1. Trust as a basis for relationships

According to Philip Pettit ^[4], trust in other people could be understood at least according to three meanings. In a vary general sense, it is trust in the fact that others, even if they are unknown will treat us well; in a more specific sense, trust in the fact that if we trust somebody, as what it happens when we get on a bus or we buy prepared food, they will not try to harm use; in an even more restricted way, it is to put oneself in the hands of another one, in a way that this be conscious. It is this third type of trust the most important in the care treatment relations, and therefore will put our attention on it.

Firstly, we can observe that there exists a relationship between the way of trust oneself and the belief. The English philosopher Henry Habberley Price (1899-1984) has the merit of having shown the distinction between belief in (somebody) and belief that (something will be done) ^[5]. To believe in somebody predisposes trust in the fact that the person who we believe will behave in a certain manner. Thanks to this distinction we can understand that trust is established with somebody related to some good^{[3, p. 101]}. A mother trusts the nanny and entrusts the child to her, because she is convinced that she will take care of him with competence and affection. A pensioner trusts an investor, because he believes that what is said to him, and is convinced that he will make his savings to grow. A patient trusts the physician because he believes that he will put at his disposal his competence in taking care of his health but not to cause him any harm. Trust is in summary an answer, which always has two references: the other person I trust, and a good I entrust him. If I trust somebody, I have faith in that what he says, I take as true that what he says, believe in it, and at the same time I am willing to entrust him something which is relevant for me.

Again Price observes that it is possible to believe in somebody in a certain aspect (I believe in the professor, in the nurse, in the lawyer for their professional competence) and to believe in somebody as total confidence in the other, as a person (for example, are of this type, the trust a little child has in his parents, a believer in God, between fraternal friends, or a married couple that love each other profoundly). Thus, the professional relationships are referred to the first type of belief, but they are subjected to the temptation of enhancing their limits, in a way as to constantly become under the risk of getting to the limit of the belief as a total trust. It is a danger in which people who are looking for trust may incur: let’s think on the centralizing entrepreneur, or in the paternalistic physician that request blind confidence and blind and absolute trust; as in those who establish trust, for example the excessively committed clerk or the patient who transforms his trust in an absolute faith in the physicians power. Here, we begin to discover the link between trust and the power of who attends or takes care, and about what we will return later.

For the time being, trust like believe and rely will lead us to think about the relationship with human freedom. To state that trust is a necessary budget in social relationships, in fact, it does not mean to claim that it is automatically given: on the contrary, precisely, cases in which it lacks or enters in crisis, reveals to us that this is the fruit of personal freedom. On the other hand, however, it doesn’t look that the fact that getting a trust from the others could simply be the product of our direct freedom: nobody can declare to simply have caused the trust others have in him. That seems rather to belong to that area of conditions that we cannot take into the existence, just for the sole fact of wanting it, but that we can only favor it, and therefore that falls under the sphere of influence of our indirect liberty. Although every professional could try to behave in a way to inspire confidence in his clients, patients or students, his effort not always reaches a good end, precisely because trust is a free answer by the others: in the end it results from both the freedom of who wants to obtain in, as well as from the freedom who entrusts it. On the other hand, there are cases in which entrusting ourselves does not seem to be the fruit of voluntary decisions, but better the effect of innate needs in men, such as the trust the little child to his parents, or the elderly person or frail person towards who takes care of them. For this, some people doubt the rational and voluntary character of the act with which we entrust confidence. In reality these two phenomena are more supplementary than opposite: man shows an original trend to trust reality and others, a spontaneous and a priori with respect to the verification of the effective reliability of that of which you trust, and the difference is presented as the induced behavior by the experience of trust failures. With intellectual maturity, emerges also the capability of submitting to reason the concession of trust in others, and therefore a form of trust that we could call a posteriori, based on some verification or guaranty with respect of the opportunity of entrusting and as a fruit of a decision. The duty if correctly inform the patient, therefore, could be seen as a condition which allows the patient to trust the physician based on various reasons, and so to transform the spontaneous trust and a priori in the physician into and intentional and rational answer. Precisely due to this reason, the communication with the patient is an important moral duty of the medical care professionals.

