As always, I welcome your constructive comments and suggestions about the material on this website and how we can all be most effective in co-creating the kind of healthcare system we all want.
by Dawn J. Lipthrott
One way of describing 'relationship' is that it is the space between you and an 'other'. It is the physical space, and it is more. It is the emotional space, the energetic space, the spiritual space between self and other. The philosopher, Martin Buber, talked about that space between two human beings as a sacred space. It is a space where true encounter and deep intimacy can be experienced, especially in love relationships. But even in non-romantic relationships, it is a space of mutual responsibility, giving and receiving. So whether two people are in a romantic relationship, family, friends, or have a professional relationship such as doctor/patient, insurance company/doctor, citizen/legislator, that space is still between them.
Each person constantly creates the climate of that space between them. Everything each person does, says, fails to do or say, the way they say or do something creates the climate of the space. Even what we think contributes to the climate. For example, if I sit and think the other person (or group) is uncaring and greedy, or unappreciative and apathetic, I am creating the climate in a negative way. Instead of relating to the person or group, I relate to my image of them. I look for things that confirm my image . . . and I will usually find what I look for (although it may be more about me than about the other.) So when that person is tired and swamped and doesn't give me the kind of time and attention I want, I will likely see it as uncaring. My attitude has colored the space as much as the behavior of the other person.
Everything we put into our relationship space either supports, develops, builds, strengthens it, or it weakens and pollutes it with tension and distress. If we don't pay attention to the space between us, it is very easy for small, and big, distresses to build up in our relationship climate, polluting the space and leading to growing disconnection, which itself creates more distress. It is not so much that someone intends to pollute the space, but more that it either they don't think about the impact on the other and the relationship itself, or they contribute to the distress in trying to protect themselves or get their needs met in a way that disregards or is at the expense of the needs of the other.
The good news is that we each have the power at any time to begin to shift the climate, to create a relationship of respect, integrity, compassion and justice and in some relationships, love, in the deepest sense of the word.
This 'sacred space between' describes ANY relationship; that of lovers, friends, family; the relationship between co-workers, employees, bosses, customers, clients, patients; the relationship between a person and the Divine; the relationship between you and your doctor; the relationship between you and the environment; the relationship between groups, religions, races, nations; AND the relationship between all the different people and groups that make up complex institutions and systems, like healthcare.
Partnership is a relationship, as described above, in which both partners (whether individuals or groups), value both their own and the other partner's well-being. It is a relationship of essential equality based on our humaness, even when there are different roles, skills or other resources and degrees of power in given situations. It also means we have mutual responsibilities toward each other.
Partnership implies a relationship in which each partner contributes their resources and power for the good of both or for a common purpose. For example, I go to a physician who has knowledge and skills that I do not have (even though I have other knowledge, skills that a physician does not have). I enter into a partnership in which each of us brings ourselves and our resources. Part of that partnership means that I bring my money in exchange for the service of the physician. But it also means that I bring my intelligence, my willingness to take part in my healthcare, my care for myself, my desire to be partners in my healthcare. We both have the goal of my health and well-being. Some of these resources we each bring are core values that characterize our relationship as an 'ethical' partnership.
The same is true in my relationship with my insurance company, in the relationship of my insurance company with my physician, in goverment or insurance or pharmaceutical companies with not only patient or physician, but with the patient/physician relationship itself. In the healthcare system, all of us are linked in relationship and all continually creating the climate of our relationship space. ALL of us are called to ethical partnership because we are in relationship and co-contributors and guardians of that relationship space. What we do, or fail to do, impacts the whole.
Ethical partnership requires each person or group in relationship to act and speak with integrity to several ethical core values:
* Personal responsibility and accountability
* Care and value for the well-being of the other as much as of self
Personal Responsibility and Accountability:
In ethical partnership each partner, whether individual or group, takes ownership of what the personally put into the relationship space. They own those things they say or do that creates distress, even if unintentionally, and commit to changing what they put in the space or find ways to minimize the amount of distress caused and to repair any damage done. Each person and group faces the fact that they do, say . . . or fail to do or say . . . things that create distress, even when that is not their intent, and that they have an obligation for the good of all to change what they are putting into the space. Personal responsibility also includes the obligation to consciously and mindfully create a climate of safety and well-being for all involved. It is not just the absence of negative action, but a responsibility for positive action that strengthens and builds the quality of the relationship space.
