Helge Skirbekk

Mandates of Trust in the Doctor–Patient Relationship

We examine the conditions for trust relationships between patients and physicians. A trust relationship is not normally negotiated explicitly, but we wanted to discuss it with both patients and physicians. We therefore relied on a combination of interviews and observations. Sixteen patients and 8 family physicians in Norway participated in the study. We found that trust relationships were negotiated implicitly. Physicians were authorized by patients to exercise their judgment as medical doctors to varying degrees. We called this phenomenon the patient’s mandate of trust to the physician. A mandate of trust limited to specific complaints was adequate for many medical procedures, but more open mandates of trust seemed necessary to ensure effective and humane treatment for patients with more complex and diffuse illnesses. More open mandates of trust were given if the physician showed an early interest in the patient, was sensitive, gave time, built alliances, or bracketed normal behavior.

The ethics of care: Role obligations and moderate partiality in health care

This article contends that an ethics of care has a particular moral ontology that makes it suitable to argue for the normative significance of relational responsibilities within professional health care. This ontology is relational. It means that moral choices always have to account for the web of relationships, the relational networks and responsibilities that are an essential part of particular moral circumstances. Given this ontology, the article investigates the conditions for health care professionals to be partial and to act on the basis of particular responsibilities to their patients. We will argue that priorities could be partial in three ways: first, because there may be exceptional circumstances that allow for giving priority to one patient over another; second, because the integrity of the patient and a health care worker may be connected in special ways; and, finally, even if impartiality is essential, the institutional basis of health care must always give ample space for an ethically qualified individual and personal care for patients. Even if difficult priorities may be necessary, the conditions of institutional health care should always seek to create the prerequisites for nurses and doctors to administer proper care.

Negotiated or taken-for-granted trust? Explicit and implicit interpretations of trust in a medical setting

Trust between a patient and a medical doctor is normally both justified and taken for granted, but sometimes it may need to be negotiated. In this paper I will present how trust can be interpreted as both an explicit and implicit phenomenon, drawing on literature from the social sciences and philosophy. The distinction between explicit and implicit interpretations of trust will be used to address problems that may arise in clinical consultations. Negotiating trust in any way very easily brings distrust into a situation, but sometimes this can be helpful for building a more functional patient-doctor relationship.

Inadequate Treatment for Elderly Patients: Professional Norms and Tight Budgets Could Cause “Ageism” in Hospitals

We have studied ethical considerations of care among health professionals when treating and setting priorities for elderly patients in Norway. The views of medical doctors and nurses were analysed using qualitative methods. We conducted 21 in depth interviews and 3 focus group interviews in hospitals and general practices. Both doctors and nurses said they treated elderly patients different from younger patients, and often they were given lower priorities. Too little or too much treatment, in the sense of too many interventions and too much drugs, combined with too little care and comfort, was admitted as a relatively frequent yet unwanted consequence of the way clinical priorities were set for elderly patients. This was explained in terms of elderly patients not tolerating the same treatment as younger patients, and questions were raised about the quality of life of many elderly patients after treatment. These explanations were frequently referred to as medically sound decision making. Other explanations had little to do with medically sound decisions. These often included deep frustration with executive guidelines and budget constraints.

Making a Difference: A Qualitative Study on Care and Priority Setting in Health Care

The focus of the study is the conflict between care and concern for particular patients, versus considerations that take impartial considerations of justice to be central to moral deliberations. To examine these questions we have conducted qualitative interviews with health professionals in Norwegian hospitals. We found a value norm that implicitly seemed to overrule all others, the norm of ‘making a difference for the patients’. We will examine what such a statement implies, aiming to shed some light over moral dilemmas interwoven in bedside rationing.

Conscientious objection to referrals for abortion: pragmatic solution or threat to women’s rights?

BackgroundConscientious objection has spurred impassioned debate in many Western countries. Some Norwegian general practitioners (GPs) refuse to refer for abortion. Little is know about how the GPs carry out their refusals in practice, how they perceive their refusal to fit with their role as professionals, and how refusals impact patients. Empirical data can inform subsequent normative analysis.MethodsQualitative research interviews were conducted with seven GPs, all Christians. Transcripts were analysed using systematic text condensation.ResultsInformants displayed a marked ambivalence towards their own refusal practices. Five main topics emerged in the interviews: 1) carrying out conscientious objection in practice, 2) justification for conscientious objection, 3) challenges when relating to colleagues, 4) ambivalence and consistency, 5) effects on the doctor-patient relationship.ConclusionsNorwegian GP conscientious objectors were given to consider both pros and cons when evaluating their refusal practices. They had settled on a practical compromise, the precise form of which would vary, and which was deemed an acceptable middle way between competing interests.

Prioritising patient care: The different views of clinicians and managers:

Background: There is little research comparing clinicians’ and managers’ views on priority settings in the healthcare services. During research on two different qualitative research projects on healthcare prioritisations, we found a striking difference on how hospital executive managers and clinical healthcare professionals talked about and understood prioritisations. Aim: The purpose of this study is to explore how healthcare professionals in mental healthcare and somatic medicine prioritise their care, to compare different ways of setting priorities among managers and clinicians and to explore how moral dilemmas are balanced and reconciled. Research design and participants: We conducted qualitative observations, interviews and focus groups with medical doctors, nurses and other clinical members of the interdisciplinary team in both somatic medical and mental health wards in hospitals in Norway. The interviews were recorded and transcribed verbatim. Ethical considerations: Basic ethical principles for research ethics were followed. The respondents signed an informed consent for participation. They were assured anonymity and confidentiality. The studies were approved by relevant ethics committees in line with the Helsinki Convention. Findings: Our findings showed a widening gap between the views of clinicians on one hand and managers on the other. Clinicians experienced a threat to their autonomy, to their professional ideals and to their desire to perform their job in a professional way. Prioritisations were a cause of constant concern and problematic decisions. Even though several managers understood and empathised with the clinicians, the ideals of patient flow and keeping budgets balanced were perceived as more important. Discussion: We discuss our findings in light of the moral challenges of patient-centred individual healthcare versus demands of distributive justice from healthcare management. Conclusion: The clinicians’ ideals of autonomy and good medical and nursing care for the individual patients were perceived as endangered.