Example

Consider the use of morning-after pills, i.e., oral contraceptives used in high doses after sexual intercourse to prevent implantation of a zygote. This is a difficult and controversial topic in the ethics of professional relationships that may clarify how perspectives are handled in the three types of professional relationships.

Sally Fourth has been a patient of Dr. Brown and has been receiving oral contraceptives for some years. She gets her prescription filled at the Grey Pharmacy. Some months ago, she decided to stop taking her oral contraceptives because she had become celibate after breaking up with her boyfriend. One morning, she called Dr. Brown to explain that she and her old boyfriend were attempting a reconciliation and had unprotected sex the previous night. She told Dr. Brown that she was afraid she may become pregnant. She asked Dr. Brown if he would prescribe a morning-after pill.

In a paternalistic relationship, Dr. Brown might be much more likely to try to convince Ms. Fourth of his opinion about whether she should use a morning-after pill. His advice might mainly reflect his own opinion of Ms. Fourth's best interest. He might discount her knowledge and disregard her wishes. He might even try to manipulate behavior (this is beyond paternalism into an authoritarian extreme). The motto for this is "doctor knows best."

In a consumerist relationship, Dr. Brown might disregard his own values, beliefs, and judgment. He would discuss the problem carefully with Ms. Fourth, but he would accept her perspective and knowledge within the broadest limits. The motto (and basic argument) might be that it is her body, her life, and her decision.

In a therapeutic relationship, Dr. Brown might help Ms. Fourth to clearly identify her desired outcome but not try to change it. He would try to make sure that she had an accurate, scientifically based understanding of the major physical, social, and psychological consequences and would try to correct misunderstandings. He would help her to develop a realistic sense of her feelings if she used the treatment, and how she could cope with any repercussions, such as regret. Together they would decide what to do.

This example also can illuminate the environment of medication use: the role of culture, research third-party payers, and government. Our culture has some shared values, assumptions, and beliefs about the proper use of medicines, and about childbearing, and some controversies. Pregnancy and abortion have become for many a passionate sociopolitical issue. There may be only a small step from Sally's philosophy that she has sovereign control of her own childbearing to an insistence on a consumerist relationship with Dr. Brown.

Culture is communicated in news broadcasts and magazine articles. It may be reflected in laws about medication use. In the United States, pregnancy tends to be viewed as a medical issue (if not a disease), and legal access to oral contraceptives is limited to a doctor's prescription. In some countries, however, the patient can decide whether to get oral contraceptives without a prescription or from a doctor. However, Ms. Fourth may not need Dr. Brown's cooperation to get the medicine she wants. Information about how to use oral contraceptives as morning-after pills is available from magazine articles or the Internet, or even from a friend. She may already have the oral contraceptive tablets on her kitchen table or be able to get some from a friend.

Control of pregnancy is, for our purpose here, a symbol of people's desire to maintain or improve the quality of their lives as they believe is best.

They may make decisions based on whatever understanding they have, and sometimes regardless of what medical or governmental authorities may intend. A therapeutic relationship is premised in part on respect for this need and a willingness to use scientific knowledge to help people toward this goal.

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