In the 1950s Pedro Lain Entralgo observed that "the curative activity of the physician is always determined by the reality of the human being towards which it is directed, that is, by the 'personal' conditions of the disease and of the patient" (p. xv). Pellegrino believes that this accommodation to the reality of the patient follows from the promise that the medical profession, in the person of the physician, makes to the patient: "The promise of help that shapes the nature of every healing act and defines the requirements for successful healing—even when cure is not possible" (p. 160). But,
Pellegrino notes, considerable confusion exists between doctor and patient about what healing means. Physicians, he says, often fail to comprehend what the patient understands by the promise of healing; patients often fail to understand what the physician thinks he or she is promising. Physicians, in response, are moving toward a restricted sense of promise, emphasizing technical competence, whereas patients expect not only competence but compassionate help as well. The wider the gap between professional promises and lay expectations, the more difficult becomes the collaboration between physician and patient to discover the equilibrium that constitutes genuine healing. As the gap increases, Pellegrino also notes, patients will be more tempted to seek alternatives to the "medical model" and lose the benefits of scientific competence.
COMPETENCE AND COMPASSION. Healing requires, Pellegrino insists, both competence (in scientifically accurate diagnosis and treatment) and compassion (the capacity to enter into the experience of illness with the patient). Competence is a necessary but not sufficient condition of healing. Healing "must be shaped at every step by the purposes of the healing acts—by the good of the person who is ill—his bodily good, of course, but also his concept of health, his value system, and his sense of the kind and quality of life he thinks is worthwhile" (p. 161). Pellegrino sums this up by declaring that the physician therefore has the obligation to protect the moral agency of the patient, to enhance it even in the face of the special vulnerabilities of being ill.
This protection of the moral agency of the patient lies at the heart of compassion; it is essential to the performance of a right and good healing action. Healing thus requires that the conversation between physician and patient encompass more than what can be accommodated by scientifically accurate medical language. As Jay Katz has observed, despite the quantity of words overflowing patients' medical charts, the world shared by doctor and patient is often one of profound silence, offering not the humaneness of shared understanding but the humaneness of services silently rendered (Katz).
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