We can then ask ourselves, which ones are the conditions in which to favor trust. If we go back to the aspects of belief and entrust that we have witnessed previously, we can indicate two: credibility and reliability of the person to whom you entrust your confidence. Both concur to make a person worthy of trust. Credibility in general indicates that quality of the person based on which the others can recognize as truthful and sincere, and therefore not a liar nor a hypocrite. In the professional field it is also linked to the possession of the necessary competence to perform a certain labor activity, and in the fact that such competence be explicit, and could be recognized by the others. Conversely, reliability is more linked to the responsibility as a virtue that a person can possess in greater or lesser degree: we recognize this quality to whom that shows the disposition to assume the responsibility with respect to his own actions and their consequences, to be accountable for what somebody does what is a duty for him and to respect the assumed commitments. In the professional field it includes, besides the competence, also other permanent qualities of the person, as the strength, the prudence, the justice and the temperance. The professional prestige, then, should be derived from the fact that a professional is credible and reliable, and therefore he is truly trustworthy. It cannot be reduced to scientific knowledge and to the technical capabilities each one possesses, because it includes some moral qualities.

The moral dimension of trust emerges also, if we ask ourselves which obstacles prevent the settlement of an authentic trust relationship, or else they could put it under a crisis immediately. On the part of whoever must inspire trust, simulation can arise: it pretends to be sincere and reliable. This is the main cause of trust misplaced. Conversely, on the part of who must grant trust, it is possible that he would be particularly cautious or skeptical, and therefore would not answer with the trust, even though the person to whom he should be granted is believable and reliable. After it has been established, trust can be put under discussion for objective motives, as for example when you reach a knowledge of some fact that undermines the credibility or the reliability of the physician, or else because of subjective motives, as for example due to a family disappointment, or because of a nervous breakdown, anybody loses the confidence in his fellow man, and therefore he becomes cautious towards all the people to whom he had already entrusted confidence, or he could reasonable grant it in the future.

However, among these phenomena, the most illustrative in order to understand the moral nature of trust, is the fact that it can be betrayed. The defamation by a friend, the fraud by a partner, the copy of a homework by a classmate of a student; they show that trust is a relationship between two people, in which a covenant is given, at least implied, based on which the one who grants the trust expects from the other to behave in a way as to deserve it, and that should not commit acts that can undermine it. The covenant can be ratified by a formal link, or else be based in the nature itself of the relationship. In adultery the formal covenant constituted by marriage is betrayed. In some professional relationships trust is guaranteed by a contract, by which if the other one does not comply what it was agreed (then he betrays my trust) can be legally prosecuted. In other relationships for example, that between a physician and a patient, between a teacher and a student, usually there is not an explicit formal commitment: nevertheless there exists an implicit covenant, because trust forms a part of the material content of those relationships, it is necessary for its good functioning. It has been already mentioned the fact that not always, the process with which a trust relationship is created, is totally conscientious and intentional, sometimes it is initiated by our spontaneous trend of entrusting the others. Notwithstanding, when we realize that our trust has been betrayed, it arises with evidence where is diminished a thing that before wasn’t, or that should have been: such type of relationship that we describe is trust, has been corrupted and such corruption is perceived as morally unjust. The betrayal of trust, even though it is a spontaneous answer and not the result of a conscious decision, has the feature of a violation of a moral duty.

The possibility of the trust granted to somebody else could be betrayed, also indicates that this relationship always conveys a risk: the same as I am free to grant my trust to a physician or to a professor, these are free of not corresponding, with their behavior, to the trust that I have granted to them. To trust it is necessary to overcome fear, both, of making a mistake about the reliability of the other one (that is to say the fear towards trust badly set), as well as to see betrayed our own confidence, and how the other one abuses the power that I grant him by providing him with my trust. We have seen that who trusts, accepts to entrust something that for him is precious (a secret to a friend, a child to the basketball coach, your own preservation to the taxi driver) or to somebody else. For this he becomes vulnerable, and therefore to grant trust is an act of courage ^{[4, p. 208}; ^{3, p. 104]}.

