Abstract
Individuals with chronic spinal cord injury (CSCI) require complex and lengthy health services based on ethical philosophy. The virtue character that is most relevant to the egalitarian concept is fairness. The aim of the study is whether the character of fairness becomes the character of a doctor serving individuals with CSCI. It is a mixed method cross-sectional explanatory study, with questionnaires sent to doctors and individuals with CSCI, interviews with doctors, and healthcare system field observation. Sixty-two doctors and 33 patients with CSCI participated in the study. The virtues most frequently chosen by doctors were love, gratitude, spirituality, zest, fairness, and kindness. The CSCI patients’ views regarding doctors’ characters were a postponement of personal interest, compassion, and loyalty to trust. All interviewed doctors indicated that they supported more than five of the 24 virtues. Doctors serve with ethical principles of virtue, even though the rewards received are inadequate. In fact, the use of health services by CSCI is still limited. Virtue ethics, especially the character of fairness, is necessary as a base of positive relationships between doctors and patients, to achieve equality of benefits for CSCI patients. Data obtained that the doctors’ character of fairness is still not the main choice.
Keywords: Virtue ethics, Chronic spinal cord injury, Severe disability, Patients benefit, Healthcare system
Introduction
Disability refers to a decrease in the function of the human body that affects many persons, either in the form of temporary or permanent disability, at some point in life. Levels of disability can be categorized as mild, moderate, and severe. Individuals with chronic spinal cord injury (CSCI) are individuals with severe disabilities whose functional abilities cannot be improved, and they have highly reduced abilities for daily living and require care with respect to some aspects of their life. However, a small number of CSCI patients can work as self-employed individuals or employees. These individuals require the help of others to accomplish some activities in their daily life. The condition of public facilities in Indonesia has not met the access needs of individuals with CSCI. According to data drawn from the Directorate of Social Rehabilitation of Indonesia (2014), the number of severely disabled people, including those with CSCI, was 163,232. This figure is expected to continue to increase (Bahrul and Karno 2017). There must be a guarantee of equal rights for persons with disability. Health services that consider the equal rights of persons with disabilities are needed (Guterres 2020).
There are an increasing number of severely disabled people, which gradually reduces their quality of life. That is necessary to design appropriate health services for persons with severe disabilities. Health services for individuals with severe disabilities, such as CSCI, must have an ethical foundation that supports the criteria of benefit, i.e., non-maleficence, autonomy, and justice (Beauchamp and Childress 2019). There are several philosophies that underlie action in healthcare, namely, deontology, consequentialism, and virtue (excellence). Deontological ethics emphasizes ethical actions that are driven by adherence to rules, regulations, laws, and institutional norms. Consequentialist ethics is a form of utilitarian ethics which focuses on the consequences of an action and evaluates decisive action based on the effects of benefits and costs (Chakrabarty and Bass 2013), and the right action produces good consequences (Driver 2014). Utilitarianism is a form of consequentialist ethics and the most influential normative ethics. The founding father of utilitarianism was Jeremy Bentham and John Stuart Mill, who argued that right morals are actions that produce the best. The utilitarianism ethics has meaning that the greatest amount of good for the greatest number. The principles underlying the application of virtue ethics are justice and good decisions. They must be adopted to be a good doctor, acting in a socially responsible manner, and reflecting the internal virtues and moral standing of the health services system (Kotzee et al. 2017; Merriam 2010). Virtue ethics was first proposed by Aristotle and is considered the most appropriate basis for health services for patients with CSCI. Virtue is a character to enact; it is not a habit without a rationale but an action that goes through a process of reasoning, consideration, and the defense of the rights of others (Lee et al. 2014; Vinnari and Laine 2017).
