Human values in health care: trying to get it right

In most medical specialties discoveries and advances are made every year. Bioethics is a field that evolves more slowly. After all, it is mainly concerned with how we treat one another, with standards, or norms, of "right" and "wrong" behaviour, and with our relationships with patients and colleagues. The age-old questions at this "micro-level" of ethics do, nevertheless, change slowly over time. No longer is paternalism or a "doctor knows best" attitude an acceptable expression of the duty of beneficence. No loner can we iustify not telling our terminally ill pa tients their prognosis on the grounds that it is not in their best interest to know. No longer do physicians believe that getting close to a patient's vulnerability is unprofessional and to be avoided. The conceptualization of health care delivery as team work is gaining acceptance, and brings with it increased respect for the contibution of each person involved in the patient's care. Even the name of bioethics is changing: many now prefer the term "health and health care ethics." The dominance of principles in ethics - principleism- is now being questioned, not because such principles are now less relevant but because they may fail to take contextual features or the meaning of relationships adequately into account. For example, a principlesbased analysis might lead to the conclusion that a given intervention for a dying person is inappropriate because it is essentially nonbeneficial. However, other considerations - such as the impending arrival of loved family members from afar might provide a context in which the intervention seems appropriate. Thus, in addition to applying ethical principles, there is need to recognize the importance of virtues (e.g., compassion, patience, making time for listening) and the ethical importance of relationships or, in other words, the sharing of experience, as epitomized by the injunction "Don't just do something, stand there!" Indeed, relational ethics may be seen to be in balance, and sometimes in tension, with principleism. Some years ago, Duff described this as the difference between "close-up" and "distant" ethics.4 Tri-Council Working Group. Code of ethical conduct for research involving humans [draft]. Ottawa; 1997. wwwmrc.hwc.ca/ethics/code/english/toc.html Duff RS. "Close-up" versus "distant" ethics: deciding the care of infants with poor prognosis. Semin Perinatol 1987;1 1:244-53.