To grant your own trust to somebody, furthermore, implies to load the other one with a responsibility. The physician maybe can refuse to attend a patient, but at the moment he accepts it, among the responsibilities he must assume, is also that one of not betraying the trust he has been granted. Also in this case, the pathological forms are useful to understand better the essence of trust. On one hand, the acceptance of the responsibility by that to whom the trust has been granted, must be proportional to the type of relationship: the physician is asked to take care of the patient’s health, not to solve for him all his relationship problems, either professional or of finance. Moreover a physician who takes advantage of a patient trust, in order to interfere in areas, which are not of his competence, could be justly accused of undue interference. On the other hand, neither who grants trust can have un-proportioned expectations, like in the case where the patient attributes the physician omnipotent powers, or loads him with the responsibility to take away all and every obstacle for his happiness. It is clear that no human being can stand up to that trust.

We can then conclude that the trust relation comes in full when somebody grants trust to another one, and this one answers in an appropriate way with the received entrusted confidence. If trust results in good allocation, and that to whom it has been granted, corresponds with his own behavior to what is required for that particular relationship, a virtuous circle is created, by which the initial trust generates new trust. He, who has received the trust, will be each time more motivated to be faithful, and that who has granted it will be confirmed in his own decision, in a way that his risk margin will be shrunk progressively. We can then speak about a trust climate that can be referred to, both to the relationships between two, as well as the relationships to the inner side of communities of people, and therefore, between physician and patient, or else in a section of a hospital or in a medical office.

In the physician-patient relationship, trust assumes the aspects we have described recently, but also understands the specific feature. Pellegrini, for example, highlights the trust that a patient has is a particular affective component, which is experimented as a “reassuring feeling” that is derived from trusting the physician and of entrusting yourself to him. The fact that the patient decides to whom trust, depends on various elements, particularly the perception of the physician’s technical competence of his relation capabilities, although also about the reputation of the institution in which he works. If the patient trusts the physician, it is more probable that he would follow his indications and also, to be satisfied with the way he is treated. Moreover, there exists, a reciprocal relationship of influence between the trust the patient puts in the physician, and that he grants to the institution in which this last one works ^[3].

As much as we have seen about trust in general, and about that the patient in particular allows us to understand why the physician has the moral obligation of respecting the trust he is granted by the patient, of not taking advantage in his benefit, and to dedicate himself to feed and keep such trust. Such obligations assumes a very relevant weight in the ethics of the medical profession, not only because in it trust is truly the key to the vault of the physician patient relationship, but also because the patient always is located in a position of particular vulnerability, both because generally he does not possesses the necessary medical knowledge to tackle his health problem, as well as his illness condition or disability.

In the last decades, a though about trust has been developed, which is inspired on the first medical ethic treaties written in English and in particular the works of John Gregory (1724-1773) ^[6] and Thomas Percival (1740-1803) ^[7]. They searched for giving an answer to ethical questions of the medical profession which were updated then, as well as they are today, such as the need for the physicians to base their own acting on a rigorous scientific knowledge, and the problem of avoiding that the cost contention requirements of the health institutions, could deteriorate the quality of treatments offered to the patients, especially the homeless. Inspired in Gregory and Percival, Laurence McCullough and Frank Chervenak have proposed to understand the relationships between physician and patient (as well as between physicians and managers of health institutions) in light of the concept of co-fiduciary responsibility. The term “fiduciary” has a judicial origin, but it is interpreted by these authors in a specifically ethical sense, in order to indicate the role of who is invested of trust granted by somebody, has the duty to assume, a role that requires responsibility and fidelity. The fact itself that the physician be always the recipient of the patient’s trust, therefore, it can be the basis of the medical ethics because it imposes to the professional of medicine a series of moral obligations: in the first place, the duty of acquiring and keeping an excellent scientific competence, even though also the performance of some ethical virtues, the commitment to make prevail the benefit of the patients over their own, and the dedication to contribute to create a culture that respects these same ethical requirements, in the institutions to which they belong to ^{[8, p. 174}; ^9].

