Medical Ethics PHIL 148 @ Binghamton University, Sum 11

10Jun/1139

Patient-Professional Relationship Debate

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Debate Question: If a young deaf child (5-years-old) expresses a desire for a cochlear implant (which has a chance of allowing her to hear), but the deaf mother of the child decides not to let her go through with the procedure, would it be morally wrong for the doctor to get a court order to allow him to perform the surgery?

Position Post:

To deny service to those in need while one is knowingly capable of providing aide is morally wrong. Doctors, before they received their license as medical professional recited an oath in which they pledged to uphold the priorities of their patient’s care above all else in their practicing field. These individuals promised to care for their patients to the upmost of their ability and in stating so the doctor presented in this case must submit to these orders. Now I understand that this particular case may break/destroy or even contradict some relationship principles but one must understand that when dealing with the sick, patients care stand above all. Proposing to receive a court order before the surgical procedure may even contradict a national law, but on ethical and moral grounds such rules fail to apply, as will be explained.

Let’s take a look at why this act of seeking a court order is morally correct based on the theories of certain philosophical principles, with the first being care ethics. Defined by the mere principles of virtue ethics in the placement of patient care at upmost priority, care ethics embodies the importance of empathy and sensitivity in the field of medicine. Proposing to get a court order against the wishes of the mother exemplifies this definition.  Note that the physician going against the mothers wishes is sure to break relationship ties between him/her and the parent. But disregarding this fact and continuing to declare one anyway demonstrates clear empathy for it takes true compassion and willpower to be able to commit such an act. It would also morally correct because not only does it embrace the principles of care and virtue ethics but also it satisfied the needs of the patient in having received an implant and a chance at a normal life.

Another ethical standpoint that stands in support of this moral action is utilitarianism. Derived into two forms (act utilitarianism and rule utilitarianism), utilitarianism states that an act or action must be only be performed when it is in good standing with the general body at hand. Meaning that the good (the pros) must outweigh the bad (the cons) in terms of its effect on the people in question. The people in question in this case would be the doctor, the parent and the child. Should the physician be granted the opportunity to possibly restore the child’s hearing both the child and the parent will benefit; and not to mention the physician as well. How this affects the child is obvious; he or she will be granted a chance at a normal life and will also be able to hear again. The parent will benefit in the sense that she is also deaf and will have a personal translator should she ever need one. In the end the physician will be content knowing that he/she upheld his/her promise of the Hippocratic oath and that both parties were satisfied with the procedure. In terms of rule-utilitarianism, the physician will be conforming to a set of rules (the Hippocratic Oath) that leads to the greatest good for everyone.

A counterargument that may be proposed against this moral action of seeking a court order may be that of a national law. Within the United States, children are said to be lawfully under the care and supervision of their parents until their legal age of adulthood at 18 years old. This means that the child may not receive treatment without direct consent from the mother.  From a legal perspective this may suggest that seeking a court order stands in clear violation of this law. I, however, propose that such violation does not exist. Courts pass judgments on “broken laws” so if they were to issue permission to the doctor then technically no law will “broken”  and it would be legally okay for the surgeon  perform the surgery.  Regardless of a legal aspect, the act of seeking a court order should not be denied anyway because it would be morally incorrect to do so.  To disregard the need of court consent is to disregard the practice of optimal care and to do that according to the theories of care and virtue ethics it is morally wrong.

Yes, it’s immoral to go against the wishes of the mother concerning the child but one must not neglect the needs of the child either. So what happens when you take both wants into consideration? Which side does one choose? Does one uphold the morals of the mother or that of the child? I say that of the child because of the many reasons presented above. At the end of the day, the child is the patient and not the mother. The needs and feelings of the patient are what should be considered and not that of the mother; even if she does have a say in the care of her child. Every mother should want the best for their child. If the mother fails to acknowledge this, the doctor should not and should therefore do everything humanely and morally possible to provide the optimal care.

10Jun/1111

Debate 1 Sammy Ahmed

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Question: If a young deaf child (5-years-old) expresses a desire for a cochlear implant (which has a chance of allowing her to hear), but the deaf mother of the child decides not to let her go through with the procedure, would it be morally wrong for the doctor to get a court order to allow him to perform the surgery?

