Friday, February 11, 2011

Paternalism, Informed Consent, and the Doctor-Patient Relationship

I. Introduction

At least since Hippocratic days, patients have been asked to trust their physicians without question. However, only in recent years have doctors been asked to trust their patients by conversing with them about medical options and soliciting their views on how to proceed. The idea that conversation will lead to mutually satisfactory decisions is not one of human beings most abiding convictions. Therefore, to ask physicians and patients to get to know themselves and each other better through conversation will encounter resistance. What has been true for the evolution of mankind is equally true for the progress of medicine. We have spared no effort to make better tools but we pay little attention to learning how to communicate better with one another.1
It is difficult, if not impossible, to enter into any discussion of the doctor-patient relationship without broaching the subject of informed consent. Informed consent assumes that a patient will receive all the information that he or she needs in order to make a decision regarding whether or not to undergo a particular set of tests or a particular operation. This assumption is based upon the belief that there will be a dialogue between the physician and the patient and that a course of action will take place as a result of said dialogue. Informed consent's implicit demand for joint decision making confronts the painful realization that even in their most intimate relationships; human beings remain strangers to one another. One can only know and understand another to a limited extent. However, the problem runs even deeper. One can only understand oneself to a limited extent. The latter impediment powerfully reinforces the former, making it even more difficult to know another.2
To heal requires a relationship marked by equality--a key element in a sound doctor-patient relationship -- a reciprocal respect. This is not automatically granted by either; it needs to be earned. Without respect, a doctor cannot gain a patient's trust. Respect is not the mush of language. As the essayist Anatole Broyard, dying of cancer, commented about his doctor, "I don't trust anyone who tells me that he loves me when he doesn't even know me." The patient desires to be known as a human being, not merely to be recognized as the outer wrappings for a disease. Only the patient is capable of widening doctor's focus to encompass the larger domain of the person who is ailing. Therein resides the art.3
In Section two of this paper I will discuss the role of the physician in the doctor-patient relationship. In Section three I will discuss the role of the patient in this relationship. In Section four I will discuss the issues of informed consent and autonomy, and Section five will provide a conclusion.

