Cristina Vaz de Almeida
We’re all patient. Sooner or later. Because being patient doesn’t mean being sick.
In the life cycle, and so even before our birth, when we are growing up in our mother’s belly, she was probably followed from the beginning of her family planning consultation, went through a series of routine consultations, ultrasounds or measurements and evaluations, until birth. And then, we officially go our way in health, as patients.
We’re like this, all patient, sooner or later.
Already in the 1950s, Szasz and Hollender (1956) envisioned patient-centered care, where the hegemony of the physician gave way to a more collaborative and representative agreement of the true dyad in health, showing the possibility of existence, in the relationship in health, of approximately equal powers between professional and patient, in mutual interdependence and satisfactory activities for both (p. 587).
Engel (1981) showed us the strength of the biopsychosocial model and the human nature of the relationship in health. Nothing is done without the person. And it is with the person that the professional makes it into what it is.
This credibility of the source is seen as the ability of the health professional to provide valid information, to which its reliability is added, that is, its veracity, without considerations of gain (Crano & Siegel, 2017, p. 98).
The professional is a reliable expert (O’Keefe & Medway, 1997).
But this introduction comes about what is intended to be reflected and what is the field of the rights and duties of patients.
The Order of Physicians (Ordem dos Médicos , 2020) designates the Charter of Rights and Duties of Users as an “instrument of partnership in health and immediately states that it is not a document of “confrontation”, but that it contributes to the “primacy of the citizen, central figure of the entire Health System” and that serves “to develop a good relationship between patients and health care providers”. This note from the OP – Order of Physicians (Ordem dos Médicos , 2020) highlights in its text that the purpose of the “letter” is “above all to stimulate a more active participation by the patient”.
But this “confrontation” to which the OP (Ordem dos Médicos, 2020) warns does not seem to make sense, when observed that we have twice the rights (12) in relation to duties (6).
In this reflection, it might be worth not to designate as “sick” the one who is represented in the “Letter”, because if we think of such a pregnant lady, who has no disease or pathology because she is simply in this state and wants to follow up on health care in the community, for example, and who will be accompanied, and well, by a general and family medicine physician (FGM) during her pregnancy, is not necessarily a “sick”, “word that etymologically comes from dolentia and that can be understood as lack or disturbance of health” (Nunes & Melo, 2010, p. 3).
And even “considering that sick people constitute a particularly vulnerable and fragile group” (Nunes & Melo, 2010, p. 9), as people who are, have the rights that assist all others. And the first of these rights is “respect for human dignity.”
When we talk about “human dignity” we assume a fundamental right, constituted in all civilizations.
Cruz and Gomes (2013), reflect that “the disease does not give or take away rights to the person; what happens is the recognition coming from outside, from the other (from the doctor), and the assent of the person who constitutes himself in the “right” and the “duty” to be healed and treated (p. 83).
For these authors (Cruz & Gomes, 2013), “there is only disease if there is a person”. Therefore, the person predates the disease, so by anthonomasia, the intrinsic dignity of the person confers on him the substantial right and duty and never circumstantial” (p. 83).
The Patients Rights of American Hospital Association-AHA Patient’s Bill of Rights (1992) stresses that optimal care should be based on open and honest communication, with respect for personal values and sensitivity to differences (e.g. cultural, racial, linguistic, religious, age, gender).
Perhaps that is why, and because the rights are well evident and the “patient” is no longer “the one who suffers in patience”, and is not simply “user” because he may not be a mere “user” of public services, that the term “patient”, immediately perceivable and recognizable in this global world, can be used effectively, and without negative connotations, transversally.
If, however, we persist in recognizing that the person uses health services as a consumer, and if we consider health as a good of consumption and not of social law, we should perhaps call it a “client”(Takauti, Pavone, Cabaral & Tanaka, 2013, p. 176).
But whether in private services or in public service, the rights reserved for us, all without exception of gender, colour, race, age, cultural, philosophical and religious convictions, presuppose that we are treated with respect for human dignity.
Information, consent and confidentiality are evident in the Charter of Rights.
This “information” is more than the junction of the sign and its content, because it is imbued with understanding, so it becomes “communication” (Wonca, 2002).
When we reflect on the “duties”, the responsibility of each one for “ensuring their state of health”is evidenced. The “Charter” is clear, that is to say that each person (or on whom it depends, for example care of elderly person or parents and children) who “must” seek to ensure the most complete re-establishment (and therefore of the own or the dependent) and extends and to the “community in whichhe lives”. In Times of Covid 19, this determination of “duty” even in relation to the community makes even more sense.
We read or hear in the widespread news, of cases of people infected with Covid 19 who leave their homes to circulate in the midst of others, that the beaches are full (of potential propagators) and not respecting this “duty” of course, many people put others at risk.
If we reflect on this inability, refusal, indifference or alienation of responsibility for the duty of these people, who put the community at risk, we cannot call them “citizens”.