 

Yes I believe it is morally wrong for the doctor to obtain a court order to allow him to perform the surgery because as a physician he/she is overstepping their boundaries in the patient-professional relationship.  The doctor would not be allowing for the patient to reserve their own autonomy.   A major issue here is whether or not the child will be able to live a normal life without his sense of hearing.  It is obvious that the child’s mother’s stance is that yes the child will be able to using herself as the example.  Though the life may be more difficult for the child it is indeed possible.  A deontologist may have a problem with the Doctor’s actions because one could argue that the doctor only wants the procedure done for his end (money).  This would infer of course that the mother’s money is all the doctor is concerned with and would give him justification to deem the procedure necessary.  The presence of the deaf mother leads to the belief that the procedure is not necessary and the child can still live a normal life like its mother is.  I also think it is significant to point out that most other parents would want this procedure done for their child because what parent would know fully allow their child to live with a disadvantage or disability.  The mother strongly believes that her child will be able to function properly and live a normal life.  The child’s state is not life threatening and thus the procedure is not entirely necessary.  The child would still be able to make most of life’s important decisions except for those obviously pertaining to sound such as what radio station the child prefers.  After all, Ludwig Van Beethoven eventually lost his hearing and he is revered as one of the most talented musicians of all time.   Furthermore, the doctor is disregarding the mother’s role as a parent.  The mother should have final say about whether or not the cochlear implant should be performed.  She may not believe the implant is appropriate for a number of reasons.  One mentioned before was that the mother does not believe the sense of hearing is necessary to live a happy successful life as she has.  Another reason for denying the cochlear implant it perhaps the mother does not have the necessary resources to make the procedure happen.   A cochlear implant may be a very expensive procedure and it may not be worth the parent’s time and effort to restore the child’s hearing.  I understand this sounds unethical on the parent’s behalf, allowing their child to “suffer”, but I believe it is up to the parent, not the doctor or the courts, to make this decision.  I don’t believe anybody else has the authority to tell a parent how to raise their child or make decisions for the parent.  The court order would force the mother to allow the doctor to perform the cochlear implant.  Unless of course the parent is deemed unqualified to raise their own children such is the case with drug addicts.  In this case however, the mother is only described as deaf so I am making the inference that she is fully capable of raising her child.

9Jun/1129

Patient-Professional Relationship News Article

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http://www.naturalnews.com/032044_doctors_patients.html

This article talks about doctors and how they go about treating their patients; essentially, the degree of truthfulness between the doctor and the patient during the diagnostic and treatment phase.  In this article, the  Archives of Internal Medicine released a study which concluded that the treatment doctors would recommend for themselves are more often a different treatment from the one they would recommend to their patients.  Duke university physicians performed two studies.  The first study involved 500 doctors who had to treat themselves and their patients for colon cancer.  37.8% of the doctors chose one method of treatment for themselves which entailed a higher death rate but less complications upon survival.  The majority of the doctors chose a different method of treatment for their patients which entailed a lower death rate but more complications upon survival.  The second study involved 698 doctors who had to treat themselves and their patients for a new strain of avian flu.  There was only one treatment, an immunoglobulin shot, which would lessen side effects but could possibly entail new ones.  Of the 698 doctors, 62.9% said that they would not treat themselves with the shot; however, when asked about the patient's treatment, the majority of doctors determined that they would recommend administering the immunoglobulin shots.

This article reveals that doctors aren't necessarily doing what they truly feel is best for the patients.  Higgs said, "It is easier to decide what to do when the ultimate outcome is clear."  Maybe this is the reason why doctors aren't being as truthful to their patients as they should be; maybe the fear of the unknown that plagues the patient plagues the physician to a equal or higher degree as well.  Telling the patients the truth is one ethical dilemma but treating them differently from how they would treat themselves is absurd.  I was shocked by the statistics that revealed how doctors would treat themselves differently from their patients.  I was always under the assumption that the doctor would be able to place himself/herself into their patients' "shoes" and be able to decide what is best for the patient or display some sort of care ethics.  There must be reasons for why there such a disparity in treatment.  Why do you think there was such a disparity in the two studies mentioned above?  In general, do you feel that doctors make decisions based on malpractice fears?  In general, do you believe doctors sometimes are caught up in care ethics and make emotion based decisions rather than fact based?  In general, do you believe doctors are just trying to be utilitarian and see, diagnose, and treat patients as efficiently as they can?

