Whenever I have the opportunity to suggest that good medicine is based on friendship, I usually get a nod of approval mixed with a quizzical look.  What’s that supposed to mean?

At a recent meeting of an editorial board on which I serve,  the reaction to my suggestion was more forceful and perhaps more honest.  The topic of the day concerned patient education, and how hard it can be to move patients to do things like exercise more or eat better.  I timidly proposed that, as physicians, we might want to start by being our patients’ friends.  The physician sitting next to me immediately objected: “I wouldn’t go that far!”

I understand her reaction.  Perhaps overwhelmed by her workload, the idea of spending more time with a patient over a meal or at the symphony struck her as particularly over-the-top.  There are also practical considerations: what about favoritism, conflicts of interest, privacy concerns, or an appearance of impropriety?

These concerns are valid, but we should be mindful that friendship is not synonymous with conviviality.  Have we narrowed our understanding of what it means to be a friend?

In the Nichomachean Ethics, Aristotle said that there are three kinds of friendship.  One might befriend another person either because he or she is useful, or pleasant, or good.  The first two types of friendship are primarily self-interested in character, where one derives a benefit from what the other brings.  But the third type, the virtuous friendship, is entered into for the pursuit of the good in the other.

And as Robert Barron put it, this type of friendship is often in pursuit of a “transcendent third,” something that lies outside the two people and draws them together.  It’s because of this shared pursuit of a transcendent third that a relationship lasts.  Otherwise, relationships only based on reciprocal self-interest fizzle once one of the friends seems no longer pleasant or useful to the other.   Of course, a virtuous friendship can also be pleasant and useful — and it often is — but it need not be so.

And it is on the basis of this “taxonomy” of friendship that Aristotle (and Plato before him) placed the doctor-patient relationship within the genus of the virtuous friendship — or philia.  A patient and a physician should enter into a relationship not primarily for personal gain but for the sake of health, the transcendent ideal that is never entirely under the control or purview of either party.

Doctors bring to the table their knowledge, skills, and objectivity.  Patients bring their subjective experience and entrust their body.  A payment can help mitigate any perceived imbalance, but it is not essential to a therapeutic relationship.  The relationship between doctor and patient is maintained precisely because of the common interest in the pursuit of health.

It follows that there are three important conditions for the success of friendship in medicine.

First, people should enter into medical friendship voluntarily.  This is particularly necessary for patients, because they are in the vulnerable position, and they will be entrusting their body.  The main opportunity they have to manifest their autonomy is upfront, in choosing the doctor.

As I’ve argued before, to the extent that licensing laws have placed sharp limits on patient choices, these have tarnished the friendship dimension of healthcare and have contributed to setting the medical field off course.

Second, doctor and patient should recognize the commitment of their relationship.  The relationship cannot be based solely on expectations of a positive result (on the part of the patient) or on condition of “compliance” with the prescribed treatment (on the part of the doctor).

The relationship must reasonably allow for unforeseen complications and an untoward course of events.  What is “reasonable” is by-and-large subjective and immeasurable, and, therefore, should mostly be for each party to decide.  To the extent that regulators dictate the parameters of acceptable complications, they too interfere with an idea of medical care based in virtuous friendship.

Third, patients and doctors should globally agree on a common concept of health.  For example, it may be unwise for a thoroughgoing transhumanist to seek the help of a committed Hippocratist, and vice versa.  One attempts to push the boundaries of human nature while the other swears to respect them.  Conflicts are likely to arise.

To the extent that we, as physicians, let our definition of health remain uncommitted, we invite medical opportunism or self-contradiction.  With this lack of clarity it is unlikely that modern medical practice can foster a therapeutic relationship based on friendship.

There is much that could be gained by restoring a view of medical care as steeped in friendliness.  The late Edmund Pellegrino had much to say about that.

Michel Accad is a cardiologist and founder, Athletic Heart of San Francisco. He blogs at Alert & Oriented.

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