An analytic review of the doctor-patient relationship (part II)

Liviu Oprea


This is the second part of an analytic review of doctor-patient relationship (DPR) from an ethical point of view. In the previous part I have described and analysed the goals of and processes in different bioethics models of doctor-patient relationship. I have argued that the bioethics models of doctorpatient relationship are normative and prescriptive in nature and that the effectiveness of different models to promote their assumed goals is not assessed empirically. In this part of the review, I analyse different clinical models of doctor-patient relationship with the aim of understanding the relation between the theoretical and philosophical arguments behind different models of doctor-patient relationship with the empirical evidence on the effectiveness of different models to promote their goals if implemented at the level of health care. The process in the DPR is at the core of the clinical models of DPR, namely patient-centred care model (PCC) and relationship-centred care model (RCC) [1]. Since its inception more than fifty years ago through the early work of Balint [2] and Engel [3] clinical models of DPR have gained a high profile in general practice and are considered a central feature of quality practice [4].In this section, I analyse through an ethical lens the concepts and ideas that are commonly described and empirically studied in the literature surrounding the clinical models of DPR. I argue that clinical models of DPR, similarly to bioethical models of DPR, are prescriptive and normative in nature. First, I describe and analyse from an ethical point of view the patient-centred care (PCC) model of DPR. I argue that some of the ethical meanings of the different dimensions of this model are not made clear by its proponents. Second, I describe and outline the relation-centred care (RCC) model of DPR and the empirical research surrounding the process in DPR. I describe the communication patterns that characterize RCC and outline the empirical research on their effectiveness to promote beneficence and patients’ autonomy. I argue that there is some evidence that a process in DPR characterized by these communication patterns could promote both benefice and patients’ autonomy. Third, I compare the clinical and bioethics models of doctor-patient relationship. I argue that the similarities between Brody’s relational model of doctor-patient relationship and RCC model of doctor-patient relationship may suggest that the implementation of this model at the level of care could be effective to promote both beneficence and patient autonomy.


Brody H., The biopsychosocial model, patient-centered care, and culturally sensitive

practice, J Fam Pract., 48: 585-7, 1999

Balint E., The possibilities of patient-centered medicine, J R Coll Gen Pract., 17: 269-

, 1969

Engel G.L., The need for a new medical model: a challenge for biomedicine, Science,

: 129-36, 1997

Mead N., Bower P., Patient-centred consultations and outcomes in primary care: a

review of the literature, Patient Educ Couns., 48: 51-61, 2002

Engel G.L., The biopsychosocial model and the education of health professionals, Ann

N Y Acad Sci.,310: 169-87, 1978

Engel G.L., The biopsychosocial model and the education of health professionals, Gen

Hosp Psychiatry., 1: 156-65, 1979

Balint M., The doctor, his patient and the illness, London: Pitman Paperbacks, 1968

United States. National Commisson for the Protection of Human Subjects of Biomedical

and Behavioral R. The Belmont report: ethical principles and guidelines for the

protection of human subjects of research, Washington, D.C: Gov Pr, 1988

Kant I., Ellington J.W., Kant I., Ethical philosophy : the complete texts of Grounding

for the metaphysics of morals, and Metaphysical principles of virtue, part II of The

metaphysics of morals, Indianapolis : Hackett Pub. Co., 1983

Duggan P.S., Geller G., Cooper L.A., Beach M.C., The moral nature of patientcenteredness:

is it "just the right thing to do"? Patient Educ Couns., 62: 271-6, 2006

Veatch R.M., Models for Ethical Medicine in a Revolutionary Age, The Hastings Center

Report., 2: 5-7, 1972

Engel G.L., The biopsychosocial model and family medicine, J Fam Pract., 16: 409, 12-

, 1983

Mead N., Bower P., Patient-centredness: a conceptual framework and review of the

empirical literature, Social Science & Medicine., 51: 1087-110, 2000

McWhinney I.R., A textbook of family medicine, New York: Oxford University Press,

Stewart M., Patient-centered medicine : transforming the clinical method, Thousand