In the healthcare system, this personal responsibility exists on an industry, professional, group or company level and on an individual level and group level within those larger groups. For example, let's take insurance. The over-arching insurance industry (which includes health, malpractice, and other forms of insurance) has a responsibility to ethical partnership with members, providers of services, employees, and the network spaces of healthcare. Within the insurance industry there is health insurance (or malpractice insurance). Sometimes there are network management companies. And within all those groups, there are individuals and groups that form them. The accountant or office clerk carries responsibility for what they put into the relationship space not only with their own company, but also with healthcare, physicians, patients, etc. as does the company CEO. So if an office clerk wastes time, steals supplies, is rude or uncaring to customers, is sloppy in inputting information, they raise administrative costs and put distress into the relationship space . . . . which ultimately impacts the whole system. The same ability to impact the entire system is true for every group that forms healthcare--physicians, nurses, other practitioners, pharmaceutical companies, the legal profession, government, supply companies, administrators, office staff, and patients!
So each of us carries personal and collective responsibility for co-creating the relationship space that is our healthcare system.
Accountability means that we are honest with ourselves and one another about our contributions to both the problems and the solutions. Accountability requires a deeper level of transparency . . . to let the other(s) in relationship with us see what we are doing and reporting about our successes and failures in partnership. Accountability starts with self . . . individual and group.
By respect I mean interacting through words and behaviors in a way that honors the other and respects difference. One of the elements that influences respect is the recognition that in spite of our different skills, knowledge, roles, and other attributes, we are all human and equal at a fundamental level. Respect is an honoring of the dignity and equality of all persons. It involves communicating with each other and behaving towards one another in ways that demonstrate the value of the other person.
Care and Valuing for Well-being of All:
This comes from a basic stance of respect with a regard and care about the other person(s) in the relationship. This includes one's self or own group, but is not limited to those who are 'us'. It includes 'them', the 'other' and their well-being. To have care and valuing, we must also develop a consciousness, an awareness, of how our own behavior and words, policies and procedures, impact the 'other'. To do that, we each must listen and take into consideration the concerns and the impact of our actions on others. How do I talk to my doctor's office staff? What happens when I don't pay my bill? What happens if my doctor overbills my insurance company? What happens if I insurance keeps raising prices to make more profit and please their shareholders? One of the weaknesses in much of the healthcare system is self-care with no regard for how our behavior effects another person, group or the whole. Ethical partnership values and honors the well-being of each and works to promote behaviors, policies, and systems which consider all stakeholders.
Justice and fairness is part of caring for the well-being of all, and acting in ways that take into consideration the rights and needs of others as well as one's own needs or desires. It means sharing benefits and burdens in a way that does not exploit or place excessive burden on the other to the benefit of oneself. For example, insurance companies reducing physicians rightful fees for service to increase their own profits or to take an easy way to save money instead of looking at the real causes of increasing costs, is not just. Premiums rising in spite of increasing profit margins at the expense of more people becoming uninsured because they cannot afford the increase, is not just. Injured patients who are burdened with the costs of avoidable injury or forced to sue even when there is no negligence is unjust to both patients and physicians.
By integrity we mean speaking, acting in congruence (ways that match) core values. Integrity is honesty of being. Part of the definition of integrity is that it is complete and unreduced. It involves totality of words and action. Partially matching one's core values indicates a compromise of integrity. Yet at the same time, full integrity is an ideal. We will all fall short of consistently acting with integrity every day in every relationship. But part of integrity is owning the fact that we do fall short and seeking ways to move closer to full integrity with those values.
Collaboration means to work together for the well-being of all instead of polarizing into self-protection and turf struggles. If we put our successes, obstacles and difficulties, our creative thinking, our skills and knowledge together, we accomplish much more than one person or group on their own. We can inspire and assist each other.
The first and most fundamental way we can do that is to be transparent . . . to make our own efforts visible to others and open for suggestions and creative thinking. When we have a concern, instead of complaining, we need to offer ideas and possibilities of how to address it in a way that builds on each other's contribution instead of criticizing and tearing down efforts.
The second way we can build collaborative relationships is to recognize, honor, and draw upon the strengths and the truths that each partner or group holds in the relationship, especially when those truths are different from our own.
The time has come, and the need is great, to create and maintain ethical health partnership at every level of healthcare. To strengthen and deepen quality of care and a healthcare system that considers and values the well-being of all, especially the patient-physician relationship, we each must commit to co-creating ethical health partnership . . . in everything we do or say, in each strategy or plan we consider. We must safeguard and build the space between us instead of pollute it and add to the distress in it. From the context of ethical health partnership and honoring the space between, we will call forth the best in ourselves and others to creatively address the problems in our healthcare system as well as our individual health and care concerns.