The thesis we would like to support in what follows is that, in order for the trust climate between physician and patient could flourish and endure, it is necessary that the relationships of reciprocal influence among people respect the limits of their own. For this, it is essential to individualize criteria that will make the power relationships just and respectful towards the patient. In an article published after the first writing of this text, also McCullough has recognized the importance to study the power of the physician over the patients, and make of the ethics of power a fundamental concept of the clinical ethics. The physicians, as he has reminded, have a considerable power over the patients: only to give an example, they formulate diagnostics and prescribe therapies, they decide what and how much information give to the patients about their conditions about the pathologies, about eventual disabilities, about the therapeutic alternatives, and therefore they influence the patients decisions, or additionally can manipulate, precisely thanks to how they transmit that information. If ethical limits are not established, added McCullough, the power of the physician runs the risk of becoming a depredator related to the interests, the rights and the wellbeing of the patients. We can observe that the history of medical practice in the last centuries has widely shown the possibility of abuse of this depredator power by the physicians, as for example in cases of experiments in patients which do not know about them, or with the therapeutically abandonment of incurable patients. In order to offer a contribution to the attempt to insert the ethics in power, to the inner side of the medical ethics, as long as it keeps trying to propose a phenomenology of the power relationships aimed to show the ethical implications ^[10].

2. Power as an action and its objective

The human capability to perform actions, that is, of voluntarily intervene in the world and on others, reveals that every man exercises forms of power, as far as he could be able to influence or affect in an infinitum different ways on all that surrounding him. It is therefore possible to analyze the power phenomenon, in light of the characteristics of the actions. An essential distinction to this purpose is then, between the objective of the action, all what the action causes in the world, and its subjective aspect, that is, the point of view the one who acts, and in particular his motivation and intentions.

To think about the object of the power action, means above all, to consider the purpose of a specific power action that it has in itself: the power to rejoice, the power to heal. Or the one to hurt somebody, they differ because they are acts which have diverse objectives. To rejoice has as a purpose, to make people happier, to make happier another person; to heal has as a purpose to restore health, and to harm has as a purpose to cause a physical, psychic, or spiritual bad thing to another person. Lastly, Power, is always the ability to do something. In order to begin to study its essence, it is necessary stop, and pay attention to this something.

The observation of man’s power over the natural world that surrounds us, for example in the harvest of plants or the raise of animals, suggests to us that power can assume three fundamental forms: a) that of guard, maintain or defend what already exists, such as the work of protecting the plants from inclemency and the parasites, or of the livestock, from illnesses or from the cold; b) the one to promote or to make it grow in order to take existence to something new as it happens at the time of fertilizing the soil, or at the time to have sheep and cows reproduce; c) the one of destroying, eliminating or removing, as it happens when you extract the weeds of the land or when eliminating sick animals in order to prevent an epidemic.

The difference between the power of guarding, the power to make grow and the power to destroy can be found in many areas of human action. Also, in the area of medical care, some of them are oriented to preserve health, let’s think on vaccinations; others to make grow, as the therapies which, potentiate development or improve the human fertility, others even to eliminate all that threatens life or health, such as the surgery aimed to remove the tumors. We can then observe that all of them are forms of power present in the human experience. To favor only one of them, implies a reductive vision of power.

The three forms of power depend on three objective features which reality can present: the fragility (which invokes the power of guarding), the potentiality (which invokes the power of developing) and the threat (which invokes the power of destroying). From all this we can conclude not only that the power as an action takes its own justification from the fact to be the answer to an appeal which reality puts to who has the power, but also that such appeal is possible only if we recognize that reality itself is provided of courage. It is in a way the porter of some importance. If reality would be indifferent or neutral, there wouldn’t be any criterion outside the subjective preferences of who has the power, in order to establish when it is proper to intervene to guard all that exists, to make grow or develop all that is only potential, or to eliminate all threats: at the bottom, there would not exist any limit to the discretion of the power of the strongest.

If, on the contrary, we understand that in reality there exist positive and negative aspects, harmful conditions and convenient conditions, of the goods and of the evil, we can not only have a criterion to establish which power is more appropriate in the various circumstances, but that we should also recognize that the man is the only being capable of understanding the various forms of importance, of capturing their hierarchy order, and to give him an answer, through his power for intervening in the world. He alone is the sole responsible of that answer that must be truthful, authentic, fit to reality, and not driven by fictitious or false reasons. In this sense, it can be said that to man is entrusted the reality, we find a term that has already emerged to describe trust, while the animals and the plants do not have that responsibility. Evidently, this perspective is the opposite to the will of power, according to which, on the contrary, reality per se does not have any value nor meaning, but this value and meaning is granted by man, precisely thanks to his power. Notwithstanding the success that this idea has had in the twentieth century culture, specially thanks to Nietzsche and to Max Scheler in a paper written in 1926 where he claimed that the power, being an end by itself, is insane and the fruit of wild imaginations of the intellectuals, far away from that what the things are ^[11].

