Axiology of paternalism.
Nataly N.Sedova
Volgograd medical academy, Russia
Moral intentions in medicine depend on the used model of a physician and patient relations. Taking into account the positions of a physician and a patient one can suggest the certain models of their moral relations. There have been four models so far.
Model 1.The Model of the technical type. It is based on the idea "physician as a scientist" which suggests his vividly expressed impartiality towards the patient. Such position is rather dangerous though there are the patients who have trust only in such approach.
Model 2.The Model of the corporate (collective) type. The physician is "a friend" to the patient and they act together as colleagues in the struggle against the disease of the patient. With all the attractiveness of such approach there is some hidden hypocrisy, because a patient doesn't have the knowledge of a physician and a physician doesn't experience the sufferings of a patient. 
Model 3. The Model of the contract type. It is based on the principle of exchanging the activities when both sides start interacting and in this way realize their opportunities for the sake of their common benefit. In this model the principles of medical ethics are revealed to the full. Moreover, this model requires the complete realization of the principle which is called "the ethics of a patient" - the things which we spoke about earlier. That's why we think this very model corresponds to the principles of bioethics. 
Model 4.The Model of the sacred type. This is another extreme when the physician abstracts from all scientific notions and acts rather than a priest or a magician and his surgery or the room in the hospital obtains some atmosphere of holiness (N. Wilson). The sacred's model is usually understood as a paternalistic one. And what's more, it has been considered to be the only possible one by many physicians up to now. 
It's important to solve the problem of mutual responsibility of a physician and a patient for the life and health of the latter in the period of their interaction. The first question is - who is morally responsible for the life and health of a man? The most likely answer will be of the stereotype character - the physician. But this is not correct from the contemporary point. And why isn't it correct? We shall surely understand it, if we try to recollect the structure of moral relations.  In the system "man - society" the state is probably morally responsible for the life and the health of a man. (But this fact doesn't seem to mean much as the state sometimes sends its citizens to "kingdom come" for the sake of life.) It must provide the opportunity of survival for every person and provide the conditions of preserving his health. To some extent all social institutions like production, legal system and economic structures perform these functions. And there is only one specially established institute for this purpose - that's the system of public health services. 
In the system "individual - social group" the members of the group (and mainly - the leader) are probably responsible for the health and the life of a man. In this aspect such group as a family is very significant. Moral responsibility in the groups which are called working groups is less evident. Different stresses at work are so usual that it seems strange when we start making moral claims to the colleagues or to the administration of the victim. 
In the system "individual - individual" which is unique in the way of our consideration there is a phenomenon of mutual responsibility of everyone for everyone. But if usually in interpersonal relations this fact isn't realized until something happens, there is quite another picture if one of the interacting people is a physician. His quite human responsibility for the life and the health of a partner increases by his professional duty imposed on him by the society. That's why there is an impression that physicians and medical workers are the only people who are responsible for the life and the health of the others. Let's underline the fact that a physician is professionally responsible for the life and health of those people whom he really interacts with. In other words a physician isn't responsible for the life and the health of those people who are only his potential patients. 
The second question is who else is responsible for the life and the health of a man besides those who he really interacts with? The answer is simple - the man himself. But this simplicity isn't evident for the moral consciousness of many people. The care of one's own health and the instinct of self -preservation are one thing and the responsibility for one's own life in the face of the others - is quite another thing. This is the very norm of morality, which hasn't obtained so far the imperative character.  The dependent attitude concerning one's own health in fact leads to new diseases. And in this aspect the problem of every person's responsibility for his life and health is one of the central problems in bioethics. 
For medical workers the attitude of a patient towards his health isn't indifferent, moreover, it is principally important for the whole process of treatment. That's why the principles of medical ethics even when strictly observed can't guarantee that morality will contribute to the success of the treatment. What are the moral requirements to the position of the patient from the point of view of bioethics?
Principle 1. The responsibility in the face of the past (preservation of gene-fund, transmitted by parents). 
Principle 2. The responsibility in the face of the future (provision of healthy posterity - transmission of gene-fund to children).
Principle 3. The responsibility in the face of the present (provision of secure bio-functions for participating in the process of creating culture).
Principle 4. The right to the worthy life (adequate)
Principle 5. The right to the health protection.
Principle 6. The right to the natural death.
This principle is very complicated from the point of its realization and brings about a lot of discussion. Each of these principles can be given concrete expression according to the concrete situations. For example, the responsibility for one's own health is simultaneously the performance of the moral duty in the face of the parents and all the other generations of ancestors who preserved and transmitted the genetic information. Thus, the responsibility of a man for his own health becomes the responsibility of Homo Sapience.
The second principle is absolutely clear because to preserve the species - means not only to take care of the living forces which are given to him but also to transmit the unique genetic information further. Unfortunately, in our society there is no legal responsibility of the parents who produced inferior posterity, but their moral fault is obvious.