The role of the physician in the doctor-patient relationship varies depending upon the trust that has been established between the two parties and the overall health and well-being of the patient. The physician can serve as parent, teacher, confidant, or friend based upon the needs of the patient. Traditionally -- and romantically -- the family doctor not only cared for the whole family but functioned almost as a member of the family. He cared for the parents, delivered their babies, and saw grandparents through their last illnesses. Delivering these services, he knew what it was to venture out beyond the office and hospital setting. He made house calls, drank family coffee, and savored its gossip.4 Given this setting, which is not the experience of many patients in the beginning of the twenty-first century, the family doctor had an extremely intimate knowledge of each patient which gave both the patient and his or her family the confidence they needed to accept whatever diagnosis and treatment the doctor recommended without question.
In our modern society there is a strong emphasis on patient autonomy and his or her right to take part in the decision making process regarding treatment or lack thereof. The history of the doctor-patient relationship from ancient times to the present bears testimony to physicians' caring dedication to their patients' physical welfare. The same history, by its account of silence that has pervaded this relationship, also bears testimony of physicians' inattention to their patients' rights and need to make their own decisions. Little appreciation of disclosure and consent can be discerned in this history, except negatively, in the emphasis on patients' incapacities to comprehend the mysteries of medicine and therefore, to share the burdens of decision making.5
The idea that a doctor should not enter into dialogue with a patient regarding her illness and possible treatment options on the basis that the patient lacks the capacity to comprehend the mysteries of medicine is understood by many as one of the most negative aspects of the model of the doctor-patient relationship known as "paternalism". In this model the doctor is acting in the role of a parent and is making decisions on behalf of the patient based upon the belief that she is acting in the patient's best interest.
The major complaint people have about their doctors is that they do not listen. Listening means hearing not only what the symptoms are but what they mean to the patient. Understanding means not only understanding the words but also understanding, in the sense of being sympathetic to the values behind those words. When medicine is conceived as a purely technological field, learning how to listen to these personal aspects of the patient's concern may not be considered part of the doctor's professional role by other professionals.6
Why should scientific-technological thinking appear to be in competition with (and, in fact, win out over) the humanist mode of thought? The roots of the problem can be found in the fact that physicians are trained to think in a manner that elevates questions of disease, phrased in a scientific way, over other questions raised by human illness.7
It would be very easy to simply blame technology for the difficulty that physicians undergo in regard to simply focusing on the scientific aspects of a patient's illness to the exclusion of such issues as the patient's values, dreams, or hopes. The technological advances which medicine has made over just the past forty years have been astounding. Medical procedures such as heart by-pass surgery, multiple organ transplantation, and intrauterine surgery would not have been possible nor had the extremely high success rate that they do without the use of technology.
Another issue is the rise of medical specialization. While a specialist may be extremely proficient in terms of knowing the workings of the part of the body which he focuses on, there is the problem that the patient is no longer seen as a whole person, but simply a collection of body parts and/or diseases. The focus of the general practitioner (GP) or "family doctor" tends to be much more holistic since the doctor approaches the patient as a whole person while working to determine his patient's source of pain or discomfort. This does not mean that the family doctor is not familiar with technology. It is a result of their role that they have a more holistic approach.
In the endless discussion of the scientific versus the "humanist" physician, the question is usually asked whether one would rather be taken care of by someone who know his technology well or by someone who just displays loving care. What is not clear is why the two are considered to be in opposition to each other. In the proposition as given I would rather have the scientific doctor. But again, why must I choose as though one excludes the other?8
Scientific medicine deals with disease; its worldview of the sick is the view of disease. The matter in which physicians are trained quite naturally emphasizes and reinforces the current definitions of disease and the view of illness that such definitions promote and their education stresses the rational analytic thought of science.9
The historical roots of the problem regarding the dichotomy between the analytic (objective) and humanist (subjective) views of medicine can be traced back to Rene Descarte (d. 1650) and the mind-body duality. This was effectively a moral-technical duality: physicians, in company with other scientists, were given the (technical) body, while the philosophers and theologians were assigned the (moral) mind. Obviously the controversy has not cooled. At issue is the degree to which the mind-self-soul is part of the human machine, and therefore understandable in the terms that define that machine. That part not understandable in scientific (machine) terms is involved with values and morals.10
Dr. Bernard Lown, a Nobel Prize winning cardiologist, is convinced that doctors must not abandon science in order to heal. On the contrary, healing is best accomplished when art and science are conjoined; when body and spirit are probed together. Only when doctors can brood for the fate of a fellow human afflicted with fear and pain do they engage the unique individuality of a particular human being, A sick patient becomes more than his or her illness. This broader engagement ignites embers of clinical imagination, hones precision in judgment, and helps overcome the agony of decision making. A doctor gains courage to deal with the pervasive uncertainties for which technical skill alone is inadequate. Patient and doctor then enter into a partnership as equals. As the patient is empowered, the doctor's curing power is enhanced. In the 1920s, Boston physician Francis Peabody counseled that the secret of the care of the patient is caring for the patient.11
Francis Peabody concluded his famous lecture on "The Care of the Patient" with these words:
[t]he good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine. One of the essential qualities of the clinician is interest in humanity, for the secret of the care of patient is caring for the patient.12
In conclusion, I would argue that the artificial dichotomy between the objective and subjective views of medicine and patient treatment must be put aside in favor of a more collaborative effort between both the patient and the doctor.

