этика, моральные представления, мораль врачей.

Formulation of the problem. Considering the problems of morality and law in medicine, we encounter such a concept as patient-centred, which in domestic medicine is interpreted as providing patients with better conditions. Patient-centeredness is characteristic mainly for the contingent of paid health care - where the main factor in choosing a clinic is not only quality medical care but also humanity, a high degree of morale. Patient-centricity can also be called a method of consumer behaviour of patients or a service component of medical services. But often, patient-orientation remains just a slogan or, conversely, becomes just a good marketing move, for which there are no real moral foundations.

Analysis of recent research and publications. The moral issue of patient-centrism in modern works of lawyers has not been discussed today, the development of some of its aspects can be explored only in the works of philosophers and marketers. Also noteworthy are medical ethics researchers such as R. Witch, Laurence McCullough, T. Caulfield, and others who have emphasized the doctor's lack of respect for the patient's autonomy, noting his or her preferences and moral needs. The rules of conduct included in the concept of "patient-centric" we draw mainly from such documents as the Helsinki Declaration of the World Medical Association (WMA), the International Code of Medical Ethics, the Code of Ethics for Physicians of Ukraine and more.

Part of the general problem has not been solved previously. Paying so much attention to medical ethics and moral principles of the physician, we find that the emergence of patient-centred in domestic medicine is not a spontaneous phenomenon, it is born of the desire of each person, and sometimes puts it in the first place, fully in line with the legal framework. However, this phenomenon has not been studied, and thus, the question arises whether there may be a moral and legal issue of patient-centrism in medicine?

Formulating the goals of the article. The purpose of the article is to reveal the problem of patient-centrism as a new type of moral category on the part of morality and law; make suggestions. patient medical service

Presentation of the main research material. One of the main points of the oath of a doctor of Ukraine is the recognition of the patient as the highest social value (which coincides with Article 3 of the Constitution of Ukraine [1]) and the commitment to adhere to the rules of professional ethics - ie to maintain their high morals [2].

If a person is asked what a good doctor is, or which doctor he would like to see in case of illness, in addition to experience and skills, patients always mention the moral qualities of a doctor. By moral qualities most often a person understands "living" compassion for himself, the attitude is not superficial, as annoying, but as one who is happy to help. A sick person already considers a doctor good and unconsciously raises his assessment if he has such moral traits as attentiveness, sensitivity, friendliness, gentleness, care, respect, modesty, interest in the patient's recovery, willingness to help, ability to comfort, and so on. Patient-centrism, therefore, is the involvement of modern patients in the need to take care of their health.

Patient-centricity, according to American scientists, is one of the mandatory and important components of the quality of care and is defined as ensuring that the patient's personal values are decisive in making all clinical decisions and is committed to meeting individual preferences, needs and values [3].

The morality of such patient-centred care is an approach that artificially corrects the physician's behaviour, for example: adherence to patients' preferences regarding treatment methods, the patient's location during treatment, persons who may be close to the patient, and so on. Analyzing this approach, on the one hand, we do not see anything immoral, unethical or illegal in it. This approach is quite justified for moral reasons, and does not depend on the results of treatment. However, a situation can be dangerous in which the patient is morally satisfied with his attitude, but the control of chronic diseases is deteriorating. In this case, the question arises: has patient-centred care been provided?

Researchers are thus only beginning to model ways in which patient-centred behaviour will contribute to better outcomes. For example, it is not the disease that treats the patient, but the patient-oriented model in Ukrainian family medicine, which is based on a longterm relationship between doctor and patient. These relationships are not limited to a single episode of the disease. They are created and strengthened in the process of communication between doctor and patient over a long period of life. Medical reform in Ukraine also addresses the issue of moral and legal principles of the patient-oriented model:

1. Respect for the values and beliefs of the patient: the right of a person to respect his individual preferences, needs and moral values; the right to make proposed clinical decisions; the right to one's own beliefs regarding methods of treatment.

2. Respect for dignity, respect and sensitivity to cultural characteristics, religion and personal autonomy.

3. Acting as a defender of the interests of his patient.

4. Providing complete information to the patient upon request about his health or about certain prognoses of his health (information about the clinical condition, progress and prognosis; information about treatment/care processes; information needed to increase patient independence, self-care and strengthening health).

5. Providing a level of physical comfort for patients: pain management; assistance in daily activities and provision of daily living needs; the atmosphere of the medical institution.

6. Emotional support and reduction of fear and anxiety associated with the disease or the patient's concern about the financial consequences of the disease.

7. Respect for the patient's right to involve family and friends in the decision regarding treatment and taking into account the possibility of the closest circle of people nearby when the patient is hospitalized.

8. Providing the patient with information on access to clinical, social, physical and financial support.

9. Providing patients with information on unimpeded access to the location of dispensaries and hospitals, the availability of public transport,

10. Ensuring ease of planning patients' visits to the doctor and making an appointment.

11. Ensuring the availability of referrals to specialists or specialized services [4].

This list is fully consistent with the Code of Ethics of Physicians of Ukraine of 2006 [5]. According to the content of this code, the following provisions can be added to the principles of patient-oriented medicine:

- The doctor must by his behaviour or other activities (lectures, conversations, online recordings, etc.) to promote a healthy lifestyle and be an example in compliance with its rules and regulations.