That the three categories just described could be a useful reference also for the medical ethics, emerges from the fact that already in the studies of authors cited previously, which are inspired in Gregory and Percival, refer to that one of the physician’s tasks is the one to «use their own knowledge and their own clinical capabilities mainly to protect and promote the interest related to the patient’s health» ^{[9, p. 16]}. This imposes, for example, bring actions to their own power of attention in a rational way, and therefore not insufficient (for example, abandoned the patient), nor exaggerated (for example, with the therapeutic aggressiveness) as well as the duty of refraining from all harmful or destructive action related to the patient, even though if there would exist cases in which in order to protect their life, that what is the threat should be eliminated, for example removing a sick organ or a gangrenous extremity. A first limit from the ethic of power for the physician, lastly, covers the resource balanced to the power of promoting, protecting and of destroying.

3. The motivations of the man of power

As we have mentioned, if we study power as an action, it is necessary to consider, besides the object of power, that which causes in the world, also the point of view of who has the power.

In man there are present needs, instincts, impulses that escape its control, but never the less the philosophical thoughts about the actions, since Aristotle, allows us to understand how does human behavior implies aspects that are essentially different from those we find in the behavior of the other animals. Jointly, the human actions can be the fruit of freedom, and therefore, with Aristotle’s expression, are those whose principle resides in the subject, in the one who acts and not to the outside of him ^{[12, III, 1111a; 21-25]}. However, two aspects which illustrate this fact, are the presence of motivation, a reason by which the actions are performed, and of an intention which indicates precisely, the willingness printed by who performs the action.

Anselmo d’Aosta already in the De Veritate recognizes that man does never act if he doesn’t have a reason for which to act: «every will has a “what thing and a why”», for what we do not want absolutely nothing unless there would not exist a reason for which we wanted ^{[13, p. 83]}. Motivation is comparable to the final cause of an action, in the sense that offers, to who acts, the purpose for which he begins the action: for example, I go out to buy the newspaper, I wash my teeth to prevent them from cavities, I study a scientific paper to keep me updated.

Well now, it seems to me that the motivations that can move a man of power, can be attributed to five categories: 1) to obtain a personal advantage, 2) overcome himself, 3) improve the world, 4) hatred, and lastly 5) love, in the sense of benevolence, of wanting the wellbeing of the other. About this topic, there are very interesting texts by Vaclav Havel, a playwright, dissident and later the first president of the Check Republic, after the fall of the Berlin Wall ^[14]. In a speed on May 28, 1991 in Copenhagen, at the time of accepting a prize for his contribution to the European civilization, he enlisted three motives that motivate people to seek power, which correspond, if according to a diverse order, to the first three motivations that I have indicated. In a speech performed some months before on August 28, 1990 in Oslo, about the Anatomy of Hatred, he described in a very sharp way the essential aspects of the fourth motivation, while his entire thought about the right use of power, present in many other of his writings and speeches, offers to us an example of the man of power who acts moved by the fifth motivation. He always makes a reference to the political man, but according to my opinion, his analyses apply to the man of power in general.

Among the motivations that can drive the political man, Harvel recognizes that there can be the desire to enjoy the benefits and the privileges that in general are granted to whom has a position of power. Even though being an understandable motive, especially in somebody who comes from situations of poverty and oppression, and that with power he also obtains wealth, according to Havel such desire tends to become a threat for anybody who is in power for a certain time, because privileges create attachment. Besides, in The power of the ones without power, one of the texts that inspire more the dissidents of the European East countries to rebel from the Soviet dominance, Havel had observed that he who reduces his own responsibility only to that which refers to his personal advantage, attempts against his identity, to the point of becoming a de-moralized person ^[15]. The use of power to obtain personal advantages, lastly, has negative consequences both for who suffers the power as well as for who uses it.