There are four distributive concepts of justice in healthcare services: the libertarian, communitarian, egalitarian, and utilitarian concepts. In the libertarian concept, each individual is responsible for their own health, well-being, and the fulfillment of the life plan. Therefore, everyone pays for their own individually experienced healthcare needs, through private healthcare insurance. In the communitarian concept, adhere not on the individual’s decision about which healthcare services is desired, but on what society considers to be necessary healthcare. The starting point for the egalitarian concept is the equality of every individual. It aims at creating possibilities for individuals to become as much as possible equal to others. According to the egalitarian concept, it is not the individually experienced healthcare need that is central, but a measurable objective determined healthcare need. Priority is given to patients with a great disease burden, and an important element in this model is to determine the disease burden of a given condition for all of the common or rare conditions. According to the utilitarian concept, the prior goal is increasing the total health of the whole population. The financial resources should be used in such a way that the greatest possible health gain for the whole population is achieved (Leget and Hoedemaekers 2007).
Indonesian law number 19 of 2011 and law number 8 of 2016 describe the commitment of the Government of Indonesia to respect, protect, and fulfill the rights of persons with disability, which is ultimately expected to improve their welfare (Laws of the Republic Indonesia 2011, 2016). The implementation of these two laws is in accordance with the concept of equity in the health sector. However, utilitarian justice also contributes to achieving the greatest benefit to the entire disabled population in healthcare.
To improve health services for persons with severe disabilities in an equivalent benefit and ethical manner, the role of bioethics in CSCI health services must be emphasized (Garland-Thomson 2017). Health problems in CSCI affected multisystem, namely, the motor, sensory, and autonomic systems, so it needs lengthy and complex healthcare (Fehlings et al. 2017), while appreciation of doctor still remains minimal, so health services delivered to patients with CSCI need to be characterized by technical skills and intellectual that are integrated in a sustainable manner as virtues characters by doctors in medical practice (Bain 2018; Bennahum 2013), to achieve measurable benefit for CSCI according to the health problems they have.
A previous study regarding the assessment of doctors’ virtues was carried out using the Value in Action Inventory of Strengths (VIA-IS) questionnaire, which consists of a list of 24 character strengths. The validity and reliability of VIA-IS were tested. The 24 character strengths are as follows (Ruch et al. 2010):
Appreciation of beauty and excellence – I recognize, emotionally experience, and appreciate the beauty around me and the skill of others;
Bravery – I act on my convictions, and I face threats, challenges, difficulties, and pains, despite my doubts and fears;
Creativity – I am creative, conceptualizing something useful, coming up with ideas that result in something worthwhile;
Curiosity – I seek out situations where I gain new experiences without getting in my own or other people’s way;
Fairness – I treat everyone equally and fairly, and give everyone the same chance applying the same rules to everyone;
Forgiveness – I forgive others when they upset me and/or when they behave badly towards me, and I use that information in my future relations with them;
Gratitude – I am grateful for many things, and I express that thankfulness to others;
Honesty – I am honest to myself and to others, I try to present myself and my reactions accurately to each person, and I take responsibility for my actions;
Hope – I am realistic and also full of optimism about the future, believing in my actions and feeling confident things will turn out well;
Humility – I see my strengths and talents but I am humble, not seeking to be the center of attention or to receive recognition;
Humor – I approach life playfully, making others laugh, and finding humor in difficult and stressful times;
Judgment – I weigh all aspects objectively in making decisions, including arguments that are in conflict with my convictions;
Kindness – I am helpful and empathic and regularly do nice favors for others without expecting anything in return;
Leadership – I take charge and guide groups to meaningful goals, and ensure good relations among group members;
Love – I experience close, loving relationships that are characterized by giving and receiving love, warmth, and caring;
Love of learning – I am motivated to acquire new levels of knowledge, or deepen my existing knowledge or skills in a significant way;
Perseverance – I persist toward my goals despite obstacles, discouragements, or disappointments;
Perspective – I give advice to others by considering different and relevant perspectives and using my own experiences and knowledge to clarify the big picture;
Prudence – I act carefully and cautiously, looking to avoid unnecessary risks and planning with the future in mind;
Self-Regulation – I manage my feelings and actions and am disciplined and self-controlled;
Social intelligence – I am aware of and understand my feelings and thoughts, as well as the feelings of those around me;
Spirituality – I feel spiritual and believe in a sense of purpose or meaning in my life, and I see my place in the grand scheme of the universe and find meaning in everyday life;
Teamwork – I am a helpful and contributing group and team member and feel responsible for helping the team reach its goals;
Zest – I feel vital and full of energy, I approach life feeling activated and enthusiastic). From all of the 24 virtue characters, it appears that the character of fairness is most appropriate to achieve equity for patients in egalitarian health services.