I personally chose this story, because I felt the statistics jumped off the page.  The two studies revealed that a majority of doctors would treat themselves differently than they would treat their patients.  This act surpasses the fact that doctors sometimes don't tell the truth; they don't act truthfully which I believe is worse.  Higgs sums it up best when he says, " However honest a citizen, it was somehow part of the doctors job not to tell the truth to his patient."

 

 

9Jun/1131

Patient-Professional Relationship News Article

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http://www.cnn.com/2011/US/06/07/sissy.boy.experiment/index.html?iref=allsearch

There have been comments and questions about whether children should be afforded a certain amount of autonomy and decision making. There seems to be a general agreement that parents and physicians should make decisions for children, but what happens when the parents and doctors are making the wrong decisions? Does the relationship between the doctor and child matter at all or only the relationship between the doctor and parents because the parents are supposed to make decisions for the child? Is this third-person medicine approach in the best interest of the child?

Not long ago, and still in some circles, homosexuality was thought of as a disease or disorder. Doctors and researchers like to cure or resolve diseases and disorders and in the case of children, refer to parents for consent and sometimes assistance in this goal. For the child this is a paternalistic model in which their perceived needs are considered over what they want, or their autonomy. In this article a clear abuse of this role was done by both Dr. Rekers and the parents of Kirk Murphy. Kirk liked to play with doll and wear his hair long, expressing his autonomy; his parents and Dr. Rekers neglected the welfare of this boy by severely punishing him for these actions that came natural to him. Eventually he was so well trained in denying his homosexuality he ended up having a long successful military career. The physical and psychological harm was evident, following him his whole life until he made his last act of autonomy by taking his life.

If you consider the relationship between Kirk’s parents and Dr. Rekers the parents, after realizing the harm they did, may say it was also paternalistic, however it could easily be said it was a partnership because the parents didn’t have to beat their son, they chose to. As a child did Kirk deserve autonomy to act how he wanted? What kind of relationship did Kirk’s parents have with Dr. Rekers? What ethical implications does their relationship have in term of how Kirk was treated? These are only a few of the many ethics questions that could be asked in regards to this article. This is obviously an extreme case of endangering the welfare of the patient an complete ignorance of his individual autonomy, what other examples could you think in which the child’s autonomy should be considered over what the doctors and parent want?

8Jun/1151

Patient-Professional Relationship Case Study (Care Ethics)

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This is a very interesting case. The issue at hand is whether or not Dr. Wilson should perform a hysterectomy on Carmen Diaz, in addition to the Diagnostic Laparoscopy which was the initial procedure. This issue arose when Dr. Wilson discovered, during the laparoscopy, that Carmen had several large tumors about her uterus. Although the tumors were benign, they tend to be painful, and were most likely to blame for the near crippling pain that Carmen experienced for the past three months. Upon signing a consent form for the diagnostic laparoscopy, Carmen granted Dr. Wilson the right "to do what is medically necessary and advisable if unexpected circumstances arise during the surgery." The question is whether this hysterectomy, which will consist of removal of Carmen's uterus, is medically necessary.

Taking stance on the ethics of care, I feel as if it is necessary for Dr. Wilson to perform the hysterectomy. Care ethics, as the name implies, focuses on caring for others, by showing empathy for them as well as showing concern for their needs and interests.  Rather than putting emphasis on universal moral standards, as do ethical theories of consequentialism and deontology, care ethics places an emphasis on the importance of relationships, and the responsibilities that arise out of such.