III. The Role of the Patient

   A doctor must rely on the art of human understanding to amplify the insights provided by science. A patient, likewise, must cultivate a special art, that of dealing with a physician. Whereas the medical transaction is largely concerned with curing a disease, the patient craves to be healed. The object of the patient's art is to have the doctor incorporate healing in the process of curing.13
   Healing requires a relationship of trust marked by equality, which is a key element in any sound doctor-patient relationship. A settled principle of medical ethics, the law, and medical practice is that physicians may not render medical care to competent patients without their informed consent.14
   While doctors differ from one another as much as individuals do, there are nonetheless some principles that are broadly applicable to the art of being a patient. First, is the need to lower expectations of what medicine can do without reducing respect for the medical practitioner. While miracles have been wrought by scientific medicine, it is important to understand that science, while seemingly unbounded, will always be constrained in dealing with the human condition. Irrespective of the expansion of medical knowledge, there will always remain human lacunae of ignorance. Medicine will never be able to prevent death, or the deterioration of age, or fully repair the consequences of severe traumatic accidents, or totally correct some birth defects. Many other conditions will long evade a definitive medical cure.15
   Even with the advances in medical science, there are still, at present, some chronic ailments for which medicine lacks precise solutions, such as arthritis, heart disease, neurodegenerative disorders, autoimmune disease, and most cancers.16 Medical science cannot even find a cure for the common cold.
Given all of the advances in medicine science and technology, there are some patients who visit their doctor with unrealistic expectations and this can easily lead to a heightened sense of dissatisfaction when they are informed that the doctor is unable to cure them. An exaggerated attitude toward the potential of medicine can prove self-defeating. In this age of hype, patients come to expect the impossible. They are not readily satisfied with mere abatement of symptoms but frequently demand nonexistent cures.        Pretensions of the health care industry and the godly posturing of some doctors contribute to such unreasonable expectations. Theatrical illusions are promoted by an unwholesome dynamic between hyperbolic professional claims and the public's inflated hopes.17
   The patient has to understand that many discomforts stem not from disease but from the rough and tumble of living. In our death-denying culture, individuals are grimly determined to purchase happiness at any cost. The sooner patients understand that doctors are not in the happiness-promoting business, the greater their likelihood of being helped. The psychiatrist, Dr. Viktor Frankl, an Auschwitz survivor and author of Man's Search for Meaning, proposed that there is such a reality as negative happiness; it is the freedom from suffering. Competent doctors are more comfortable relieving suffering than in purveying happiness.18
   The fact that our culture denies death has led many to even deny the fact that they are getting older. We have all seen various celebrities undergo numerous plastic surgery procedures in order to maintain their youth indefinitely. However, these procedures are not limited to celebrities. There are countless people who undergo Botox injections and other procedures in order to assuage the appearance of aging.
There is a vanity in all this and it demeans us. At the very least, it brings us no honor. Far from being irreplaceable, we should be replaced. Fantasies of staying the hand of mortality are incompatible with the best interests of our species and the continuity of humankind's progress. More directly, they are incompatible with the best interests of our own children. Tennyson says it clearly, "Old men must die; or the world would grow moldy, would only breed the past again."19
   It is essential that patients ask questions of their doctor, not in order to know the intricate details of the process by which a given illness has come about biologically but in terms of gaining insights into how best to deal with their present situation. I believe that there are many patients who do not ask questions of their doctor simply out of fear of hearing the response. While it may be difficult for some doctors to inform a patient that "there is nothing more I can do", given the wide range of tests and procedures which can be performed on a given patient, the truth is that eventually there comes a time that medical science has run its course and all that is left is to assist the patient in being as comfortable as possible as they prepare for death.
   The sharing of information between a doctor and patient can be difficult for the doctor as well. She has not been trained to reflect upon the values, desires, and hopes of her patients, but in curing their illness or providing them comfort to deal with their condition. While it is not true of every doctor, there are some who withhold information from their patient under the guise that informing them that they have cancer, for example, will serve no purpose and the patient will only lose hope. Even if the news is unpleasant, it is essential that the doctor tell the patient the truth.
   In his article entitled Truth Telling20, Roger Higgs addresses this issue of truth telling from a variety of standpoints, including, but not limited to, possible malpractice on the part of the individual doctor and/or one of his colleagues as well as "shielding" a patient from unpleasant information.
