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BY: FR. THOMAS A. NAIRN, OFM, Ph.D.

As we look at the term "person-centered care," we might think that the meaning of "person" is self-evident, especially in health care ethics. In the history of bioethics, however, this has not always been the case.

The term "person-centered care" is evocative of the patient-centered care movement that has developed over the past decades.¹ This movement has partly been a reaction to the medical paternalism that characterized previous generations of medicine. According to bioethicist Howard Brody, patient-centered care is

... based on a physician-patient relationship that is highly satisfying to the patient and the physician ... the patient, not the physician, occupies center stage. From first contact through the completion of the care episode, the patient must meet with consistent and competent care ... all patients will receive care that is culturally and linguistically appropriate ... practices strive to meet patient and community needs for integrated care by giving patients what they want and need — preventive care, acute care, rehabilitative care, chronic illness care, and supportive care — when they want and need it by anticipating patient needs and by designing services to meet those needs.²

The goal of patient-centered care is to return control in the care setting to the patient rather than the physician or other caregiver. Does an understanding of "person-centered care" add anything to this model?

WHO IS A PERSON?
Anyone old enough (or enough of a student of the history of the discipline) to remember the debates of 40 years ago among ethicists such as Joseph Fletcher,³ Paul Ramsey⁴ and Richard McCormick⁵ knows that theologians and philosophers have used the term "person" in a variety of ways for a variety of reasons. One of the first ethicists to discuss personhood was Fletcher, who used the term to exclude rather than to include, maintaining that only those humans who actually had the capacity for self-consciousness should be acknowledged as persons. Citing Genesis and the biblical notion that the human being is created in the "image of God," he explained that the image of God that makes the human being a person consists in the capacity for "intelligent causal action."⁶ Later, he would explain, "Homo is indeed sapiens, in order to be homo. The ratio, in another turn of speech, is what makes a person of the vita. Mere biological life, before minimal intelligence is achieved or after it is lost irretrievably, is without personal status." He added as a corollary to this statement that an individual with an IQ of less than 40 is "questionably a person" and that anyone with an IQ of less than 20 should not be considered a person at all.⁷

Ramsey's classic text, The Patient as Person, is at least indirectly a reaction to the sort of reasoning used by Fletcher. Although he does not address Fletcher directly except in a discussion of euthanasia,⁸ the book reacts strongly to a notion of person that limits the sorts of humans that may be considered persons. Rather, Ramsey speaks of respecting the sacredness of the person:

Just as man [sic] is a sacredness in the social and political order, so he is a sacredness in the natural, biological order. He is a sacredness in bodily life. He is a person who within the ambience of the flesh claims our care. He is an embodied soul or ensouled body. He is therefore a sacredness in illness and in dying. He is a sacredness in the fruits of the generative processes ... The sanctity of human life prevents ultimate trespass upon him even for the sake of treating his bodily life, or for the sake of others who are also only a sacredness in their bodily lives.⁹

Ramsey thus articulates a very different and much more inclusive understanding of person, an attitude which treats all human life as sacred. All instances of humanity, from conception until natural death, deserve deep respect by the very fact that they are human.

Members of the next generation of Christian bioethicists continued to display a suspicion of the term person. Stanley Hauerwas, for example, has argued that "person" has not been very helpful in medical ethics and asks why the discipline is even interested in who is a person. He suggests that our use of this language is tied to a desire to ensure that bioethics still rests upon a moral consensus. He explains:

The introduction of the notion of "person" as regulatory ... might be an attempt to find a firmer basis than the more historically and socially contingent notions can provide. But I am suggesting that is just what the notion of "person" cannot do without seriously distorting the practices, institutions, and notions that underlay how we have learned morally to display our lives More technically, what advocates of "personhood" have failed to show is how the notion of person works in a way of life with which we wish to identify.¹⁰

In his typical fashion, Hauerwas challenges Christian bioethics to "be willing to have our medicine as fragmented as our moral lives,"¹¹ and acknowledge that virtues by which physicians ought to practice medicine are the elements that are important, and these may lead physicians in a direction that is very different from what is claimed by the language of "personhood."

COUNTERING REDUCTIONISM
Throughout the Ethical and Religious Directives for Catholic Health Care Services (ERDs), one sees the emphasis on the dignity of the human person. If one looks closely at how the term person is used in the ERDs, one can see a corrective, not dissimilar to that of Hauerwas, to some problematic uses of the term. The ERDs' emphasis on the well-being of the whole person serves as a corrective to those understandings of the person that try to limit those who may be considered persons. Their emphasis on the mutuality between caregivers and patients can serve as a corrective to those notions of person-centered care that tend to emphasize control.

