Abstract
In his revised Foundations of Bioethics, Engelhardt has provided a rich and far-reaching account, not just of the moral foundations of bioethics, but of their implications in a wide array of areas. From issues of birth, life, and death, to defining the concept of disease, to patients’ prerogatives in choosing and refusing their health care, to the shape and future of the nation’s health care system, Engelhardt offers a coherent picture of the ways in which particular controversies should be addressed. Even the most comprehensive account, however, cannot discuss every issue. This chapter takes up a significant challenge in the changing economics of health care, one whose resolution has already begun but whose future directions need careful consideration. The chapter is not a critique, but rather an extrapolation of the ways in which Engelhardt would probably regard this issue.
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Notes
The middle ages were known for guild control over many occupations, but the widespread use of licensing to regulate professions is largely a feature of the twentieth-century. By the mid-1800s, an antiregulatory movement in the country had opened the medical profession essentially to anyone who chose to hang a shingle. Only after the turn of the century did licensing laws emerge. See D. B. Hogan, “The Effectiveness of Licensing: History, Evidence, and Recommendations,” Law and Human Behavior 7 (1983): 117–138, at 118–20. See also P. Starr, The Social Transformation of American Medicine (New York: Basic Books, 1982).
Howard Brody would call this power the physician’s “Aesculapian power”—the mastery of facts, theories, and skills that achieves healing results. Brody distinguishes this sort of power from the “charismatic power” that a physician may win based on personal qualities, and from the “social power” that arises from the special authority that society has given physicians to determine what will count as truth and knowledge in medicine. H. Brody, The Healer’s Power (New Haven: Yale University Press, 1992), 16–17. Brody’s account of social power points toward the legal and economic power discussed just below in this essay, but does not entirely capture the force that arises when society grants physicians exclusive legal permission to define, diagnose, and treat disease, or the economic authority to determine how much others will spend on their care.
Hogan, “The Effectiveness,” 129–130.
Cited in Medical Licensing Board of Indiana v. Stetina, 477 N. E. 2d 322 (Ind. App. 1985). In Tennessee: “Any person shall be regarded as practicing medicine who treats, professes to treat, operates on, or prescribes for any physical ailment or any physical injury to or deformity of another.” T.C.A. §63-6-204. The statute explicitly does not apply to “the administration of domestic or family remedies in cases of emergency” or to dentistry, military physicians, midwives, veterinary surgeons, osteopaths, chiropractors not giving or using medicine, opticians, optometrists, chiropodists, Christian Scientists, physician assistants, registered nurses, or licensed practical nurses rendering services “under the supervision, control and responsibility of a licensed physician.”
C. C. Havighurst, “The Changing Locus of Decision Making in the Health Care Sector,” Journal of Health Politics, Policy and Law 11 (1986): 702.
Cited in Sermchief v. Gonzales, 660 S. W. 2d 683 (Mo 1983).
B. R. Furrow, S. H. Johnson, T. S. Jost, R. L. Schwartz, The Law of Health Care Organization and Finance (St. Paul: West Publishing Co., 1991), 69 ff.
C. C. Havighurst, “The Changing Locus,” 703.
See K. Leffler, “Economic and Legal Analysis of Medical Ethics: The Case of Restrictions on Interprofessional Association,” Law and Human Behavior 7 (1983): 183–192. Chiropractors are licensed as primary care providers in all fifty states, but are limited practitioners in that they are not allowed to prescribe drugs or perform surgery; some states specify that they are not permitted to treat infectious or contagious diseases (at p. 186). See also Wilk v. American Medical Association, 895 F. 2d 352 (7th Cir. 1990) (cert. denied 111 S. Ct. 513 (1990)).
D. W. Light, “Is Competition Bad?” New England Journal of Medicine 309 (1983): 1316. For a more detailed discussion of this historical picture and relevant bibliographical cites, see E. H. Morreim, Balancing Act: The New Medical Ethics of Medicine’s New Economics (Washington, D.C.: Georgetown University Press, 1995).