Another motivation according to Havel, that can motivate the man of power, is the desire to reaffirm himself, to leave a trace, to be respected and appreciated. This motivation corresponds to a feature of the human person, because man has a natural need to be recognized by the others and to recognize himself by the effect of his own actions. Saint Thomas Aquinas already defended as essential the need of a man to be honored, recognized as good and capable of doing the good ^{[16, II-II, 27, 1, ad 2]}. On the other hand, however, this motivation also presents a danger, which is the one to be absolutized until becoming the only motive for wanting the power: in this case, every action of power is transformed in a spasmodic search of the celebration itself, of the others recognition, and the pleasing of the own vanity. Havel makes a comment that who puts all his efforts in celebrating himself, ends by transforming himself in that what he wants to create, a stony bust, lifeless. We can add that the second motivation allows us to explain why the possession of a power by a man, always carries with itself the danger of arrogance: jointly with the possibility with making visible its excellence, he who comes to power immediately meets also with the temptation of losing the sense of proportions, forgetting that his power of being human, mortal and imperfect, is not only assessed comparing it to the power of other human beings, but in absolute in the way to preserve the conscience that what he has will always be a small thing with respect to the absolute power of a perfect and infinite being.

Havel recognizes that a motivation for the power men, can be the desire to make a better world, of organizing the society (a state, an enterprise, an association, or any human initiative), on the basis of certain values in which it is believed. Havel sharply notes that whoever has power is always inclined to declare that this is his sole motivation. For this reason, it is necessary to be vigilant over itself, in a way to find out if the originally altruistic motivation has not been overshadowed with time by one of the preceding things we have mentioned. The fundamental question laid down by this type of motivation, altruistic and commendable per se, is referred to the balance between the ideal tension and right diagnostic of reality. If the ideal is false, or the analysis of reality has a deficit, the power will create situations of injustice, suffering or at least failure and frustration even though it has been moved by the most elevated motivations.

The fourth motivation that can boost he who has the power, is hatred, in its various versions. The man of power might want to revenge due to an injustice (real or supposed) suffered, could have identified a scapegoat on which discharge the blame for a critical situation, personal or that something that affects a certain social group of which he is a part, he can feel personal resentments or envy towards a concurrent or an adversary, and so forth. In all these cases, the purpose of the power action is to bring damage to object of this hate, that is to say destroy him or at least defeat him, overcoming him. The presence of hatred easily leads to an excess in the use of power, the use of strength and violence, to abuses which end in effect much more destructive and devastating, that any rational motivation could have boosted for action.

The fifth motivation can move anybody who has the power, in summary, is founded in an attitude which, is exactly opposed to the previous one, and consists in the love towards the objects of the action of power. The history of Christianity shows that all those that, being in a position of power, have exerted the Christian virtues to such a point as to be recognized as saints by the Church, were boosted by this motivation. Also in professional life there exists people who perform their own work moved by the love to the profession and to the people which are submitted to them. Only to give an example of a recently deceased Italian entrepreneur, Giovanni Ferrero, known by having invented many of the sweets most loved in the last eighty years, has managed always his companies with an attention to people and their wellbeing.

If we apply this analysis about the motivation of who holds power to the medical profession, it is possible to conclude that also the various motivations of who has the power, imposes ethical limits. The purposes of their profession impose to the physician to remove the hatred among the motives of his professional performance, even though it is also to respect a hierarchical order in the motivations that lead his behavior. In particular, the achievement of the primary values of the profession, that is, the excellence in care and the wellbeing of the patient, must be put in front of the self-confirmation and to the search for personal benefits that the profession allows to obtain.

4. The intention of power: the meaning of serving

A second important aspect in order to understand power from the point of view of who applies it is referred to the intention. This term is used by the theory of the action, to indicate the will that puts action in movement. Intention has a very close relationship with motivation because the purpose I intend when I act (FINIS AGENTIS (purpose of the agent) or motivation) determines also the will that moves me into action. Nevertheless, intention involves many aspects, besides motivation, for example the object of the action per se pursues, the elected media in order to reach the purpose, the foreseen consequences or at least foreseeable, the relevant circumstances for the action. It is the intention, the one which allows us to identify, in what way an action is voluntary to evaluate an action, either from the legal point of view, or from the ethical point of view, the issue of the subject’s involvement is summarized in the question about, if and to what extent, the action was intentional.

