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It is time to remind the Medical Community of some of the fundamentals underlying its ability to do what it does for the sake of patients. Specifically the Doctor-Patient Relationship and Æsculapian Authority are re-examined and their applicability re-assessed.
Between 1971 and 1990 I used to be a practicing Anæsthetist (Anesthesiologist to those who know nothing of the etymology of the term) as well as being a General Practitioner and Orthomolecular Physician. When I was due to anæsthetise a patient electively I would always have the opportunity to see him/her ahead of time to assess her/his fitness to undergo anæsthesia. As part of this process I would tell the patient what to expect. Essentially what I would do is poison the patient close to death during the procedure which the surgeon was going to do, keep the patient alive while I was doing it despite the poisons which I was administering, and then restore the patient to independent life again once the procedure was over. Of course I never put it those terms. Otherwise no patient would let me near. But they were pretty clear that I, and the surgeon, were going to be doing something quite drastic. As we parted company the patient inevitably would thank me–and would thank me again when I made post-anæsthetic rounds. Similarly, a surgeon would tell the patient words to the effect: “I am going to slash open your body, mutilate one or more of your internal organs, and then try to put you together. I also hope that your body will recover from this insult.” That is the reality of sugery, but a surgeon would never put it that way. And almost always the patient would thank the surgeon after it was all over.
To drive the point home even more forcefully, when I developed Acute Myelogenous Leukæmia,1 the oncologist told me that he would poison me to death and then try to rescue me. And I thanked him and asked him to proceed.
Something odd is going on here. Doctors are being sued all the time. To hear the presentations by the lawyers of the plaintiffs and the learned judges, one would believe that they know far more about medicine than the physician or surgeon in the firing line, who is having to make important decisions at extremely short notice, often while very fatigued.
So? You develop a severe pain in the right lower belly. You have a pretty good idea that it is appendicitis. To save your life you know that you will have to entrust your life to someone who will cut open your body leaving you with an unsightly scar, while someone else poisons you into insensibility to within a few minutes of death to prevent you feeling the pain imposed by the first person. You believe that lawyers are so much more knowledgeable than doctors, right? So you’re going to ask one lawyer to take out your appendix while another learned gentleman of the court administers an anæsthetic to you, right? I thought so.
The difference is that the doctor is in the Doctor-Patient Relationship and has Æsculapian Authority. And this is an extraordinarily powerful situation.
This is based upon the work of my father, the late T.T. Paterson.2 Dr. Paterson gained his Ph.D. in Cambridge and became a Fellow of Trinity College. Among his many colleagues were Father Pierre Teilhard de Chardin, Helmut de Terra, the Leakeys (Louis and Mary), Vivian Fuchs, Margaret Mead, Gregory Bateson and Rheo Fortune. He took part in many expeditions, to East Africa, India, Greenland and Northern Canada. As curator of the Museum of Archæology and Anthropology in Cambridge he had the opportunity to immerse himself in details of many human cultures. During the Second World War he became a trouble-shooter for the Royal Air Force. Shortly afterwards he embarked on a detailed inquiry into industrial relations in the British Na-tional Coal Board. The funding for this dry-ing up in post-war austerity, he returned to academic life in the University of Glasgow in the Department of Social and Economic Research where his multitudinal observations crystallized into a new field which he named “Methectics”. He applied Methectics, now more appropriately known as “Methexis”, successfully to the turmoil of strife-torn industry in Glasgow, and later to major inter-national industries and even governments. While this was happening he transferred to the then new University of Strathclyde, whose School of Administration he built up into the largest in Europe rivaling the Harvard School of Business Administration. In the mid 1950s Paterson began to work with Dr. Humphry Osmond on the concepts upon which this paper is based.
Before an argument can be made either for or against a case, the meanings of the terms used must be clear and unambiguous. Otherwise no meaningful communication exists and no resolution is possible. Indeed clarification of terms inherently solves potential disputes before any argument has a chance to develope. Such clarifications then creates axioms, i.e. self-evident truths about which there can be no argument.
I shall attempt to present some such axioms.The literal meaning of the word “doctor” is teacher,3 hence Ph.D., LL.D.., D.D., etc., all the possessors of which are also entitled to be addressed as “Doctor”.