When Carmen signed the consent form and gave Dr. Wilson the right to do whatever was medically necessary, she (Carmen) made way for their relationship to take form of the friendship model. The friendship model is right in tune with care ethics, contending that in a medical setting, the physician assumes the interests of the patient, while the patient puts his/her trust in the physician. In this situation, Dr. Wilson would be assuming the interests of Carmen since Carmen trusted her so much as to give her such significant rights. With the knowledge that Carmen has large tumors that are painful, Dr. Wilson would be acting in the best interest of Carmen by performing the hysterectomy and removing the tumors. This would rid Carmen of a terrible pain that has restricted her physical activity and worsened the quality of her life. Dr. Wilson would also be acting in the best interest of Carmen by performing the surgery now, and not allowing Dr. Wang to awaken Carmen and plan the hysterectomy for a future date. If the surgery is put off, Carmen would still have to deal with the crippling pelvic pain until her rescheduled surgery. Dr Wilson would also be acting in the best interest of Carmen in terms of Carmen's psychological health. If the surgery is put off until a later date, Carmen has to carry two burdens; the burden of pain that the tumors are causing her, and the burden of fear and anxiety that she would soon have to undergo a serious surgical procedure, and she would soon have her uterus removed.

In assessing Carmen's needs, I believe we can all agree that Carmen needs for her pain to cease as soon as possible. The terrible pain she experienced impaired her ability to work and to do routine daily chores, thus making life that much more difficult. Since the ethics of care are normative, Dr. Wilson is able to assess those needs and determine whether or not she is taking the right action. However, it does seem tough to try and balance the right and wrong of this procedure; is it right to rid Carmen of her pain, or is it wrong to perform a procedure as drastic as removing a uterus without notifying Carmen first?

Care ethics hints at a gender difference in reasoning. Thanks to Carol Gilligan, it is understood that females are more inclined to protect the interests of everyone involved, whereas men are more inclined to sacrifice one's interests. It can be argued that while Dr. Wilson was trying to protect Carmen's interests by performing the hysterectomy, Dr. Wang (who is a male) was sacrificing Carmen's interests by planning to awaken her and delay the hysterectomy. What are your opinions on that matter?

Another interesting question is whether empathy is a competent approach to determining right and wrong actions in the medical field. Empathy consists of attempting to recognize one's feelings and trying to share in those feelings, without actually being in the same situation. In this case, Dr. Wilson couldn't be aware of Carmen's feelings because Carmen was anesthetized. Could Dr. Wilson adequately share in Carmen's feelings of learning that she no longer has a uterus and therefore no longer has a functioning reproductive system? Surely Dr. Wilson doesn't know the pain of waking up to the news that you won't be able to reproduce. If Dr. Wilson were to perform the surgery, what do you expect Carmen's reaction to be? Will she be happy that the pain is gone, or sad that she can't have children, or both? Will she understand that Dr. Wilson was acting in her best interest?

8Jun/1143

Case Study: Patient-Professional Relationships (Utilitarianism)

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The major conflict in this case revolves around whether or not it would be proper and ethical for Dr. Wilson to perform a laparoscopic hysterectomy on Carmen, after it was discovered through a diagnostic procedure that she had several benign, but painful uterine tumors.  Although Carmen signed a consent form that gave Dr. Wilson the rights to do what is “medically necessary and advisable”—the anesthesiologist, Dr. Wang has doubts about whether Carmen has given proper consent for the hysterectomy and if it is in fact medically indicated.

As a quick recap, utilitarianism seeks to create the “greatest possible good (or happiness) for the most amount of people.” Happiness or the “maximization of utility” is primarily defined in two different ways: Bentham believed it to be pleasure and the absence of pain, Another way to analyze utilitarianism, is to understand how closely it is tied to the idea of “opportunity cost,” a concept developed by Jon Stewart Mill which refers to the value of whatever one had to give up in order to pursue another course of action.  Typically, a utilitarian will want to pursue the course of action with the lowest opportunity cost, thus making the most efficient use of resources.

