In medical practice, the adequate doctor-patient relationship is fundamental, since most of the medical help is sought during this direct encounter. This relationship has undergone a series of changes that has been influenced by historical and sociocultural elements, moving from a paternalistic approach to one more focused on respecting the autonomy of patients, but always in search of the unalterable objective of medicine: to help patients and improve their quality of life.[1,2,3]
The historical changes in the nature of this relationship are linked to the way in which medical knowledge is generated in each era, which provides a frame of reference for clinical activities and shapes the relationship with patients.
A good patient does what he is told without asking
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Figure 1. Engraving of Hippocrates by Pedro Pablo Rubens, 1638 | Source: Public domain
There are many contributions from Hippocrates, the Father of Medicine, also the founder of a system based on observation and experience through the use of his senses and reason as the only diagnostic instruments: rational medicine. This well-known character began clinical practice at the bedside and introduced the first ideas on medical ethics, the area of study that concerns the clinical relationship.
The relationship between the doctor and the patient during this time was supported by two main ideas: 1) the principle of beneficence by which the doctor will always act for the good of the patient, and 2) the patient as a morally handicapped person, unable to take decisions.[4]
This was established in some of his texts, in addition to the etymological origin of the word sick (from the Latin infirmus), made up of the prefix in, which indicates negation, and the word firmus (firm), which together refers to “the one who does not is firm”, representing the lack of firmness of the patients, not only physical but also mental and moral.
These principles conform to a vertical and paternalistic practice where the patient is treated as a minor who cannot do anything other than obey someone superior (doctor) who knows what will do them good. For the Greeks of the time and for many who came after them, being paternalistic was a sign of professional distinction and considered a strict moral obligation.
During the Middle Ages, the spread of Christianity directly influenced medical practice. The limits that nature previously imposed on the action of doctors are reformulated under the possibility of reaching spiritual perfection even in a sick body, which is why the care of terminal and dying patients is extended. The doctor is visualized as a character who exercises a charitable trade and his assistance should be provided to any patient, like Christ himself.
Another event that strongly influenced the practice of medicine at the time was the founding of the first institute of medieval medicine in the 9th century: the school of Salerno, in Italy, where the study of the art of healing was formalized and texts of figures were gathered. such as Hippocrates, Galen and Dioscorides, as well as writings of Arab and Jewish treatments. At this time he began to bet on the culture of prevention.
Figure 2. Salernitana Medical School represented in the medical encyclopedia The Canon of Medicine written by Avicenna, circa 1020 | Source: Public domain
In medieval medical care, the categories according to the social classes of this historical moment stand out; those considered poor and slaves were cared for in hospitals, artisans and the so-called “rising bourgeois” at home, giving rise to the figure of the “family doctor”; the most powerful social class had its own main doctor who attended inside his residence.[5]
Despite these changes that had an influence on the clinical relationship, it continues to be paternalistic.