There were studies about virtue on physicians, and the study was conducted by reference to 584 medical students and 274 doctors. The character strengths most widely embraced by the two groups include fairness, honesty, consideration, kindness, and teamwork (Huber et al. 2020). The VIA-IS instrument was adapted and studied in the Indonesian population with 315 non-medical student respondents at an Islamic university in Jakarta (Listiyandini and Akmal 2018). Another study was conducted to investigate 104 patients, and data were collected regarding the ethical virtues of doctors that are considered to be the most important by patients, namely, intellectual honesty (30.3%), loyalty to trust (29.3%), compassion (13.1%), virtue (9.1%), prudence (7.1%), justice (7.1%), and postponement of personal interest (4%) (Carvajal 2020). The patient’s view of the doctor’s virtue needs to be explored, to find out whether the doctor’s virtue character matches the patient’s view of the doctor’s virtue character.
This study aims to analyze whether the virtue character of doctors prioritizes fairness, which supports equality in health services at CSCI.
Methodology
This study was a cross-sectional study using a sequential explanatory mixed method (Carvajal 2020). There were 3 stages of research, i.e., a quantitative questionnaire survey, qualitative interviews, and an observation. The first stage was a quantitative study. The research was conducted using a Google Form, which was distributed to the participants via the WhatsApp application. This was followed by a qualitative study to determine doctors’ explanations regarding the implementation of virtues in health services provided to CSCI patients. In the qualitative study, explanations for the selection of certain virtues on the questionnaire were elicited. Finally, an observation was conducted to determine appreciation for doctors’ services and the utilization of health services by patients with CSCI.
The researcher received ethical clearance from the UGM Research Ethics Committee on 19 May 2022 (KE/FK/0601/EC/2022). The study was carried out in May–June 2022. The research location was in the Jakarta area and its surroundings. All of the participants have received an explanation of the purpose of the study and have agreed by signing an informed consent.
The research subjects included physical medicine and rehabilitation specialists who were actively practicing. The research subjects also included patients with CSCI who were members of an association for persons with disability and who lived in the Jakarta area and its surroundings. One hundred subjects were contacted via telephone to explain the objectives and research methods, following which they used the WhatsApp application to sign the informed consent form and complete the Google Forms questionnaire. Interviews were conducted via telephone, followed by field observations were carried out at two hospitals, i.e., a government hospital and a private hospital. An explanation of how to complete the questionnaire was provided when the Google Form was sent, and there were also opportunities for discussion when respondents experienced difficulties completing the form.
In-depth interviews with three female doctor respondents were conducted by the researchers via telephone. The interview time was 15–20 minutes. Prior to the interview, an explanation of the purpose of the interview was provided, and the respondents were invited to agree or disagree to participate in the study. All respondents had also participated in filling out the previous questionnaire. The questions asked in the interview were as follows: What is your impression of caring for patients with CSCI? What is your attitude in dealing with obstacles to CSCI services? How is this related to skills improvement in CSCI services? What is your view on teamwork in CSCI services? What is your view on remuneration in CSCI services? What is your attitude toward CSCI service activities that are covered by the media? Open coding was carried out regarding the meaning of the responses to each question, and then, final coding was carried out in accordance with each virtue. The data were processed in terms of averages and percentages using SPSS 22 software.
Results
Based on data from the questionnaires, interviews, and field observations, the results included 83 (83%) completed doctor questionnaire forms, while 21/83 (26%) forms were completed incorrectly and so could not be used for data processing. In total, 62 doctor respondents completed the questionnaires correctly. There were difficulties distributing the Google Form to patients with severe disabilities, partly because many of these individuals did not have an email address or use the WhatsApp application. In addition, their domiciles were difficult to reach, so only 33 (55%) of these respondents returned correctly completed questionnaires.
Most of the doctor respondents were women (71%); the average age of all doctor respondents was 46.3 (31–71) years, and the average length of practice was 11.3 (1–32) years. Table 1 illustrates that the most doctors practice in private hospitals (45.2%), followed by government hospitals (23%), and then both public hospitals and private hospitals (22.6%).
