Norman Quist

In this essay, by example of the physician-patient relationship and drawing on the work of D.W. Winnicott, I explore what may be possible together in relationships, and in the pursuit of health and flourishing, at understanding what we need, and getting ourselves and the other “right”—what we are afraid of and how we get each other wrong, and the distance or gap between “what has been” and “what might be.” In pursuit of these questions, I consider what both physicians and patients might endeavor to do together to address this distance: to recognize and respond to each other, and to identify and address common needs and felt distances. And, how, along the way, we may be able to better identify and understand fundamental challenges to all relationships. Finally, I ask the reader to imagine a physician-patient encounter (and all relationships) as vulnerable possibilities. And I suggest a method for a way forward. While we may not always get what we want in a relationship, perhaps our earnest effort at knowing together will open a potential space for us to get what we need. This is where I imagine that the physician-patient relationship begins: where all relationships begin.

What process ought to guide decision making for pediatric patients? The prevailing view is that decision making should be informed and guided by the best interest of the child. A widely discussed structural model proposed by Buchanan and Brock focuses on parents as surrogate decision makers and examines best interests as guiding and/or intervention principles. Working from two recent articles by Ross on “constrained parental autonomy” in pediatric decision making (which is grounded in the Buchanan and Brock model), I discuss (supportively) features of Ross’s effort visa-vis the best interest standard. I argue that any pediatric decision-making model that brackets or formally limits an engagement with the child patient assumes too much. Further, any model that under appreciates the place of parents and their autonomy, and the dynamic parent-child relationship, misses an opportunity to broaden the clinical encounter by considering questions of justice for the child (Rawls) and within a family (Ross). In this context, I focus on the child’s emerging and ongoing emotional and intellectual development and autonomy—their capabilities and identifying primary goods.

Questions that arise in the doctor-patient relationship may be transforming. The discussion begins with a compelling example: When parents ask, “Doctor, if this were your child, what would you do?” it is always a “high-stakes” question. What the question means and how it is understood depends on how we understand, and how sensitive we are, to the context and the complexity of several different relationships, and what each uniquely asks or requires. Working from the parents’ question, “What would you do . . . ?” the present discussion will develop a broader understanding of questions within the doctor-patient relationship and the possibilities for finding meaning that they introduce. A clinical narrative is used to show that questions are most meaningful when they are understood in the context of a unique relationship--and a "potential space"--that is both interpersonal and ontological.

Something is not working in ethics consultation: in certain situations, relationships within families and with careproviders and surrogates have become so emotionally charged and destabilized that attention is dominated by conflict and misunderstanding, foreshadowing a loss of dignity and hope. In a compelling, urgent article, informed by events in the Schiavo case, with examples from the literature on theory, practice, and outcomes, Caplan and Bergman address this situation: redirecting our attention to what they see as “a lack of effective mechanisms” for dealing with a “painful class of disputes in which families disagree with one another, or with doctors, about the care of those who cannot communicate.”1 It is no small matter that many of these cases are situated in the immediate, intense environment of end-of-life decision making. How might we understand these encounters, and their limits? What can we hope? Following the tack of Caplan and Bergman, I will extend the discussion of the complex relationships between patients, families, surrogates, and physicians, and “hope for consensual resolution,” offering a somewhat different account of what is lacking. While Caplan and Bergman foreground an apparent irreconcilability of appeals to competing biomedical principles as what is lacking, I will suggest that a “salient characteristic” among participants, what Caplan and Bergman identify as a common concern for the patient’s best interests, may be far less stable and more complex, and thereby less directive, than first imagined. When Caplan and Bergman sketch their expectations for mediation and for mediators, they are right in noting that abstract principles “articulated as dispositive by designated ‘experts’ fail to capture, and arguably respect, the unique and complex nature of each such individual decision-making process,” and that “patients and families are at the extreme end of a power imbalance.” It is less clear that their descriptions — or their hope for mediation — capture this enormous challenge.

Investigations and commentaries on domestic violence and its sequelae have been featured in several recent medical journals. For discussion purposes, I will highlight aspects from three of them. According to Megan Bair-Merritt and her colleagues, in a recent issue of the Journal of Pediatrics, screening for domestic abuse in a pediatric practice can uncover cases that otherwise might not be identified.1 Of the women who brought their children to a pediatric clinic at Johns Hopkins Children’s Center, 23 percent disclosed that they had been victims of either emotional or physical abuse; 57 percent of the abused women indicated that at least one child had been exposed to this violent interaction.

What is best for the hospitalized patient? How do we increase the prospects that a patient will receive the best care a hospital can provide, and how is this accomplished? It has been argued that what is best for the patient is to be in the care of highly functioning collaborative teams, teams with certain unique qualities, teams that have esprit de corps. But how do we get there? In furtherance of this discussion, the author, in a Quintilian-like spirit, deliberates about "necessity" and "possibility" in what is best for the hospitalized patient and the challenges these teams must navigate: responsibility, accountability, team relationships, leadership, moral distress, dissent, and personal and professional risk.