The introduction to Part Two of the ERDs explains, "Since a Catholic health care institution is a community of healing and compassion, the care offered is not limited to the treatment of a disease or bodily ailment but embraces the physical, psychological, social, and spiritual dimensions of the human person." Similarly, Directive 33 states: "The well-being of the whole person must be taken into account in deciding about any therapeutic intervention or use of technology." These statements serve as an antidote to biological reductionism that can so easily creep into the practice of medicine. As the cardiologist sees only the heart, and the pulmonologist the lungs and the oncologist the site of a cancer, it is easy for the patient — the person — to get lost.

Furthermore, the patient's well-being goes beyond the medical. In this sense, person-centered care is ultimately a theological and spiritual point of view, and the Catechism of the Catholic Church is illustrative. It speaks about "reasonable care" which respects the person, while also "taking into account the needs of others and the common good"¹² and rejecting the forms of control that "can lead to the perversion of human relationships."¹³

A MUTUAL RELATIONSHIP
Concern for the total well-being of the patient thus leads to a concern for the healing relationship between caregiver and patient. Part Three of the ERDs is emphatic that this is a mutual relationship. The section begins with this sentence: "The person in need of health care and the professional health care provider who accepts that person as a patient enter into a relationship that requires, among other things, mutual respect, trust, honesty, and appropriate confidentiality." It continues by noting, "The ... multiplication of relationships [in a clinical setting] does not alter the personal character of the interaction between health care providers and the patient."

If the thrust of patient-centered care is to change the locus of control in the patient-physician relationship so that "the needs and values of the patient will become much more powerful drivers" of the activities of physicians and staff,¹⁴ perhaps person-centered care in a Catholic context demonstrates that the healing relationship is one that is controlled neither by physician nor by patient, but is a mutual relationship. The ERDs emphasize, "Neither the health care professional nor the patient acts independently of the other; both participate in the healing process."¹⁵

The term "person" remains ambiguous. It can be a term of exclusion or one of inclusion. As used in Catholic health care, the ideal of person-centered care calls all involved in the healing relationship to an attitude — what Hauerwas calls a virtue — that takes into consideration the multiple aspects of the life of the sick person, his or her total well-being. It achieves this by acknowledging that caregiver and patient are both part of the same team, involved with each other in a relationship of mutuality, a healing relationship.

FR. THOMAS A. NAIRN, OFM, Ph.D., is senior director, ethics, Catholic Health Association, St. Louis.

NOTES

1. Howard Brody speaks of three phases of this movement, which he characterized as epistemology, therapy and policy. See The Future of Bioethics (New York: Oxford University Press, 2009): 51-55.
2. J.C. Martin et al., "The Future of Family Medicine: A Collaborative Project of the Family Medicine Community," Annals of Family Medicine 2 (Suppl 1): S14.
3. Joseph Fletcher, Morals and Medicine (Boston: Beacon Press, 1954). See also "Indicators of Humanhood — a Tentative Profile of Man," Hastings Center Report 2, no. 5 (Nov. 1972): 1-4.
4. Paul Ramsey, The Patient as Person: Explorations in Medical Ethics (New Haven: Yale University Press, 1970).
5. Richard A. McCormick, "To Save or Let Die: The Dilemma of Modern Medicine" in How Brave a New World? Dilemmas in Bioethics (Washington, DC: Georgetown University Press, 1981): 339-51.
6. Fletcher, Morals and Medicine, 218.
7. Joseph Fletcher, "Indicators of Humanhood," 1.
8. See Ramsey, The Patient as Person, 148-52.
9. Ramsey, The Patient as Person, xiii.
10. Stanley Hauerwas, "Must a Patient Be a Person to Be a Patient? or, My Uncle Charlie Is Not Much of a Person but He Is Still My Uncle Charlie" in Truthfulness and Tragedy (Notre Dame, Ind.: University of Notre Dame Press, 1977):130.
11. Hauerwas, "Must a Patient Be a Person," 131.
12. Catechism of the Catholic Church, para. 2288.
13. Catechism of the Catholic Church, para. 2289.
14. See Brody, The Future of Bioethics, 56-57.
15. United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services, Fifth Edition (Washington, DC: USCCB Publications, 2009): Introduction to Part Three.