Table 1.
Characteristics of the doctor respondents
| Characteristic | N | % | Mean |
|---|---|---|---|
| Total subject | 62 | ||
| Gender | |||
| Male | 18 | 29 | |
| Female | 44 | 71 | |
| Age (year) | 46.3 (31–71) | ||
| Years of practice | 11.3 (1–32) | ||
| Health services | |||
| Private hospital | 28 | 45.2 | |
| Government hospital | 15 | 23 | |
| Government and private hospitals | 14 | 22.6 | |
| Private | 3 | 4.8 | |
| Clinic | 2 | 3.2 |
Doctor respondents were asked to choose 6 virtues from the list of 24 virtues in rank order. Selection was performed by determining one virtue for each rank. The main choice was the first choice, and the sixth option was the last choice. Table 2 describes the five most commonly selected virtues for each rank.
Table 2.
Five most commonly selected virtues for each ranking
| First choice 15 virtues |
2nd choice 18 virtues |
3rd choice 19 virtues |
4th choice 22 virtues |
5th choice 21 virtues |
6th choice 23 virtues |
|
|---|---|---|---|---|---|---|
| 1 | Love (11) | Gratitude (10) | Hope (11) | Hope (8) | Creativity (7) | Teamwork (10) |
| 2 | Gratitude (10) | Kindness (8) | Creativity (6) | Zest (5) | Kindness (6) | Zest (7) |
| 3 | Spirituality(8) | Honesty (6) | Honesty (5) | Love (4) | Love (5) | Gratitude (4) |
| 4 | Zest (6) | Hope (5) | Humility (5) | Fairness (4) | Prudence (5) | Creativity (4) |
| 5 | Fairness (5) | Fairness (5) | Teamwork (4) | Social intelligence (4) | Teamwork (5) | Hope (3) |
| 6 | Kindness (5) | Teamwork (5) | Gratitude (3) | Honesty (4) | Humility (4) | Humor (3) |
| 7 | Hope (3) | Zest (4) | Perspective (3) | Humility (4) | Gratitude (3) | Kindness (3) |
| 8 | Bravery (3) | Creativity (3) | Perseverance (2) | Gratitude (3) | Bravery (3) | Bravery (3) |
| 9 | Teamwork (2) | Spirituality (3) | Prudence (3) | Love of learning (3) | Social intelligence (3) | Honesty (3) |
| 10 | Curiosity (2) | Love of learning (2) | Love (2) | Humor (3) | Judgment (3) | Appreciation to beauty and excellence (2) |
| 11 | Judgment (2) | Bravery (2) | Fairness (1) | Spirituality (3) | Hope (2) | Love of learning (2) |
| 12 | Social intelligence (1) | Judgment (2) | Kindness (1) | Bravery (2) | Humor (2) | Prudence (2) |
| 13 | Honesty (1) | Perseverance (2) | Bravery (1) | Leadership (2) | Perspective (2) | Humility (2) |
| 14 | Humility (1) | Humor (1) | Leadership (1) | Teamwork (2) | Curiosity (2) | Perseverance (2) |
| 15 | Creativity (1) | Leadership (1) | Forgiveness (1) | Judgment (2) | Zest (2) | Judgment (2) |
| 16 | Humility (1) | Perspective (1) | Appreciation to beauty and excellence (1) | Spirituality (2) | Perspective (2) | |
| 17 | Judgment (1) | Curiosity (1) | Kindness (1) | Perseverance (2) | Spirituality (2) | |
| 18 | Self-regulation (1) | Zest | Prudence (1) | Fairness (1) | Love (1) | |
| 19 | Spirituality (3) | Creativity (1) | Honesty (1) | Fairness (1) | ||
| 20 | Forgiveness (1) | Leadership (1) | Social intelligence (1) | |||
| 21 | Self-regulation (1) | Appreciation to beauty and excellence (1) | Leadership (1) | |||
| 22 | Perspective (1) | Teamwork (1) | ||||
| 23 | Forgiveness (1) |
For the first choice, a list of 15 selected virtues was obtained; then, for the sixth choice, a list of 23 virtues was obtained. The number of selected virtues increased with the last selection. The six most chosen virtues for the first choice included love, gratitude, spiritualism, zest, fairness, and kindness. The virtue of fairness is selected by five subjects in the first and second choices in 5th position, then chosen by one subject in the 3rd choice, four subjects in the 4th choice, and only selected by one subject in the 5th and 6th choices. From these data, it appears that the character of fairness is still not the first choice.