   From the standpoint of Catholic moral theology it is not advisable for a doctor to withhold information from a dying patient which that patient has a right to know. Not informing a patient that she is dying because the physician wants to "shield" her from bad news violates the principle of patient autonomy and does not allow the patient to come to grips with the diagnosis and hopefully begin the grieving process so that she can eventually come to the point where she has accepted what is taking place. While it is possible that she may never come to the stage of acceptance, it is still not the doctor's right to withhold information. The truth is that most people have a keen intuitive sense that they are dying. They realize that their body is shutting down at some level and they want to know that what they are experiencing is grounded in some medical reality.21
   The physician's bedside manner comes into play at this point. How does the doctor explain to the patient that she is dying? This needs to be done in a compassionate, caring, sensitive manner so that the patient does not lose all hope and she is given assurance that the doctor and hospital staff will do as much as they can to make her stay as comfortable as possible.
   Withholding information due to the fact that there might be a possible malpractice lawsuit involved is extremely dishonest on the part of the doctor. Once again, the patient has a right to know what has transpired and it is up to the individual patient to determine whether or not they will bring legal action against the doctor and/or hospital, rather than allowing the doctor to determine that no legal action will be brought simply because the patient will not be informed of any possible errors.
   The reality is that the patient is an acting agent who needs clear, concise information in order to be able to make an informed decision and be able to give consent to possible treatment options. The fact that you or I might believe that we would not be able to deal with certain information does not mean that we have a right to withhold information from someone who is entitled to it.
   With this being said, it is also important to keep in mind that there are times when a physician cannot crudely tell the whole truth, especially when he knows that the patient does not have the strength to deal with such a revelation.22 A physician is forbidden to lie, according to the Eighth commandment; however, telling a patient the whole truth when the physician knows that this patient cannot handle it is a violation of the principle of "Primo non nocere" (first do no harm).
   The doctor-patient relationship is based upon trust. In order for a doctor to properly treat a patient it is essential that the patient feel comfortable with his doctor so that sensitive and important information be provided. The patient, for her part, believes that any information provided to the physician will be kept confidential, provided that the patient has no intention of hurting herself or others. The issue of confidentiality is of paramount importance to the relationship between the doctor and patient. Guaranteeing privacy and confidentiality in the doctor-patient relationship is as old as the practice of medicine itself. The Hippocratic Oath, written in 400 BC states, "Whatever, in connection with my professional practice or not, in connection with it, I see or hear, in the life of men, which ought not to be spoken of abroad, I will not divulge, as reckoning that all such should be kept secret."23 and this oath is still maintained by countless physicians throughout the world.
   In order for any health care system to work properly it is essential that those participating in it have confidence that whatever private health information they provide to their physician will be kept confidential and will not be become a matter of public record. Living in an electronic age it is possible to access almost anything via the internet. What if with one click of the mouse those who have no right to your private medical information access that information and do whatever they want with it? Imagine yourself receiving unsolicited calls from pharmaceutical companies offering to sell you the latest medication to control your high blood pressure or they can provide you with some medication to help you deal with a very sensitive and embarrassing sexual issue. Should patients begin to receive such phone calls what is the likelihood that they would be forthcoming with sensitive medical information to their physician in the future?
   The issue of confidentiality also has ramifications in the area of public health. In order for epidemiologists and other public health professionals to be able to keep track of illnesses and maintain records necessary to assure public health it is essential that they have accurate information. The possibility that someone could be stigmatized by virtue of unauthorized access to private health information would not only make them less likely to provide such information, but may actually discourage those who most in need of medical care to stop receiving the care that they need.
   In summary, it is essential that patients speak with their doctor about their illness and any treatment options which may be available. While medical science has made major strides in the curing of disease, the fact remains that there are some things which are presently outside its knowledge in order to provide a cure. Patients need to enter into the doctor-patient relationship with reasonable expectations in order that they do not become despondent if a cure is not available. Doctors have a responsibility to share all necessary information with their patient so that the patient can make an informed decision regarding any possible treatment options. The issue of confidentiality is of paramount importance in maintaining a working relationship between doctor and patient.