The difference is that the Medical Doctor takes a history from a patient, carries out whatever examination is necessary, and requests what tests seem appropriate, all in order to define the nature of the medical problem and to teach the patient how the problem ought to be handled. Usually this means how the patient ought to handle the problem. Even in the case of surgery it is the decision of the patient to go ahead with the procedure, based upon what the surgeon teaches about the pros and cons of what is proposed.
In this the Medical Doctor is in the role of “Doctoring.” We all play roles in a culture, in an analogous fashion to the roles which actors take in a play. Shakespeare saw this clearly as he wrote “All the world’s a stage”. It is how cultures function. The members of the culture either take upon themselves a role or have a role bestowed upon them to fulfil the needs of whatever culture in which they live, from a newborn child to a centenarian. The only exception to this is the Norse “nidding”, meaning “nothing”, the most terrible punishment meted out in Norse times, in which the criminal literally ceased to exist as far as the people of the culture were concerned.
If there is a “relationship” between any two or more entities, anything from quarks through humans and on up to large clusters of galaxies, then they exert some influence upon each other. What that influence might be depends upon the nature of the entities and the mode by which they interact with each other. Quarks interact by means of gluons. Galactic clusters interact by means of gravity and, possibly, Einstein’s cosmological constant. How humans react with each other is considerably more complex involving their personalities, the roles that they play, and the multitudinous modes of communication available. The word “client” is being advocated as the politically correct term for the person who comes to a doctor for medical care. This should be opposed. A client is a generic term for any person coming to any profes-sional individual for the services provided by that individual. The term “patient” is much older, probably dating from the time of Asklepios three and a half millenia ago (see below), and refers specifically to the special relationship between the sick person and the doctor. It refers to the need for the patient to be patient with the therapy, i.e to allow time for the doctor’s suggested management to work. This is particularly important for the Orthomolecular Physician whose treatments may take many months to begin to work, albeit with lasting efficacy, as opposed to the “toximolecular” Physician whose treatments begin to work within a short time but whose lasting efficacy might be in considerable doubt. Thus we have the doctor-patient relationship. However, as the doctor has the role of doctoring so the patient has a special role. This is known as the Sick role.
The Sick Role was defined by Parsons4 as the role occupied by the sick person, that is temporarily absolved of the normal duties of society, while taking on the new duty of complying with the advice–see below– of the doctor in order to become well again. Someone who is “sick” is not healthy, i.e. sufferring from some illness or disease. Perhaps the last word would be better spelled “disease” to clarify that he or she is not feeling “at ease”. Being sick the patient is not able to function normally in the role which she or he has in society under usual circumstances. When sick the wise person seeks the aid of a doctor to become well again. One of the most important acts/duties of the doctor is to bestow the Sick role.
The corollary of this is that when the doctor judges that the patient is no longer suffering from the disease, then the doctor removes the patient from the Sick Role and returns that patient to his or her former role in society. The doctor can carry out both these acts this by reason of Æsculapian Authority. The nature of “Authority” and, later, “Æsculapian Authority” merit considerable discussion.
Forms of Authority
Authority as a term has bad public relations at this time because of the confusion between its meaning and that of the word “power”, the two often and incorrectly being used as synonyms.
Power is that which is used to change the way people function/behave without their consent. In effect it makes slaves of them, denying them the rights and privileges of citizenship while imposing upon them merely duties and responsibilities. Military people are familiar with this in the form of conscription, a conscript army being indistinguishable from a slave army.
This is an appropriate point to consider the term “Swanelo.” This Ugandan word was identified by Paterson5 as expressing the essence of citizenship. In return for voluntarily carrying out a person’s Duties and Responsibilities to society, society in return bestows certain Rights and Privileges upon that person. However, a person who has only Rights and Privileges is a tyrant, and, currently, there are too many tyrants in society all demanding their Rights without consideration of what Duties they ought to perform to merit such Rights. A slave has merely Duties and Responsibilities, having no say in how his or her life ought to be conducted. Someone without either Duties and Responsibilities or Rights and Privileges is nothing, not even human as we understand it–see “nidding” above. A citizen has Duties and Responsibilities in pefect balance with Rights and Privileges, i.e Swanelo.
