Guest Post Author: Andreas Eriksen, ARENA, Centre for European Studies, University of Oslo, Oslo, Norway; SPS, Centre for the Study of Professions, Oslo and Akershus University College, Oslo, Norway

Paper: Conflicting duties and restitution of the trusting relationship

Medical professionals constantly face hard cases in their interaction with patients, colleagues, and the public. They are torn between different considerations and exposed to seemingly incompatible expectations from their surroundings. Doctors find that their duty to respect patient autonomy can appear contrary to their duty of beneficence. A nurse might experience it difficult to exercise duties of care and concern in a way that respects considerations of comparative fairness between her patients. Medical researchers sometimes see their duty to scientific progress as in tension with the duty to respect human life. My new article Conflicting Duties and Restitution of the Trusting Relationship investigates what a conflict of duties entails in moral terms. When is conflict genuine? Are patients wronged in scenarios of genuine conflict?

Some believe that even when medical professionals make the right choice between conflicting duties, the overridden duties can persist and taint the decision-makers. The existence of an undischarged duty is said to put moral dirt on their hands. For example, if patient confidentiality is trumped by beneficence, there is allegedly a sense in which the professional failed to honor a commitment to the patient. In this vein, Tom L. Beauchamp and James F. Childress speak of the appropriateness of moral compensation, deep regret and a sting of conscience on the part of medical professionals when one duty cannot be discharged because another takes precedence.

I argue that calls for regret and compensation are misguided in cases where professionals have acted responsibly. Decisions that alter the trusting relationship because of inevitable conflict of duty are importantly different from decisions that express betrayal of trust. Contempt for the trusting relationship will taint the medical professional, but the mere fact of conflicting duties does not signal any blameworthy attitude. Nevertheless, conflicts do seem to alter the normative situation. The disappointment of those who relied on the overridden duty is morally significant; it calls for address by the profession. But what kind of address?

I suggest a way of seeing conflicts of duty as generating special responsibilities for medical professionals, yet not necessarily entailing any form of moral taint. As opposed to seeing conflicts as creating a duty of compensation, I see them as triggering a “duty of restitution.” By this, I mean a duty to facilitate the healing of the relationship and to make it clear why trust in the profession is still warranted. Those who represent the profession need to reestablish the trusting relationship in order to care for and respect the patient. Ways of discharging this duty include ensuring that the patient understands the situation, explaining the reasons for the decision, expressing solicitude, and taking measures to curtail possible negative effects. Most importantly, it is about engaging with the patient to find a shared perspective and a plan to move forward. The goal is not simply to coax the patient into adopting a more positive attitude to the profession and the role holder, but rather of reestablishing a relationship based on shared reasons. The goal is to reconnect with the patient as someone with whom one acts with, not merely acts on.

Consider what is sometimes described as a conflict between the duty to instill hope and the duty to be truthful in cancer treatment. Some believe that the concerns and fears of the moment can undermine rational deliberation and justify not telling the whole truth. Imagine, then, a physician torn whether to give a cancer patient with generally good prognosis some bad news. The physician knows this is most likely a minor setback, but does not know how the patient will react. The physician decides to give all the information, resulting in the patient reacting destructively and wanting to end the necessary treatment (now falsely perceived to be futile). By hypothesis, the physician has correctly assessed that truthfulness legitimately overrides conceivable benefits of not disclosing full information. In this situation, the duty of restitution can involve creating a space for rearticulating mutual expectations and shared meanings, which enables an understanding of how minor setbacks be conveyed without destroying cooperation in treatment.

The restitution view acknowledges that conflicts of duty can generate circumstances where patients feel that the moral equality of the relation is threatened and they may also sense a gap between their and the professional’s understanding of the situation. These circumstances call for measures that enable trust to be regained, but that does not imply that trust has been betrayed. Even a professional loyal to the trusting relationship may be faced with the need to make a decision that undermines legitimate patient expectations. Responding to this decision with deep stings of conscience and a desire to compensate reveals lack of commitment to the decision, whereas an ambition to restitute the relationship expresses continued loyalty to the patient’s interests.

Competing interests: None declared.