IV. Informed Consent and Autonomy

   Valid informed consent is standardly understood to have three components. First, the patient must have been informed about her diagnosis, available alternative treatments for her condition including her rational and likely prognoses with those treatments as well as with no treatment. Doctors are responsible for providing this information to patients in an understandable form. Second, patients' choices must be voluntary. This means that the choice must have been made without coercion, manipulation, or undue influence by others such as physicians or other family members. Doctors are responsible for ensuring that patients' choices are voluntary, which means helping to free patients from coercive forces when necessary. The third requirement for valid consent is that patients have decisional capacity or competence to give or withhold valid consent to the treatment in question.24 Should there be any doubt regarding a patient's competence to make such health care decisions this issue may have to be decided in court.
Patients have a legally protected right to refuse treatment. The right to refuse treatment has been grounded, most importantly, in federal and state constitutions. In a series of cases over the last two decades, namely, Washington v. Harper (1990), Riggins v. Nevada (1992), and Sell v. United States (2003), the Supreme Court has recognized that a competent person has a constitutionally protected "liberty interest" in refusing unwanted medical treatment. The Court's jurisprudence provides ample reason to believe the Constitution safeguards treatment decisions, which are among "the most intimate and personal choices a person may make in a lifetime, choices central to personal dignity and autonomy."25
While a patient does have a right to refuse treatment, the state can mandate treatment based upon its three interrelated interests regarding compulsory treatment. These are: health preservation (harm to the individual), prevention (harm to others), and preservation of effective therapies (continued usefulness of key medications).26
   An initial point of considerable importance is that while the refusal to receive treatment may often serve as a reasonable trigger for the evaluation of competence, it does not constitute evidence for the patient's incompetence. Rather, the evaluation should be of the patient's decision making process regarding the treatment in question and evidence for incompetence should consist of impairments and shortcomings in that process.27
   This very issue was addressed in Brian Clark's play "Whose Life is it Anyway?" The main character is involved in a car accident and loses the use of his entire body, except for his hands. After several months in the hospital, the patient decides that he wants to end all treatment, sign himself out of the hospital, and go home to die.
   While the patient suffered numerous severe injuries, there is every indication that he is quite lucid and able to make an informed decision. His doctor, believing that the patient is suffering from depression, refuses to abide by the patient's request and continues his treatment. Eventually, the patient hires an attorney and a competency hearing is conducted in the hospital. The judge finds the patient to be completely competent to make informed medical decisions and he orders that the patient be released from the hospital in accord with the patient's wishes.
   While the issue of whether or not the patient should have chosen to refuse treatment is not addressed, the fact that the doctor did not agree with the patient's decision does not automatically deem the patient incompetent.
   Throughout the centuries numerous doctors around the world have taken the Hippocratic Oath. Beginning in the Middle Ages the oath has been updated several times. Often, the additions made to the Hippocratic Oath are as historically interesting as their deletions. Many of the oaths taken currently will include vows not to alter one's practice on the basis of the patient's race, nationality, sex, religion, socioeconomic standing, or sexual orientation. Others include assurances of the doctor's accountability to his or her patients, protection of patient's autonomy, and informed consent or assistance with decision making. In a very real sense, all these changes help to make the act of oath taking eternal, a process that constantly changes to accommodate and articulate changing views in medicine and society.28
Autonomy can be threatened by illness. Most doctors believe that the patient's independence and freedom of choice are removed by the effects of disease -- by the uncertainties and impediments to understand an action that inevitably accompanies serious illness. In fact, helping patients regain autonomy would seem to be a prime function of medicine. Often, in the current decades, doctors are perceived to threaten the patient's autonomy -- they are seen as paternalistic, authoritarian, and too concerned with profit to be reliable servants or partners in care. In the same manner, modern drugs are often viewed with the suspicion that their side effects are more prominent than their benefits. During their convalescence from serious infection, for example, patients may attribute their fatigue to the effects of the antibiotics rather than to the illness from which they are recovering.29
   Another aspect of autonomy to take into consideration is psychological autonomy. Psychological autonomy refers to the extent and limits of a person's capacities to reflect and to make choice inherent in the psychological nature of human beings. As an ideal construct, psychological autonomy refers to the capacity of persons to reflect, choose, and act with awareness of the internal and external influences and reasons that they would wish to accept. It must be clearly kept in mind that this is an ideal definition. Choice on the basis of a complete awareness of the influences and reasons that impinge on it is never attainable, but awareness can be significantly improved through self-reflection and conversation with others.30
   One's ability to engage in self-reflection and converse with others can be effected by where they fall on the dependence/independence continuum. At one pole is the overly dependent person who needs the support, approval, and presence of others in order to feel secure, adequate, and loveable. At the other extreme is the overly independent person who needs no one and who prides himself on being self-sufficient.31 Most people fall somewhere between these two extremes.
   While people have a preferred style in regard to dependence/independence, it is also true that circumstances may cause some flexibility in functioning. For instance, a person may act/feel more independent in a work situation than she does in a home environment. In addition there will be periods of "situational dependency" such as bereavement, unemployment, illness, or hospitalization. Such situations momentarily force people to be or feel more dependent than they might normally be or feel.32
In conclusion, patients have a legal right to be told the truth regarding their health status, to give informed consent regarding treatment, and to even deny treatment provided that they are mentally competent.
Patient autonomy is an important consideration; however, it can be compromised, perhaps severely at times, depending upon the patient's health status or other factors.