Also, for the act of power is very important to establish in what way is intentional. It has already been mentioned, the fact that it is possible that man is impulse by instincts, and this can also happen when power is exerted. Never the less, his actions are more human, the more they are the fruit of his capacity to understand and to wish. For this, it is important to think about intentionality. A criterion to evaluate the intention in actions of power can be found drawn from the concepts of use and service. More exactly, it is necessary to consider the difference among three types of intentions that can be presented in the exertion of power: 1) The intentions of making use of something, 2) intention of subdue somebody else of something different of himself, 3) the intention of serve somebody else or to some other thing.

4.1 The power of making use of

The typical power form in the relationship between man and inanimate nature is the technical or instrumental performance, that is to say the capability to transform things in useful instruments in order to reach some purpose. This is the emblematic example of the intention of making use of something, thanks to power itself. Such type of power can be exerted also to other living things (I use a horse as a means of transportation, and a hen to obtain her eggs) and our fellow men (I hire a gardener to take care of my garden, I go to the barber and I have my hair cut). In the professional field there exist uncountable forms of this type of power. This is the power to subdue somebody or something, to reach that purpose. Power as a relationship that uses others as an instrument, has as a value criterion of reference all that that belongs to the useful. The action, the persons involved, the purposes reached, have a value as far as their efficient in order to reach specific purposes.

The fundamental ethical problem set by the relations between a man and another one, in which on subdues the other one, is if it is licit to use another person. Use or subdue, in fact, unavoidably treat the other one as a thing. Experience shows us, many cases in which, is considered completely licit. The general that leads his army, the manager that provides directions to his employees, as well as the surgeon which gets help from his assistants in the operation room, they establish power relations in which somebody “subdues” from somebody else, in order to obtain purposes which are diverse from the direct advantage for the interested parties: they could constitute an advantage for whom holds power, or else be a common good, as the firemen who are employed to fight an arson. In other cases, this common good is also a favor to those who are subdue by the one who gives orders, as the employees that contribute to the prosperity of an enterprise and, when the purpose is reached, they can enjoy economic safety and of the prizes they get for their work.

Therefore what justifies, the possibility of using power to make use of other people for the purpose of reaching some objective? A first condition could be, that the others would give their consent, and in the case of professional relationships, be rewarded by an allowance and for other benefits. A second condition is described by Kant with an imperative statement mentioned in the Foundation of the Metaphysics of Costumes^{[17, II]}: «act in a way of treating humanity, both in your person, as well as in that of anybody else always as a purpose and never simply as a medium». This principle recognizes that there exist cases in which it is licit to subdue from other people, even though such instrumentation has unsurpassed limit. A fundamental difference exists between cases which the object is reduced to a mere instrument for the exercise of a power, as the hen that becomes the main course of a meal, or the slave who is chained and lashed for him to continue rowing, and the case in which the object is used as an instrument, even though he is not reduced to an instrument. About this principal it is based, in the medical field, the duty to intervene the one to is about to be born, only if that brings to him an advantage in terms of health, as well as the prohibition to turn to subrogated motherhood.

Man is capable to exert power on his fellow men, reducing them to mere things. Experience tells us that there exist exceptional cases in which it is justified to act on somebody without considering him as you. For example, in helping an unconscious person who is in danger of death, the physician not only has the right, but also the moral and judicial obligation to intervene, treating the operation room personnel only as a medium to save the sick person, and without establishing any relationship I you with the sick person deprived of conscience. But not even in those situations the physician can forget that his colleagues and the patient are human beings and not things of animals. More in general, we can say that the power over others cannot be exerted without their understanding or against their will, if they are capable of understanding and wanting. Lastly the instrumentalization, cannot be the only way to exert power over other people. The totalitarian regimes that have tried and still keep trying to apply that depersonalizing and instrumentalizing form of power over complete populations, perform criminal actions not only against the victims, but against the whole human kind.

5. Conclusion

Meanwhile, we have seen that the power relationships moved by the intention of make us of and of subdue the other, the last is reduced to a means, while in the relationships in which there is at least the intention of serve the other, and this last one assumes the role of purpose in himself. The individualistic tradition that has opened a path in modern times, and has culminated in the claim of radical autonomy of man, understood as an ideal of independence of any attachment or external conditioning, leads to understand every relationship of power as the instrumentalization of the other one. In order to justify the fact that the experience does not present to us only instrumental relations of power, it replicates that also the relationship that apparently is more altruistic and abnegated, in reality it would always have the intention to link the other person to himself, and of using him in order to obtain personal satisfactions, as for example to perform the self-need of feeling indispensable.