An important aspect of Swanelo is Authority. It is society, or a component of society such as a company or other organization, which bestows authority upon a person by common consent. And it is that consent which distinguishes Authority from Power. Which form of authority (or combination of forms) is given depends upon what function or role that person is to fulfill in society. Understanding of the forms of Authority in a clear and unambiguous fashion helps us to use it constructively. And it is a very potent tool which the group uses to make the decisions which it has to make, often to acheive the very survival of the group.
Paterson identified five basic forms of Authority6 and defined these in the following terms:
Structural Authority–the right to command (and discipline) by reason of a person’s position within an organization. An example of this is the authority of the manager of a business. The manager is required to secure the economic survival of the business. An employee enters the business to perform some function which the business requires to further aim of the survival of the business. And the employee voluntarily accepts that the manager has Structural Au-thority. Without that authority the manager is unable to give the necessary orders to ensure that the business does survive, and the employee’s very livelihood, and ultimately survival, depends on that. It also confers the right to discipline by reprimand, or even more severe sanctions, if the employee acts in a fashion which is contrary to the survival of the enterprise.
Sapiential Authority–the right to be heard by reason of a person’ superior knowl-edge and experience. The wise manager recognises that the employee has knowledge about her or his job which the manager can-not possess. While the ultimate responsibil-ity for the outcome of the employee’s work lies with the manager, it is better for the business if that knowledge is recognised. The unwise manager gives arbitrary orders without acknowledging the Sapiential Authority of the worker. An important aspect of Sapiential Authority is advisability, the right to give advice. But this does not confer the right to retaliate if the advice is not accepted.
Charismatic Authority–literally God given Authority–the right to be heard by reason of the religious, or pseudo-religious, mantle borne by the person. Commonly this is bestowed upon the clergy of the various world religions, but can be a feature of other ideologies. It tends to be used to bring about correct behaviour within the tenets of the ideology. The danger is always that of “righteousness”, a rigidity of thinking which cannot tolerate deviations from such tenets even though such deviations might bring about an improvement in a situation. Currently many medical authorities and licensing bodies are guilty of righteousness.
Moral Authority–the right to be heard because the person is trying to bring about a betteringness of the situation. I hold frequent meeting between myself and the staff of my office. First of all I do so to bring home that I recognise their Sapiential Authority. But, more importantly, I invoke everyone’s Moral Authority to improve the service provided by my office, which is “a good thing” and far from righteous.
Personal Authority–the right to be heard by reason of a person’s personal qualities. In the meetings referred to above, there are members of my staff who tend to speak up more on matters than others. Necessarily they have more Personal Authority.
Either consciously, or unconsciously, humans seem to recognise these forms of Authority. Perhaps that recognition is hard-wired into our brains genetically by evolution. Certainly they are universal in all known human cultures, even those separated from each other by many millenia of separate development. This is also true of Æsculapian Authority.
No individual is restricted to one form of authority. Often, depending on the circumstances and the differing roles which we play, we may switch from one form to another or even adopt combinations.
Æsculapian Authority7 consists of a combination of four forms of authority.
Paterson named it after the Greek Physician, Asklepios or Æsculapius, who lived about 3,500 years ago. He was so effective with his therapy that the Hellenic world deified him, made him a god in their pantheon. His symbol is the staff entwined by a single serpent, the correct symbol for Medicine. [The rod entwined by two serpents surmounted by wings is the Caduceus, the symbol for Mercury, or Hermes, the messenger of the gods. It has nothing to do with Medicine, but is widely and incorrectly used as a symbol for Medicine by the functionally uneducated.]
Asklepiads, centres of healing based upon the precepts introduced by Asklepios, were established all over the Hellenic world. The Asklepian therapy is very familiar to those who practice Orthomolecular Medicine which probably makes him the first known Orthomolecular Physician. He withdrew the patients from the normal stresses of their lives and administered clean water, fresh and unpolluted air, good food, a modicum of spirituality, an appropriate balance of rest and exercise, and time –hence “pa-tient”. Of course once they became well again they were required to return to their former roles in the Greek culture.