There were more male than female respondents among the patients with CSCI. The mean age was 43 (27–65) years. Most patients with CSCI were self-employed, followed by private employees or unemployed. Table 3 illustrates that most of the CSCI respondents had a high school education, followed by those with a university education.
Table 3.
Characteristics of the respondents with CSCI
| Characteristic | N | Mean |
|---|---|---|
| Total subject | 33 | |
| Gender | ||
| Male | 18 | |
| Female | 15 | |
| Age (years) | 43 (26–65) | |
| Occupation | ||
| Self-employed | 12 | |
| Private employee | 6 | |
| Unemployed | 6 | |
| Employed part time | 5 | |
| Social worker | 2 | |
| Athlete | 2 | |
| Education | ||
| High school | 14 | |
| University | 11 | |
| Elementary school | 4 | |
| Diploma | 2 | |
| Junior high school | 2 |
Table 4 illustrates seven doctor virtues that CSCI patients considered the most important. From the questionnaire data, it was determined that the CSCI patients’ most commonly selected virtue for doctors was “postponement of personal interest”; that means, the prioritization of the interests of patients over personal interests and the patient expects to come first. These data seem to be the patients’ view of doctors’ character in accordance with the doctors’ characters that prioritized love and gratitude.
Table 4.
Frequency of the selection of doctor virtues by patients with CSCI
| Virtue | N |
|---|---|
| Postponement of personal interest | 13 |
| Compassion | 7 |
| Loyalty to trust | 5 |
| Benevolence | 3 |
| Prudence | 3 |
| Intellectual honesty | 2 |
| Fairness | 0 |
The results data below were open code, and final code of the virtue characters was from in-depth interviews with three subjects.
Respondent 1
| Open code | Final code |
|---|---|
| Feeling compassion for patients with CSCI | Love |
|
Many obstacles in service Rarely find cases Service is more of a social service |
Bravery |
| Creative effort | Zest |
| Teamwork is important in handling CSCI | Teamwork |
| Want to serve even though the reward is minimal | Kindness |
| Social work is still limited and needs to be covered through social intelligence campaigns | Social intelligence |
Respondent 2
| Open code | Final code |
|---|---|
| Patient | Self-regulation |
|
Many obstacles Creative |
Zest |
| Participation in social services | Social intelligence |
| Interested in increasing knowledge | Love of learning |
| Need teamwork | Teamwork |
|
Low remuneration Keep doing service even though time is limited |
Kindness |
| Care campaign for patients with CSCI covered by media | Social intelligence |
Respondent 3
| Open code | Final code |
|---|---|
|
Many challenges Trying to be creative |
Zest |
|
Have limited time Patient with CSCI seek services when they have severe conditions |
Perspective |
|
Strive to serve within limitations The need for direction/education for the patient |
Perspective |
| Give advice | Perspective |
| Do not care about compensation | Kindness |
| Participation in social services | Social intelligence |
| Interested in increasing knowledge | Love of learning |
| Need teamwork | Teamwork |
|
Low remuneration Keep doing service even though time is limited |
Kindness |
| Care campaign for patients CSCI covered by media | Social intelligence |
The data from Table 5 shows the list of characters chosen by doctors obtained from in-depth interviews with doctors. All respondents choose more than five characters as a base of ethics virtue in serving CSCI patients. Five virtues that emerged from the in-depth interviews with the three respondents were compassion, teamwork, kindness, social intelligence, and love of learning. The virtues of love and bravery were mentioned only by respondent 1, and virtue of perspective was chosen by respondent 3, while the character of fairness is not chosen by any of the respondents.
Table 5.
