Hans-Martin Sass, Ph.D.
International Scholar, Kennedy Institute of Ethics, Georgetown University, Washington DC 20057, USA.
The First Rules stress the lay person's obligation to actively search for and to find the right expert and the expert's obligation to serve her or his patient as a fellow human and not just as a technician of medicine. No educated person will leave important issues such as health care professional we rightly request not just best technical service but personal attention, compassion, patience, helpfulness and even sacrifice. At times difficult balances between patient autonomy and expert responsibility, between beneficence (bonum facere) and non-maleficence (primum nil nocere) need to be established; this will not be possible without trust as the underlying virtue and principle of all parties involved.
The Second Rules call on the educated lay person to educate herself or himself in matters of health and to develop individual competence in the care of health, while the health care expert is called to teach and to educate the lay person and to assist her or him in accepting health care responsibility. Health care primarily has to be understood as a human and civil obligation, rather than a right which can be claimed from others. Professionals should be partners rather than elitists and not withhold information necessary to the educated citizen for her or his self-determination in health care matters.
The Third Rules emphasize the particular importance of mutual responsibility and interaction of the lay and the expert in predictive and preventive health care, while the Fourth Rules remind both groups that acute medicine has its limits and risks and calls for trust-based cooperation and risk partnership. The principle of informed consent to medical treatment does not meet the challeneges of preventive and acute health care in the future; it has to be transformed into principles of trust-based communication and cooperation and into the principle of shared responsibility.
The Fifth Rules underline that it is the lay person first who carries prime responsibility in preventive care for health, while the expert's role is reduced to understanding and compassionate information, advice and support. The obligation to care for one's own health is the precondition for rights one might claim that others should care for one's health. Expert advice as well as treatment has to be individualized; individual risk parameters, values, goals and which mark the limits of "objective" health care. The Sixth Rules stress, that qualities of life can only be defined individually, never objectively and not easily by others. Health care professionals have to strive to continuously educate themselves in best possible technical services. Educated citizens have to recognize that qualities of life transform, not descend, over the years and that they have to redefine or adjust goals and preferences accordingly. Professional health care advice therefore must respect individual preferences and choices in the delivery of the incompetent, the terminally ill and the dying. Therefore Seventh Rules call on the professional to assist the lay person in understanding suffering, weakness, and dying, to help her or him to recognize those values and wishes and to establish those directives in advance which should govern trusted surrogates and health care experts to make adequate decisions in circumstances of incompetence.
Rules eight remind both, lay citizens and health care experts, that it is a matter of justice and solidarity to be responsible in the allocation of health care funds. Modern health care depends on a complex system of prevention and intervention, basic and supplementary care, distribution of labour, cooperation and specialization, also on effective and just administration and allocation of funds. Therefore it is mandatory that all players in the field of caring for health, for the suffering and the dying, are responsible for the protection and improvement of existing health care delivery systems.