Navigating the complexities of the good in modern medical practice

The concept of "the good of the patient" has been a cornerstone of medical ethics, revered as both a guiding framework and a moral imperative in the practice of medicine. This philosophical tenet embodies health care professionals' commitment to prioritize their patients' well-being and values above all. However, defining what constitutes 'good' is complex in a modern, diverse society where multiple perspectives and values coexist. Exploring this nuanced concept through a historical lens and contemporary practices helps bridge the gap between traditional medical ethics and the individual experiences of patients.

The relationship between a physician and a patient is foundational in the clinical setting. It can be profoundly influenced by the ethical framework proposed by Dr. Edmund Pellegrino, a revered figure recognized internationally as one of the most prolific and passionate spokespersons on clinical ethics and the medical profession. At the heart of Pellegrino’s work is the argument that medicine is a moral enterprise based on a trusting patient-physician relationship. What makes medicine a special activity begins with understanding the nature of illness as a universal human phenomenon in which patients’ predicament of illness leads them to entrust their care to another human being in a relationship they might not usually enter.

This need for trust constitutes the moral imperative for the health professional to serve the patient with the patient’s best interest at heart and in mind. In turn, health care professionals use the knowledge gained through the privilege of a medical education not for personal gain but for the good of the person struggling with illness. For Pellegrino, it is not the degree that symbolizes one’s membership in the medical profession. It is the public promise or “profession” to be competent and to use that competence in the best interest of the patient.

Pellegrino’s framework is pivotal for understanding each patient’s unique needs and aspirations during their journey toward health and happiness. Built on the premise that a patient seeks a physician's expertise to either restore health or effectively manage illness, Dr. Pellegrino's model aims to help patients resume a lifestyle conducive to personal fulfillment. In this partnership, the physician commits to prioritizing these patient-defined ends, fostering a relationship grounded in trust and mutual respect.

Dr. Pellegrino categorizes the patient's goods into four distinct yet interconnected levels. At the foundational level is the biomedical good, which focuses on medicine's technical and scientific aspects. The physician’s role is characterized by applying medical knowledge and skills to effectively diagnose and treat physical ailments. This biomedical perspective is essential but limited, as it does not encompass the broader spectrum of the patient’s experiences and needs.

The second tier considers the patient’s personal perception of good, which varies widely among individuals. Health care professionals must recognize and respect these personal views, as they directly influence a patient’s decisions regarding treatment options. Acknowledging the patient’s informed preferences underscores a commitment to patient-centered care, which respects individuality and fosters a supportive therapeutic relationship.

The third tier emphasizes protecting and respecting each individual's dignity. This universal good transcends the medical details to focus on respecting the patient as a human being capable of making reasoned decisions. In cases where patients cannot express their will due to medical conditions affecting cognitive functions, it becomes the responsibility of health care professionals and designated surrogates to uphold and advocate for the patient’s dignity and previously expressed wishes.

At the highest level, Pellegrino introduces the concept of the patient as a transcendental being, where considerations extend to spiritual or existential dimensions of health. This perspective recognizes the profound questions of life’s meaning and purpose and the existential reflections that often arise in the face of illness. Addressing this level of good acknowledges the full scope of human experience and supports patients in navigating the profound impacts of health on their overall life narrative.

Integrating these four levels into every clinical encounter poses significant challenges and offers a comprehensive framework for addressing patients' multifaceted needs. Health care professionals must continually strive to balance these dimensions, ensuring that medical advice and interventions align with the holistic good of the patient. Just as educators tailor assignments to achieve educational outcomes, physicians must design health interventions that support the patient's overall well-being, encompassing physical, emotional, and spiritual health.

The philosophy of "the good of the patient" remains a dynamic and evolving concept in medical ethics. By continually reflecting on and adapting our approach to meet the diverse needs of our patients, we not only honor the rich historical tradition of medical practice and the medical profession but also advance a more empathetic, patient-centered approach to health care delivery. As we move forward, it remains imperative that we keep the patient's definition of the good life at the forefront of our ethical and clinical deliberations, ensuring that our interventions and care strategies truly align with their biomedical good, values, and aspirations.

Mark Sullivan, MD, is an internal medicine physician at North Virginia Family Practice in Arlington, Virginia,