Paterson pointed out that, under the umbrella of Æsculapian Authority the doctor has Sapiential Authority in that he does possess superior knowledge and experience in the field of Medicine to that possessed by the patient. After all the doctor has passed through the trial of medical school, has served his or her apprenticeship in the various, postgraduate training positions, and continues to improve her or his knowledge by further study and attendance at continuing medical education meetings. But the wise doctor also knows that the patient also has Sapiential Authority too with respect to the doctor since she or he alone knows what he or she is feeling. As I often put it to the patients, they are the world’s greatest authorities about what they feel when they are sick.
Medicine deals with issues of life and death, which remain imponderable, unknowable, arbitrary, and capricious de-spite our increasing knowledge of disease processes. Such issues involve a feeling of religion, the involvement of higher powers. Hence the doctor has Charismatic Authority. This is conferred by the rite de passage, the trial of passing the final examinations in the course at medical school, which converts the medical student into one who wears the quasi-religious mantle of “doctor”.
The doctor has no reason for existing other than the betteringness of the patient, and, hence, has Moral Authority. This is always the attribute of a good doctor. Of course when a doctor takes advantage of a patient for his or her own selfish ends then the Moral Authority is violated, and society rightly expects severe punishment for such a transgression.
But often a doctor uses her or his personal qualities to enhance the effectiveness of the management of the patient’s problems, and hence has Personal Authority too. However a doctor may have the personality of a limp dish rag and still be an excellent member of his profession. By contrast charlatans rely on the force of their personalities to feign Sapiential Authority. The orthodoxy often complains that Orthomolecular Physicians acheive their results through force of their personalities, even making accusations of charlatinism. But fake doctors cannot sustain their lack of knowledge long since results acheived by mere force of personality have no lasting benefit (in an analogous fashion to the placebo effect), while genuine efficacy does have sustained benefit.
What a doctor generally does not have is Structural Authority. He or she cannot command a patient to do anything, nor may discipline that patient for failure to comply with the advice given. The only sanction which a doctor has against a non-compliant patient is to regretfully withdraw from the care of that patient, an action which is entirely accepted by the various licencing authorities.
The concept of “Doctors Orders” is equally a complete myth. Except where a doctor actually employs a nurse, say in her or his own office, he or she does not even have Structural Authority over the nurse in a hospital, and cannot either command, rebuke, or discipline her or him. That is a function of the nurse’s superior. What the doctor gives is a request, which is best accompanied by the word “Please”.
A doctor can have Structural Authority over another doctor. This usually happens in a teaching hospital where there is a clear hierarchical structure such as in North America with the Attending Physician down through the Senior Resident, Junior Resident to the Intern, each rank being entitled to command the more junior. The equivalent in the British Hospital system is Professor/Consultant through Senior Registrar, Registrar, Senior House Officer, to Junior House Officer. The necessity for this is clear. The more junior grades exist as training posts in which the occupants are learning from the more senior grades. It is also clearly recognised that this is a duty of the more senior grades derived from the Hippocratic tradition. The right to command and discipline is imposed for the sake of the welfare and safety of the patients as the juniors work their way up through the hierarchy via the learning process towards professional autonomy.
The other odd thing in this situation is that when I ask medical students or other Physicians about their right to do what they do with respect to patients, none (with very few exceptions) can answer in terms that are clear-cut and unambiguous. The responses vary but are typically of the following general forms:—
1. “The College (or what ever other li-censing authority there is in the jurisdiction) checked my credentials, and then gave me my licence.” Well and good, a fancy piece of paper on a wall is very impressive. But patients are not treated by paper on a wall, they are treated by another human being.
Yet, when doctors and patients are observed during their interactions, it is clear that both parties are functioning within the confines of the Doctor-Patient Relationship.
How has Such a Situation Come to Be? In describing Structural Authority I mentioned that the role of the manager was to secure the survival of the business. This is but a particular aspect of something far more general. It is the business of all cultures, all societies and all organizations within their framework to survive — the Survival Imperative. It is inconceivable that they can survive unless there are mechanisms in place to secure the survival of the individual human beings of which they are composed, although this might not always be possible. Human beings are subject to diseases which threaten either the survival of the individual or threaten the ability of the individual to function within her or his role in society. There has to be a mechanism in place to deal with that problem.
Without such a mechanism the individual cannot survive, nor can the role, nor can the society itself.
Without exception no known society has been without somebody in the role of healer, shaman, doctor who invokes the Doctor-Patient Relationship using the power of Æsculapian Authority.
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