However if we consider, the diverse characteristics of power that we have described, it is possible to capture that the human person is capable to put in act also relations of power in which the other one is not used only as a means, but it is considered as an end in itself, and therefore recognized and treated as a good in itself and the true purpose of the relation of power. Relationships as those between physician and patient, between a teacher and a student, between parents and children; they can lose their original vocation, and transform in relations of power in which, the other one is instrumented. But we perceive as unjust, the relations in which the father uses the son in order to confirm to himself or discharge his own instinct, either the one of paternity/maternity or lower instincts, as the one to dominate or subdue, or the one where the physician uses patients as a means to make a career or to show his power.

Medical treatment requires considering, the person who is the one that receives care, and therefore, is the object of a relation of power, as a human to be respected, protected, and guarded, and also make him grow. The therapeutic action then, could have an object that belongs to all the categories we have presented (to guard, make grow and destroy all that is harmful). Instead, it is not like this, for what is referred to as the point of view of who takes under his care: this type of relationship has as the most proper motivation the love of benevolence, that puts the good of the other one at the center, and as a privileged intention that of intervening for the other one, and therefore to serve the other one, and not making use of him, nor of trying to subdue him.

Here is why we can claim that the power of taking care is an essential aspect for the human being. In the first place, because every man necessarily goes through faces in life, in which he has the need of caring from others (childhood, old age, sickness, disability, experience of psychological and moral suffering). In second place, because the human person performs his own capacity of love, in the sense of benevolence, and of the gift itself that this has, mainly in search for the good of others, and therefore in offering care ^[20]. Finally, the relationship of offering care is, jointly with the labor activity, a privileged way to give sense to your own existence. Precisely the authentic care is a relationship that makes flourish the person who offers care.

Then, is we would want, to return to the initial topic of this essay, we can find the intimate union which connects the power of the physician and trust, precisely in the understanding of the treatment relationship as a benevolent service, or as it has been recently defined regarding education, as the generous responsibility for the others: only if we understand power this way, this will be able to create that reciprocal trust climate, which is a necessary condition to be able to take in full all the people involved ^[21].

To pursue the objective of exerting the own power as a generous responsibility, nevertheless, demands from the physician to possess specific personal qualities. Together with knowledge and scientific and managerial skills, he must acquire also and ethical competence. For example Chervenak y McCullough ^[22], retaking Pellegrino y Thomasma ^[23] proposal, propose four virtues that should constitute the basis of the relationship between physician and patient, and we can observe they have a direct relationship with the exercise of power by the physician. The virtues are: modesty, self-effacement, which lead to become impartial in judgements, not to discriminate and not to act based on prejudice; the spirit of sacrifice (self-sacrifice), and therefore the capability of making prevail the patient’s interest over those of other nature, even at the cost of assuming personal risks, if they are required by the patient’s needs; the compassion that is the capability to understand somebody else’s suffering, and the commitment to heal it; lastly, the integrity, that imposes to act according to intellectual and moral standards of excellence, as well as not to incur in deceit, mislead and behavior aimed to avoid assuming the responsibility of their own mistakes.

The effort to reach that moral excellence which supports the ethics of the physicians power, will allow them, to reinforce the interpersonal trust, of the patient towards the physician, but also the social trust of the patient towards the institutions. We can then conclude again citing Pellegrini and his image of trust as keystone. «My advice to you is that in future interactions with your patients, you should always have in mind the power you have, with your words and your behavior, to reinforce both social, as the interpersonal trust. Trust is in such a measure the keystone of the physician-patient relationship that is an indispensable virtue for a good physician. Without this virtue, the relationship with the professional is torn apart, as it happens to an arch when the angular stone is removed from it. With it, we increase our capability of healing the body and the soul of the patient, of the doctor, and of the team. I believe that in the heart of the professional ethics there exists the concept that imposes to the members of the profession, the obligations of fidelity to trust» ^{[1, p. 98]}.