Under utilitarianism, it seems that Dr. Wilson’s intention to perform the laparoscopic hysterectomy would not only be the reasonable course of action, but the preferable one as well.   In terms of resources, Dr. Wilson conserves both time and energy by performing the laparoscopic hysterectomy while she already has Carmen in surgery and anesthetized. I believe doing the hysterectomy during the laparoscopy is the option that has the lowest opportunity cost.   By getting rid of the ailment in this one procedure, Dr. Wilson allows both her and Dr. Wang to have a greater amount of time in the future to help other patients that need care, since the will not have to put the surgery off for another appointment.  Utilitarianism is concerned with the “good of everyone,” thus only having one procedure will benefit those in need of medical care (which Carmen’s second procedure might have prevented). Additionally, there is a certain amount of risk for a patient each time they go under anesthesia, by consolidating the diagnostic and treatment surgery, this risk is compounded.  According to Bentham, pleasure is defined as an absence of pain, by only having one immediate surgery, Dr. Wilson is preventing Carmen from experiencing the pelvic pain that has so limited her daily life for the past few months. Also, by only having one surgical procedure—Carmen is saved the pain of a second procedure. Because Carmen will have had the procedure already completed, she will be able to return to work sooner and not have to miss yet another day to treat the tumors.  Dr. Wilson's decision to perform the laparoscopic hysterectomy makes the best use of medical resources and prevents Carmen from experiencing any more of the pain that had severely impacted her daily life, and thus would likely be supported by the utilitarian perspective.

Utilitarianism is a form of consequentialism, and as a consequence of this surgery, Carmen will most likely be relieved of the pain that has been so heavily impacting her life—the main goal of her.  The other consequences are hard to determine and require a fair amount of speculation; I find this to be a weakness of the utilitarian perspective and it was hard to determine specific consequences for certain without more information. For example, what if Carmen, upon being informed of the hysterectomy, becomes deeply depressed at the idea that she will be unable to have children and though physically well, is unable to continue.  Despite the infinite variety of consequences, I still believe that under utilitarianism, Dr. Wilson's intention to perform the hysterectomy is the best course of action and the utility is maximized to a degree where it seems to outweigh the possible negative consequences.

  • How do the goals of utilitarianism in this example compare with the ethical perspective that you are looking at? Even if the goals are different- did anyone come to a similar conclusion?

Utilitarian perspective aside, this case is something I struggled with. Personally, I found it hard to put my feelings aside in order to argue the utilitarian perspective.   From a patient perspective, I just can’t help but to think how I would feel emotionally, waking up from a surgery that was supposed to be diagnostic to find that my uterus had been removed. Here are some questions that I started to think about while I was analyzing the case study that I think would be very interesting to explore.

  • How does the solution offered by the utilitarian perspective compare to the “restoration of autonomy” that Ackerman argues is the goal of medicine? Are there any perspectives that you feel offer a better solution?
  • Though Carmen’s physical problems have been solved, how would the solution offered by the utilitarian perspective impact her personal identity?
  • After Carmen was told that it would be a diagnostic procedure, was Dr. Wilson overstepping her bounds and deceiving Carmen in wanting to perform the hysterectomy—or was she just doing what she thought was “medically advisable and necessary?”  What implications might this have for Dr. Wilsons future relationship with Carmen?
  • If you could, using the different patient-professional models we read about this week, how would you revise either Dr. Wang's or Dr. Wilsons' approach? Would this revision change the outcome according to your philosophical perspective?

 

7Jun/110

Week 02>Quiz

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The Patient Professional Relationship

This week we covered the patient-professional relationship--including autonomy concerns, truth telling, and nursing. Test your knowledge of the readings using the quiz.

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5Jun/1129

Lecture 06/06>The Patient-Professional Relationship

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The question we are faced with today, and will be faced with throughout the semester, is “what is the object of medicine?” The answer to this question severely impacts what the answer to the various ethical questions we ask will be. Is the purpose of medicine merely to heal physical injury and disease? Or is it meant to aim at something more. Notice the language that all of the articles you read for today use in discussing the various bioethical issues: their main concern is the balance between patient health and patient autonomy. Notice as well that when they discuss health, they are not merely discussing physical well-being, but also mental well-being.  There is an important distinction underlying all of these articles: that between disease and illness.

Disease, injury, whatever word best expresses the point, refers to the underlying physical cause of trouble for an individual. This is the broken bone or the clogged arteries; the damage to the brain, the loss of sight. These are all problems that fall under the category of disease. Illness, on the other hand, refers to the impact of disease on the individual. Illness is a subjective category closely tied to the individual life of the patient and the way they approach their disease or injury.  The readings for today are largely concerned not simply with disease, but with illness--a concern largely represented through the concept of patient autonomy.