Virtue coding based on interviews with respondents
| Virtue | Respondent 1 | Respondent 2 | Respondent 3 |
|---|---|---|---|
| Love | x | ||
| Bravery | x | ||
| Zest | x | x | X |
| Teamwork | x | x | X |
| Kindness | x | X | X |
| Social intelligence | x | X | X |
| Love of learning | x | X | X |
| Perspective | X |
The results of the observation of medical rehabilitation services indicate that the interest of CSCI patients in taking advantage of national health insurance to obtain health services in hospitals remains limited. In fact, 80–90% of patients used national health insurance.
Data from observations on the number of case visits in two hospitals, a government hospital and a private hospital, showed that the most frequent cases involved low back pain, knee osteoarthritis, developmental disorders in children, and acute/subacute poststroke functional disorders. The services data show that there were a small number of CSCI/severe disabilities visiting hospital services regularly.
Discussion
Individuals with chronic spinal cord injury (CSCI) require complex and lengthy health services (Fehlings et al. 2017). The virtue character of doctors is needed in health services to achieve justice and good decisions that benefit individuals with CSCI.
The data shown in Table 2 describe the virtues that were most commonly selected as the first choice, namely, love, gratitude, spiritualism, zest, fairness, and kindness. It is necessary for doctors to have virtues, which aim to provide justice and benefits for the patient’s health status (Furler and Palmer 2010; Leget and Hoedemaekers 2007). To achieve equitable and justice in health services, in accordance with the governing law, the virtue ethics of fairness is expected to be prioritized. The virtue of fairness appears as the 5th most selected virtue for the first- and second-rank choices. The results for the selection of virtues found in this study are different from those of the research conducted by Huber and Strecker with medical students and doctors, in which the most commonly selected virtues were fairness, honesty, perspective, kindness, and teamwork (Huber et al. 2020). The pattern of virtues selected in previous research reflected the importance of fairness and honesty. Meanwhile, the pattern of virtues chosen in this study more reflected the importance of love and gratitude. The subjects in Huber study were not disabled (CSCI) patients, which can affect the doctors’ character. Then, the question is whether the virtues of compassion and spirituality are able to promote the realization of a specific action that can be reached by health services that benefit patients.
Egalitarian justice is most compatible with the health system in Indonesia, i.e., creating possibilities for individuals to become as much as possible equal to others, whereas libertarian concept is guided by each individual responsible for their own health, while the communitarian concept adheres to what society considers to be necessary healthcare, and according to the utilitarian concept, the most important is increasing the total health of the whole population. Since egalitarian justice is the most compatible healthcare justice, it is necessary to analyze whether the virtue ethics of doctors support the justice. As described above, the virtue character that is most compatible with equality is the character of fairness. The results of the data from the doctor’s virtue character do not yet prioritize the ethics of fairness as a virtue that supports justice.
The most commonly selected doctor virtues by patients with CSCI in this study were postponement of personal interest, compassion, and loyalty to trust. Research study on the views of individuals with disabilities on the character of doctors is still very limited. There are several similar studies; i.e., the study in Canadian multidisciplinary academic urban primary care practice on 18 patients with various disabilities found that strong positive relationships, particularly with the medical team and administrative staff, profoundly affected perceived access and experience of care. Participants said that many access, coordination, and physical barriers were eased by team relationships and communication (Walji et al. 2021). Another study at a community center in Milwaukee, on 19 subjects with and without disabilities, describes numerous barriers to receiving desired services, i.e., poor coordination of care among providers; difficulties with insurance, finances, transportation, and facilities; short duration of visits with physicians; inadequate information provision; feelings of being diminished and deflated; and self-advocacy as a tool for better services. Persons with disability described specific ways in which they perceived their disability affected their care. Many persons with and without disability described frustrating experiences within a multifaceted and fragmented healthcare system (de Vries Mc Clintock et al. 2016).
The views of patients with CSCI on virtues in this study may support the study of Walji, S., et al. and deVries Mc Clintock, H.F., et al. Subjects with disabilities realize that their condition needs specific care, so their view for doctors’ virtue is “postponement of personal interest”; that means, patients need to come first. This result study supports the idea that the importance of patients with disabilities could be amplified, as they enable appropriate accommodations (Walji et al. 2021).