Oaks: Sage Publications, 1995

Brody H., "My story is broken; can you help me fix it?" Medical ethics and the joint

construction of narrative, Lit Med., 13: 79-92, 1994

Parsons T., The social system, London: Routledge & K. Paul, 1951

Illich I., Limits to medicine, London: Lothian, 1976

Lipkin M. Jr., Patient education and counseling in the context of modern patientphysician-

family communication, Patient Educ Couns., 27: 5-11, 1996

Lipkin M. Jr., The medical interview as core clinical skill: the problem and the

opportunity, J Gen Intern Med., 2: 363-5, 1987

Lipkin M. Jr., Quill TE, Napodano RJ, The medical interview: a core curriculum for

residencies in internal medicine, Ann Intern Med., 100: 277-84, 1984

de Haes H., Dillemas in patient centeredness and shared decision-making: A case for

vulnerability, Patient Education and Counselling., 62: 291-8, 2006

Crow R., Gage H., Hampson S., Hart J., Kimber A., Thomas H., The role of expectancies

in the placebo effect and their use in the delivery of health care: a systematic review,

Health Technol Assess., 3: 1-96, 1999

Winefield H., Murrel T., Clifford J., Farmer E., The search for reliable and valid

measures of patient-centeredness, Psychology and Health., 11: 811-24, 1996

Kimlycka W., Contemporary political philosophy: an introduction, Oxford; New York,

Stewart M.A., Effective physician-patient communication and health outcomes: a

review, CMAJ., 152: 1423-33, 1995

Roter D., The enduring and evolving nature of the patient-physician relationship,

Patient Educ Couns., 39: 5-15, 2000

Stewart M., Brown J.B., Donner A., McWhinney I.R., Oates J., Weston W.W., et al, The

impact of patient-centered care on outcomes, J Fam Pract., 49: 796-804, 2000

Ducharme L.J., Knudsen H.K., Roman P.M., Trends in the adoption of medications for

alcohol dependence, J Clin Psychopharmacol., 26 Suppl 1: S13-9, 2006

Safran D.G., Taira D.A., Rogers W.H., Kosinski M., Ware J.E., Tarlov A.R., Linking

primary care performance to outcomes of care, J Fam Pract., 47: 213-20, 1998

Education P-FtoApH, Health Profession Education and relationship-centered care, San

Francisco: Pew health professions Commision, 1994

Beach M.C., Inui T., Relationship-centered care. A constructive reframing, J Gen Intern

Med., 21 Suppl 1: S3-8, 2006

Suchman A.L., A new theoretical foundation for relationship-centered care. Complex

responsive processes of relating, J Gen Intern Med., 21 Suppl 1: S40-4, 2006

Aristotle, Thomson J.A.K., Tredennick H., The ethics of Aristotle: the Nicomachean

ethics, Harmondsworth ; New York [etc.]: Penguin, 1976

Williams G.C., Frankel R.M., Campbell T.L., Deci E.L., Research on Relationshipcentered

care and Healthcare Outcomes from the Rochester, Families, Systems and

Health: The Journal of Collaborative Family HealthCare., 18: 79, 2000

Firedman M., What are friends for?: feminist perspectives on personal relationships

and moral theory, Ithaca, NY: Cornell University Press, 1993

Roter D.L., Frankel R.M., Hall J.A., Sluyter D., The expression of emotion through

nonverbal behavior in medical visits. Mechanisms and outcomes, J Gen Intern Med., 21

Suppl 1: S28-34, 2006

Tait R.C., Empathy: necessary for effective pain management? Curr Pain Headache

Rep., 12: 108-12, 2008

Mast M.S., On the importance of nonverbal communication in the physician-patient

interaction, Patient Educ Couns., 67: 315-8, 2007

Betancourt J.R., Cultural competency: providing quality care to diverse populations,

Consult Pharm., 21: 988-95, 2006

Pellegrino E.D., Toward a Reconstruction of Medical Morality, American Journal of

Bioethics., 6: 65-71, 2006

Minkler M., Personal Responsibility for Health? A Review of the Arguments and the

Evidence at Century's End, Health Educ Behav., 26: 121-41, 1999

Emanuel E.J., Emanuel L.L., Four models of the physician-patient relationship, Jama.,

: 2221-6, 1992

Brody H., The physician-patient relationship: models and criticisms, Theor Med., 8:

-20, 1987

Quill T.E., Brody H., Physician Recommendations and Patient Autonomy: Finding a

Balance between Physician Power and Patient Choice, Ann Intern Med., 125: 763-9,

Dobie S., Viewpoint: reflections on a well-traveled path: self-awareness, mindful

practice, and relationship-centered care as foundations for medical education, Acad

Med., 82: 422-7, 2007

Charon R., Narrative Medicine: A Model for Empathy, Reflection, Profession, and

Trust, JAMA., 286: 1897-902, 2001.


  • There are currently no refbacks.

Copyright (c)