V. Conclusion

   Paternalism is one of several models used to describe the doctor-patient relationship, including fighter, covenant, and others. While this model was quite common throughout most of our history, it has taken on a pejorative sense. The fact that this model has taken on a pejorative sense does not, of necessity, mean that the model is not valid. While some, if not many, adult patients would resent being treated like a child, the truth is that illness can often compromise one's ability to think clearly and make rational decisions in their own best interest. As stated earlier, many people who are quite independent, under normal circumstances, can become rather dependent given the right situation and it is important that they have someone to turn to who is looking out for their welfare.
   While it is true that there are some doctors who are motivated by finances, the vast majority of them is concerned about their patients' health and well being and will do whatever they can to benefit the patient. Most doctors have little difficulty with and, in fact, encourage their patients to ask questions about their medical condition. This is a sign that the patient is taking an active interest in her recovery and is open to listening to her doctor's advice. The challenge comes when patients search WebMD or Google Health and engage in self-diagnosis before ever seeing the doctor and then proceed to act as though they are the doctor's colleague. The truth is that she is not a colleague; she is a patient who has come to see someone whom she hopefully believes has the necessary skills to deal with her particular issue. The process of self-diagnosis runs the risk that the doctor will view their patient as a hypochondriac which could lead to a genuine illness or ailment being overlooked completely.
   Each evening there are numerous advertisements on television for everything from Viagra for erectile dysfunction to Symbicort for chronic respiratory ailments, particularly COPD. Each one of these advertisements encourages the viewer to "ask their doctor if this product is right for you". These are advertisements which are produced by a pharmaceutical company in order to promote their product and yet many patients present this information to their doctor as though they were receiving medical advice through their television.
   While there is no denying the fact that a patient has the legal right to refuse treatment, the more important question to ask is "should she?" Depression can certainly result from someone feeling unheard or not taken seriously or believing that they have no hope; however, having an open, honest conversation with one's doctor can help to alleviate those feelings and once the patient believes that he is being listen to, a sense of hope can quickly return.
   As important as instilling hope in a patient is, this certainly does not justify lying to a patient about their condition or offering exaggerated claims of a cure. Medical science has made numerous advances in the past fifty years; however, there is still a great deal that doctors do not know anything about and, in spite of the doctor's best efforts, the patient still dies. There is a great deal of guesswork involved in treating a patient.
   For some patients, there is an element of magic attached to medicine. There are terminal patients who exhaust all their resources based upon the belief that they can find that one special doctor who will make their cancer go away. For a patient to pin all of her hopes on a magical cure may be understood as a form of personal emotional cruelty perpetuated on the patient by herself and for a health care professional to hold out hope for such a cure would also be an act of emotional cruelty.
   While I firmly believe that miracles can and do happen, I would be reluctant to inform someone who is coming to me for spiritual advice to place all of their hopes on a miracle. Should such a miracle not take place, the devastating emotional impact that could have on this person could easily undermine their faith in God and perhaps even undermine their eternal salvation.
   Even though our culture makes every effort to deny the existence of death, the fact is that death is a reality and it is just as important to assist people in dying well as it is in helping them to live well. While a doctor may not be comfortable talking to her patient about his spiritual values, she can certainly offer him compassionate care in the form of pain management and hospice.