The results of this study were different from previous research conducted by Carvajal, regarding the most commonly selected virtues, namely, intellectual honesty, loyalty to trust, and compassion (Carvajal 2020). There were differences in the first and second most commonly selected virtues within this study. It is necessary to understand that the subjects in Carvajal’s study were not disabled patients. It can be suggested that communication between doctors and patients that build based on virtue is very important, besides patient views about doctors’ character also support clear and respectful communication.
Thus, it can be suggested that whatever type of virtue character is adopted by doctors, it is expected to be able to build positive relations with patients and provide solutions to patient needs.
The results of interviews with 3 respondents in Table 5 show five of the characteristics from interviews with the three respondents, namely, compassion, teamwork, kindness, social intelligence, and love of learning. Based on the data on the value selections of the three respondents, the data obtained via questionnaires were strengthened; these data illustrated the importance of empathy and compassion more strongly than the other virtues. Explanations of the virtues of fairness and perspective were offered only once by the 3rd respondent. Although the appreciation for doctors is considered inadequate and facilities are limited, doctors still serve patients with CSCI based on their virtue. In this way, doctors demonstrate the virtues of love, gratitude, and spirituality. Virtue character describes doctor-patient togetherness in the form of “being-with,” which according to Zygmunt Bauman is driven by a relationship of love and sympathy. This form of relationship prioritizes comfort during doctor-patient interactions, but does not yet have clear results. Meanwhile, to achieve equality and benefits for patients, a doctor-patient relationship with a “being-for” means patients’ needs as a goal is the most important (Furler and Palmer 2010). A longer observation time actually needs to observe the doctor-patient relationship.
The results of observations of the implementation of health services in two hospitals, i.e., a government hospital and a private hospital, showed that the highest number of outpatient cases involved low back pain, followed by knee pain and acute-subacute poststroke. There are still few cases of CSCI and another chronic severe disability. There are some problems like physical barriers, transportation, communication, client and provider attitudes, and coordination of care that have been described which affect the quality of healthcare received by individuals with disabilities (Lawthers et al. 2003). A study by Potvin describes the need for support in booking appointments for patients with disabilities (Potvin et al. 2019). Thus, it can be assumed that the limited use of health facilities by persons with disabilities may be due to a lack of communication and coordination that can provide solutions to the obstacles. This is important to establish more positive and constructive communication effectively based on virtue ethics. However, positive relations among doctors and the team, with CSCI patients that guarantee solutions for persons with disabilities, are not entirely the responsibility of doctors and the healthcare team. There is necessary support from authorities and health service facilities to facilitate transportation, access, appointments, and healthcare insurance for persons with disabilities.
This study faces several limitations; namely, data collection was conducted only once, it is possible that personal bias could determine strength of character, and the sample size of the study may have been insufficient.
Conclusion
Physicians who serve individuals with CSCI have virtue character, namely, love and gratitude, while CSCI patients view doctors’ character, i.e., postponement of personal interest and compassion. Virtue character fairness, which is more supportive of equality and benefit for patients in health services at CSCI, is still not the main choice of virtue character. Virtue ethics among physicians and team, as well as patients’ view about doctors’ virtue character, need to be a foundation of positive relationship between doctor and patients, to ease many barriers in health services.
Recommendations
It is necessary to increase doctors’ knowledge regarding virtues that support positive communication in the context of egalitarian and utilitarian justice, through education in the faculty of medicine, hospital management, and hospital ethics committees, as well as increase knowledge among individuals with severe disability, especially those with CSCI, to develop views and expectations that support the concept of justice in long-term health services. Support from authorities and health service facilities is also important to facilitate transportation, access, appointments, and healthcare insurance for persons with disabilities.
Data availability
The data can be made available on reasonable request.
Declarations
Ethics Approval
The researchers received ethical clearance from the UGM Research Ethics Committee on 19 May 2022 (KE/FK/0601/EC/2022).
Consent to Participate
All of subjects received an explanation of the objectives and research method. This research was conducted by prioritizing the subject’s authority, providing benefits to the research subject, not harming, and fulfilling justice for the research subject.
Conflict of Interest
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Data Availability Statement
The data can be made available on reasonable request.