The Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No 164) was opened for signature on 4 April 1997 in Oviedo (Spain). 20 countries has signed the document so far.

In Spain, the doctor – patient relationship is regulated by Law 41/2002, of November 14, which regulates the autonomy of the patient and the rights and obligations in terms of information and clinical documentation.

The tradition of medical care since Hippocrates began to be called “Paternalistic” 50 years ago, product of undoubted abuses in the practice of care (not only by doctors but by all health sectors), and against this paternalism was forged the concept Autonomy of the patient.
Few years later  we can see that the so-called autonomy has changed the doctor-patient relationship (RPM),  becoming either defensive, or transfering the whole responsibility to the patient.

However, there is a real asymmetry in the relationship of doctor and patients, but  even further the Autonomy has derailed from its objective of improving the perspective of the patient by means of the economic contract.

John Rawls and the contractual philosophical theory of political and moral philosophy is based on the Concept of the Original Position of the Social Contract. It turns out that with respect to health can not be raised the same premises.  There could not be a hypothetical Veil of Ignorance (Rawls, 2006) because a) it’s impossible to feel the disease by a “neutral judge”, and b) Justice does not exist while fear and insecurity reing, as it is during an illness.

But above all there is no Rationality. The patient, or his family, is not an equal subject. The disease distorts the capacity for judgment, plain and simple expressed. A sick person (or a family with a sick person) can not make complex decisions regarding the economic impact of their illness. “He will buy everything that is sold to him and he can pay”, uncritically.

The same desperation that leads families to contact healers and put the patient, after payment, through all kinds of trickery, has allowed some professionals to offer therapeutic attitudes in which the benefit for the prescriber far exceeds the benefits for the treaty, choosing the most expensive option or surgery when another treatment should be tried, or redundant diagnostic tests for the benefit of the collector, and so on.

This kind of professionals often gets great social impact and visibility, in glittering centers, and therefore, they are the main advocates that the patient is completely autonomous to make their decisions.

I believe, not because of old paternalism, but precisely as a consequence of the social model created, the patient can not be left abandoned at the mercy of economic forces, because the relationship is asymmetric.
Under this approach, I think you should make sure that “diseases must be paid by the healthies, because the sicks can not decide”. That’s my understanding of the Original Position of Harsanyi developed by John Rawls.

Dr. Armando Molina Betancor