Being a “citizen” is a title of credibility and responsibility that is given to those who intervene in beneficence, to their own, to those who depend on them and to those who live in a community for the construction of a better society.
Continuing by the duties, this is particularly interesting, the “duty to provide health professionals with all the information necessary to obtain a correct diagnosis and appropriate treatment”. Will there be those who lie? Who’s ashamed or ashamed of what they have? Probably the answer is yes. We know that it is the ones with the lowest health literacy (Espanha, Ávila & Mendes, 2016) who are the most embarrassed and ashamed, and probably here will be not only those who have limited or scarce education and incomes. The shame and embarrassment of the disease affects many people regardless of their status.
If there is “freedom” to accept the indications given by health professionals, the patient has a duty of cooperation, that is, he must collaborate for the intended purpose (preventive, curative, promotion).
This participation of the patient in health also implies that, when using health services, it does so appropriately.
When another of the duties also consists of their active collaboration to reduce unnecessary expenses, we return again to the determinant of health that is health literacy, which involves cognitive (own) and social skills (knowing how to live in community) to manage their health and make decisions that improve their state or on whom they depend, responsibly and with citizenship.
The question remains whether this citizenship needs more promoting education, not only health knowledge, but the value of dignity and human respect.
We are and we will always be patient. Patients in health, no doubt and patients at all?
There is an urgent need to educate. It is urgent to change. There is an urgent need to intervene.
Excerpt from the Charter of the Rights and Duties of patients (extracted from the public site of the Order of Physicians (Ordem dos Médicos, 2020)
- The patient has the right to be treated with respect for human dignity.
- The patient has the right to respect for his cultural, philosophical and religious convictions.
- The patient is entitled to receive the appropriate care for his/her health, in the context of preventive, curative, rehabilitation and terminal care.
- The patient is entitled to continued care.
- The patient has the right to be informed about existing health services, their skills and levels of care.
- The patient is entitled to be informed of his/her health situation.
- The patient has the right to obtain a second opinion on his/her health situation.
- The patient shall be entitled to give or refuse his consent before any medical act or participation in research or clinical teaching.
- The patient has the right to the confidentiality of all clinical information and identifying elements that respect him/ her.
- The patient has the right of access to the data recorded in his clinical process. 11. The patient has the right to privacy in the provision of any and all medical acts.
- The patient is entitled, by himself or by the person who represents him/ her, to make suggestions and complaints.
- The patient has a duty to ensure his/her state of health. This means that it must seek to ensure the most complete recovery and also participate in the promotion of one’s own health and the community in which it lives.
- The patient has a duty to provide health professionals with all the information necessary to obtain a correct diagnosis and appropriate treatment.
- The patient has a duty to respect the rights of other patients.
- The patient has a duty to cooperate with health professionals, respecting the indications recommended to him and freely accepted by him.
- The patient has a duty to respect the rules of operation of health services.
- The patient has a duty to use health services appropriately and to actively collaborate in reducing unnecessary expenditure.
American Hospital Association. (2003). The patient care partnership: Understanding expectations, rights and responsibilities. Disponível em: http://wwwahaorg/content/00-10/pcp_english_030730.pdf
Crano, W. D., & Siegel, J. T. (2017). Social signals and persuasion. In J. K. Burgoon, N. Magnenat-Thalmann, M. Pantic & A. Vinciarelli (Eds.), Social signal processing (pp. 97-109). Cambridge, UK: Cambridge University Press.
Cruz, J., & Gomes, C. (2013). O conceito de filosofia da medicina em Pellegrino e Thomasma. Revista de Bioética Latinoamericana, 11, 82-99 / ISSN: 2244-7482
Engel, G.L. (1981). The clinical application of the biopsychosocial model. Journal of Medicine and Philosophy, 6, 101-123.
Espanha, R., Ávila, P., & Mendes, R. M. (2016). A literacia em saúde em Portugal. Lisboa: Fundação Calouste Gulbenkian
Nunes, R., & Melo, H. (). Parecer n.º p/18/apb/10 – carta dos direitos do utente dos serviços de saúde relatores. Porto; Associação Portuguesa de Bioética. www.apbioetica.org.
O’Keefe. D.J. & Medway, F.J. (1997). The application of persuasion research to consultation in school. Psychology, 35(2), 173.193.
Ordem dos Médicos. (2020). Carta de direitos e deveres dos utentes. Disponível em: https://ordemdosmedicos.pt/carta-dos-direitos-e-deveres-dos-utentes/
Szasz. T., & Hollender M. (1956). A contribution to the philosophy of medicine: the basic models of the doctor-patient relationship. Archives of Internal Medicine, 97, 585−592.
WONCA. (2002). Definição europeia de medicina geral e familiar (Clínica Geral/Medicina Familiar). Barcelona: WONCA.