End Notes

1 Jay Katz The Silent World of Doctor and Patient (MD: Johns Hopkins U. Press, 2002) p. xli
2 Katz, p. xlv
3 Bernard Lown The Lost Art of Healing: Practicing Compassionate Medicine (NY: Ballantine Books, 1999), p. 313
4 William F. May The Physician's Covenant: Images of the Healer in Medical Ethics (PA: The Westminster Press, 1983), p. 38
5 Katz, p. 28
6 Eric J. Cassell The Healer's Art (MA: MIT Press, 1995), p.94
7 Cassell, p. 98
8 Cassell, p. 99
9 Cassell, p. 99
10 Cassell, p. 112
11 Lown, p. xvi
12 Francis Peabody "The Care of the Patient" 88 JAMA 877 (1927)
13 Lown, p. 313
14 R.R. Faden and T. L. Beauchamp A History and Theory of Informed Consent (NY: Oxford University Press, 1986)
15 Lown, p. 314
16 Lown, p. 314
17 Lown, p. 314
18 Lown, p. 317
19 Sherwin B. Nuland How We Die: Reflections on Life's Final Chapter (NY: Vintage Books, 1995), p. 86
20 Rosamond Rhodes et al (ed.) The Blackwell Guide to Medical Ethics (MA: Blackwell Publishing, 2007), pp. 88-103
21 Jeremiah R. Grosse Truth Telling and the Doctor-Patient Relationship[Back]
22 Pope Pius XII, "Christian Principles and the Medical Profession" (Nov. 12, 1944), The Human Body: Papal Teachings, pp. 62-63.
23 Francis Adams (trans.)  (accessed 11/28/10) 
24 Rhodes, p. 128
25 Lawrence O. Gostin Public Health Law: Power, Duty, Restraint (CA: University of California Press, 2008) p. 412
26 Gostin, p. 414
27 Rhodes, p. 130
28 Howard Markel "I Swear by Apollo" -On Taking the Hippocratic Oath, NEJM 2004: 350:2026-2029
29 Eric J. Cassell The Nature of Suffering and the Goals of Medicine [2nd Ed.] (NY: Oxford University Press, 2004), p. 25
30 Katz, p. 111
31 Rodney Hunter (ed.) Dictionary of Pastoral Care and Counseling (DPCC) (TN: Abingdon Press, 1990), p. 273
32 DPCC, p. 273 


  • Adams, Francis (trans.) 12/13/09)
  • Cassell, Eric J. The Healer's Art (MA: MIT Press, 1995)
  • Cassell, Eric J. The Nature of Suffering and the Goals of Medicine [2nd ed.] (NY: Oxford University Press, 2004)
  • Faden, R.R. and Beauchamp T.L. A History and Theory of Informed Consent (NY: Oxford University Press, 1986)
  • Gostin Lawrence Public Health Law: Power, Duty, Restraint (CA: University of California Press, 2008)
  • Grosse, Jeremiah R. Truth Telling and the Doctor-Patient Relationship
  • Hunter, Rodney (ed.) Dictionary of Pastoral Care and Counseling (DPCC) (TN: Abingdon Press, 1990)
  • Katz, Jay The Silent World of Doctor and Patient (MD: Johns Hopkins University Press, 2002)
  • Lown, Bernard The Lost Art of Healing: Practicing Compassion in Medicine (NY: Ballantine Books, 1999)
  • Markel, Howard "I Swear by Apollo" -On Taking the Hippocratic Oath NEJM 2004: 350:2026-2029
  • May. WiIliam F. The Physician's Covenant (PA: The Westminster Press, 1983)
  • Nuland, Sherwin B. How We Die: Reflections on Life's Final Chapter (NY: Vintage Books, 1995)
  • Peabody, Francis "The Care of the Patient" 88 JAMA 877 (1927)
  • Rhodes, Rosamund et al (ed.) The Blackwell Guide to Medical Ethics (MA: Blackwell Publishing, 2007)

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