The third principle is connected with the fact that culture is the way of preserving the biological nature of a man. And if irresponsible attitude to one's health doesn't permit a man to fulfill his functions of creating culture, it naturally influences the prosperity of other people. Consequently, there is a violation of moral interrelations between people.
On the other hand, according to the principle of exchange of the activities a man who performs his duties on the part of the surrounding people has a right to demand the same. The right to the worthy life is differently realized in different societies and at different times. The main thing here is a great respect to the personality. But the right to health protection can be differently understood in the conditions of state and insurance medicine. 
One should remark that the given principles refer to both the medical workers and the patients. As for the moral position of a physician from the point of view of bioethics, it is entirely exhausted by the principles of medical moral. And it is important to point out only initial positions.
Moral attitudes of a physician and a patient can be conventionally divided into three stages, which correspond to the stages of medical treatment of a patient: Diagnostic stage, Treatment stage, and Rehabilitation stage. And at all these stages the moral contact of a physician and a patient has its own peculiarities. At the first stage the most important thing is the establishing of moral-psychological contact with the patient. In this aspect the physician has to:
* evaluate the personality of the patient in general;
* find out the degree of somatics;   
* find out the hierarchy of moral values which are essential for the patient;
* choose the forms of behavior with the concrete patient;
All this leads to hypertrophy of the role of a physician, he becomes a figure concentrating responsibility for patient's life and health, and a patient perceive him exactly like thus. Such a situation is typical for the developing countries' public systems, where the inner medical specialization is weakly developed. The contemporary situation in the world reveals a great burden of patients' personal and social problems, their need in consolation purely human help is address to a physician.
Some moral creativity on the part of a physician is necessary at all the stages of treating the patient, only generally accepted principles of medical ethics and deontology remain unchangeable:
* Don't make any harm;
* The principle of saving treatment  (compare with the principle of the least harm; 
* The principle of the careful attitude towards the patient;
* The principle of preserving the medical secret;
* The principle of differential approach to the announcement of the diagnosis (compare with the principle of the informed agreement);
* The principle of excluding the Cushing's syndrome.
These are the basic principles which are made concrete and which are supplemented depending on the situation typical in different conditions. However, all this principles bear a relation to only one of the participants of the interaction - to a medical worker, though first of all. The arising contradiction can be solved by several ways. However, the most propagated of them is the way of accepting the paternalistic model of treatment. It justifies one-side views of medical ethics moral principles. On the other hand, there is a need in such a model among patients themselves. It's rather connected with dependent's spirits in the sphere of medicine, which had been formed for a long period of time and which can't be overcome so easily.
It should be marked here, that the form of moral regulation in spite of the contained in them invariant which exactly helps and allows the representatives of different public health system in the world to understand each other have strongly express national peculiarities. There is no and can't be a nation without unique genofund, without unique ecological niche. Therefore the preservation of its human potential is closely connected with preservation of these components and of forming them cultural-historical ways of surviving. That is why paternalistic moods are inherent in patients to a greater extent, the behavior in the respect of their health is formed on the basis of: a) a low-level of medical problems competence, b) great nervously-psychic overloading and desires to shift off a part of their own problems on a physician, c) disorientation in the new forms of medical service, prices and medical remedies.
Who else are the social subjects of paternalism? Representatives of pharmaceutical companies working in drug's market as well maintain the support of the paternalistic model. The paternalistic model is also suitable at making clinical trials. It should be acknowledged, that paternalistic model is profitable to insurance companies too, since their stuff  in some countries mostly consists of specialists in the field of medicine, rather then specialists in the field of insurances or social work. There is one question left, how much physicians themselves are interested in conservation the paternalistic model in medicine. Theoretically they should be interested in it by two reasons: 1) they are taught exactly this form of contact with patients in high medical school and 2) under the conditions of the paternalistic model the volume of work is less as there is no need to discuss something with patient, there is no need to daily raise the qualification etc. 
There were revealed the factors, supporting directions for realization of paternalistic model in medical practice. This (on measure of decrease): 
1.Cultural and religious traditions.
2.Educational installations.
3.The low level to professional qualification and the absence of motives for its increasing. 
4.Incompetence in the questions of bioethical regulation of the physician activity.
5.The financial interests.
However, in general the trend of paternalism' "washing away" in medicine has appeared. But there is only one question left - do we need it? We dare to express the opinion that until there is a need in paternalism both with patients, and with physicians, it will on exist. Paternalism is considered as good by the majority of members of society, so it will probably remain leading model in relations of physician and patient in medicine. At the moment on should speak not about the struggle against paternalism, but about the creation of the ethical field for development of other models of such relations. And here the main role belongs to ethical education, to professionalism of physicians and to including "paternalistic' countries" into the global ethical processes of the world medicine.





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