- The doctor must provide medical care to patients regardless of age, sex, race, nationality, social status, political views, place of residence, citizenship and other non-medical characteristics, including financial status.

All the above makes it possible to say that such a new approach in medicine, focused on the person (patient) is fully consistent with the basic principles of the Helsinki Declaration of the World Medical Association (WMA), which defines the duty of the doctor in the following words: will be my main concern "[6], and the International Code of Medical Ethics states:" A doctor must act in the interests of the patient when providing medical care "[7]. According to paragraph 4 of the Declaration of the MMA, the doctor's duty is to maintain and protect the health, well-being and rights of patients, including those involved in medical research, and the knowledge and conscience of the doctor should be used to serve this debt [6].

However, it should be emphasized that a doctor is an independent person, and therefore he has no right to lose his professional independence before the policy of the medical institution, or in the case of motives of material reward, career or satisfaction of their own ambitions. The principles of patient-centred medicine should not conflict with the ethical principles of the physician, and in some cases, the moral principles of the physician should prevail. For example: a patient requires conditions of treatment that are generally legal and moral, but will harm the patient, or the patient needs conditions, or treatment with which the doctor cannot agree. Therefore, the doctor must be honest with patients, colleagues and with himself. For example, if a doctor is against artificial birth at all, then no one has the right to persuade him to do so.

Patient-oriented medicine should not appoint a doctor as a submissive servant and should legally protect his dignity and principles, because the doctor should have the right to refuse treatment if the patient humiliates the doctor or distorts his own treatment without following his doctor's instructions, or other actions that will make treatment impossible.

Thus, patient-oriented medicine is a certain benefit, subject to certain conditions:

- ensuring the doctor's right to professional and personal moral independence and autonomy;

- granting the doctor the right to refuse to provide services to the patient in cases of unethical treatment of the doctor, because if the method of treatment proposed by the doctor is rejected by the patient, provided that another method of treatment is not correct;

- imposing an obligation on the doctor to offer or refer to another qualified specialist, whose services will be better for the interests of the patient;

- imposing a duty on the doctor to provide complete information on the content of the services offered, in particular concerning time and money;

- in the presence of a conflict of interest, the moral principles governing the professional activities of a physician should be a priority for any business or activity.

Researchers believe that the patient is the best judge of whether the interaction is patient-centred. This assumption is understandable, but sometimes what patients think they want is not what they need. A doctor who agrees to a patient's request for unnecessary antibiotics may have a happy patient, but an inappropriate appointment can hardly be called patient-centred care. Researchers also point to the need to address several other issues in patientcentred medicine: first, it is a problem of informing patients (these are cases where the patient demands to tell the truth about his condition, but the doctor thinks it can harm him); secondly, patients' misunderstanding of the reality (when patients often overestimate the capabilities of doctors or do not understand the essence of their own disease). Thus, the researchers concluded that the need for psychological and legal training of physicians to assess patient orientation [8, p.21].

Conclusions

Of course, the approach to medicine aimed at the patient is completely new to Ukrainian realities. And of course, such a change of values and approaches will require some time and effort. But the status of doctors in recent years and their financial support is growing. And this places additional responsibility on doctors - for the quality of medical care and for raising the level of personal morale. Patient- centrism can then be recognized as an effective and qualitative component of a doctor's professional ethics, when it will be based on open and effective two-way communication between doctor and patient.

In connection with the above, we consider it appropriate to supplement the Code of Ethics for Physicians with a separate chapter "Patient Orientation", the main elements of which should be:

- the desire for self-improvement, which includes experience, training, gaining the authority of a doctor;

- tolerance to the sick person, who is the centre of care during treatment;

- bilateral awareness, taking into account mutual trust and respect,

- taking into account the preferences and expressed needs of people;

- coordination and integration of assistance;

- joint work to ensure proper communication;

- providing physical comfort and safety;

- emotional support with family and friends;

ensuring continuity between and within services and ensuring that people have access to appropriate assistance when they need it.

References

1. Constitution of Ukraine. URL: ttps://zakon.rada.gov.ua/laws/show/254K/96-Bp

2. Decree of the President of Ukraine of June 15, 1992 No. 349 "On the Oath of a Doctor". URL: https://zakon.rada. gov.ua/laws/show/349/92

3. Institute of Medicine. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. 360 p.

4. Eight principles of patient-centred model in family medicine. URL: https://ibuhgalter.net/ru/news/6253 (appeal date: 11/19/2019)

5. CODE OF ETHICS OF THE DOCTOR OF UKRAINE by the decision of the Ukrainian Medical Council protocol № 18 from January 27, 2006 URL: https://mcu.org.ua/nadlezhashhaya-medicinskaya-praktika/eticheskij-kodeks-vracha- ukrainy/

6. Ethical principles of medical research with the participation of man as a subject. HELSINKI DECLARATION OF THE WORLD MEDICAL ASSOCIATION. Adopted at the 18th General Assembly of the Military Medical Academy, Helsinki, Finland, June 1964. URL: http://uacm.kharkov.ua/download/2014_11/22.pdf

7. International Code of Medical Ethics Adopted by the 3rd General Assembly of the Military Medical Academy, London, England, October 1949. URL: https://zakon.rada.gov.ua/laws/show/990_002

Epstein RM, Street RL Jr. Patient-Centred Communication in Cancer Care: Promoting Healing and Reducing Suffering. Bethesda, MD: National Cancer Institute, NIH; 2007.

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