These readings frame the object of medicine as restoring the patient to an autonomous state or, where not possible, carrying out the patient’s autonomous wishes. These might be called illness concerns. On the other side of the equation are the disease concerns—the drive to solve the physical malady. The object of medicine might be to solve the illness concerns, but this might only be done by solving the disease concerns. Yet, these two kinds of concerns can conflict and it is not a simple resolution where these conflicts take place.

If the world was absolutely certain and we understood one another perfectly, it is likely that there would be little conflict between illness and disease concerns. However, the world in general and the medical world in particular both operate under the burden of mere probability. Complicating matters, individuals are not transparent to one another.  As Childress and Seigler point out, we have varying different values and these values might not be shared by both the patient and the health care professional.

Autonomy is often treated as if it is an all or nothing concept, but this seems wrong. An individual might be diminished in their autonomy capacity, yet still be able to make certain kinds of decisions. If illness simply robbed an individual of their capacity to act autonomously, then there would be very little to discuss in medical ethics—medical professionals would have the freedom to treat patients in whatever way would best suit the problem. Precisely the fact that medicine does not work in this way demonstrates that autonomy is a continuum on which we all operate at various levels depending on our circumstances. This is true even in our day to day lives. In some situations, we feel completely in control. In others, we feel powerless. In these situations out capacity for autonomous action is operating at different levels. Of course, in these situations medicine does not interfere. Medicine only deals with autonomy problems related to physical ills.

Consider the flu. If you have ever been sick with the flu, you know that it weakens you physically; it drains you of energy; and it makes it difficult to function properly. In a certain sense, you have lost control of your life through the interference of this malady. But the flu is (generally) minor. You are bedridden for a few days and you make a slow recovery. Within a week, you are almost back to normal functioning. The impact of the flu is minimal. It may have some drastic effects immediately, but it’s overall impact on one’s autonomy competency is slim. This is because the flu is a blip on the radar of your life. It is (usually) easily dealt with. Some medication, bed rest, and it passes. The treatment is simple and easy to grasp. The whole medical element of the flu is minimal.

There are, however, two ways in which disease or injury might rob one of autonomy in a more serious way. The first is directly related to the disease. The more pervasive a disease or injury is, the more it dominates one’s identity. The loss of a leg might throw a person of balance, not merely physically, but mentally. Imagine an individual whose identity was closely wrapped up with their physical ability. The loss of a leg would deal a large blow to their ability to make sense of themselves and, through that, their world. The self might be considered a kind of faux stationary point from which one may move the world. It is the strength of one’s self that gives one the competency to be autonomous. This autonomy can be eliminated by a disease that robs an individual of their identity, their stationary point, or which forces them to reconceive of themselves as weak and dependent in some sense.

The second more serious impact of disease on autonomy is only indirectly related to the disease but directly related to the treatment of the disease. Just as disease can throw an individual off balance and so rob them of autonomy competency, being admitted into the medical system can have just as damaging an effect. The medical system operates under the idea that the patient is weak and dependent and, as they serve to overcome this, they reinforce that perception--this is what Ackerman calls the "sick role.' Further, the medical system is alien to the patient in many ways (at least most patients) and this feeling of alienation further reinforces the loss of control. Thus, a patient who was already struggling with autonomy becomes further undermined in their treatment.

Yet, if this diminishing of autonomy can later serve to strengthen and repair autonomy, shouldn’t such a diminishing be allowed?

It is this balancing between diminishing and balancing autonomy that is at stake in the conflict between illness and disease concerns. In order to treat the illness, the disease must be treated. Sometimes treating disease requires taking actions that the patient might not want to consent to. Sometimes treating the disease requires taking actions that the patient is not able to understand. Both of these cases raise issues of competency and to decide them a balance needs to be struck between the patient’s present level of autonomy competency, the potential diminishing of autonomy competency by the treatment, and the desire to increase the patient’s autonomy competency.

Key Concepts:

  • Autonomy
  • Disease
  • Illness
  • Paternalism

Some Questions to Consider:

  • Is the object of medicine really to treat illness and not merely disease?
  • Can we adequately talk about medicine in terms of autonomy? Or is this a misleading conversation?
  • What obligation does the health care professional have to the patient?
  • What obligation does the patient have to herself?