B. B. Roe, “The UCR Boondoggle: A Death Knell for Private Practice?” New England Journal of Medicine 305 (1981): 41–45; T. L. Delbanco, K. C. Meyers, E. A. Segal, “Paying the Physician’s Fee: Blue Shield and the Reasonable Charge,” New England Journal of Medicine 301 (1979): 1314–20.
Havighurst suggests: “Although the tenets of the professional paradigm of medicine are nowhere officially set down, they seem to include the following: • Medical care should be evaluated only on the basis of safety and efficacy, without regard to cost considerations. • Decisions concerning the appropriate utilization of medical services should be based exclusively on scientific evidence and expert opinion. • Consumers are generally incapable of making appropriate choices about their health care. • Patient preferences should be honored under the profession’s ethical principle of informed consent but not by letting consumers choose qua consumers with costs in view. • Consumers should look to physicians and not to other agents to protect their interests. • Physicians, as professionals guided by scientific principles and ethical concern for patient interests, should enjoy autonomy in their professional work and be accountable only to other independent professionals. • Professional norms alone should set the limits of physician judgment.” C. C. Havighurst, Health Care Choices: Private Contracts as Instruments of Health Reform (Washington, D.C.: The AEI Press, 1995), 113.
C. C. Havighurst, J. F. Blumstein, “Coping with Quality/Cost Trade-offs in Medical Care: The Role of PSROs,” Northwestern University Law Review 70 (1975): 26; Havighurst, Health Care Choices, 117.
In 1932, the AMA renounced a blue-ribbon panel, sponsored by several philanthropic organizations, that concluded group practice would be desirable. “The physicians of this country must not be misled by Utopian fantasies of a form of medical practice which would equalize all physicians by placing them in groups under one administration.... It is better for the American people that most of their illnesses be treated by their own doctors rather than by industries, corporations or clinics.” (editorial), “The committee on the costs of medical care,” Journal of the American Medical Association 99 (1932): 1950, cited in K. Grumbach, “Requiem for Traditional Medical Practice in the United States,” Archives of Family Medicine 4 (1995): 756–57.
American Medical Association v. United States, 317 U.S. 519 (1943).
J. M. Alexander, “Potential Legal Problems Associated with Integrated Systems,” in Integrated Health Care Delivery Systems, ed., A. Fine, (New York: Thompson Publishing Group, Inc., 1993), 147; J. G. Wiehl, et al. “Legal Issues Related to Systems Integration,” in Integrated Health, 12, ed., A. Fine; Furrow, et al., The Law of Health Care, 189–90; Havighurst, “The Changing Locus,” 703; Starr, The Social Transformation, 24.
Havighurst, “The Changing Locus,” 706–707. Note how the rapid diffusion of new technology via defensive medicine, identified above, becomes a self-fulfilling prophecy: widespread adoption on the assumption that it will be expected by courts renders it a prevailing approach, therefore the standard of care.
Furrow, et al. The Law of Health Care, 41; Havighurst, Health Care Choices, 330; E. Rayack, “Medical Licensure: Social Costs and Social Benefits,” Law and Human Behavior (1983): 147–156.
See Virginia Pharmacy Bd. v. Va. Consumer Council, 425 U. S. 748 (1976), Bates v. State Bar of Arizona, 433 U. S. 350 (1977), and National Society of Professional Engineers v. United States, 435 U. S. 679 (1978), discussed below.
W. C. Hsiao, et al., “The Resource-Based Relative Value Scale,” Journal of the American Medical Association 258 (1987): 800.
Starr, The Social Transformation, 22 ff.
Hogan, “The Effectiveness”; Rayak, “Medical Licensure.”
Blue Shield of Virginia v. McCready, 102 S. Ct. 2540 (1982).
Hogan, “The Effectiveness,” Rayak, “Medical Licensure”; Furrow et al., The Law of Health Care, 41; S. E. Baker, “The Nurse Practitioner in Malpractice Actions: Standard of Care and Theory of Liability,” Health Matrix 2 (1992): 325–55.
E. H. Morreim, “Am I My Brother’s Warden? Responding to the Unethical or Incompetent Colleague,” Hastings Center Report 23, no. 3 (1993): 19–27.
E. H. Morreim, “The Impossibility and the Necessity of Quality of Life Research,” Bioethics 6 (1992): 218–232; I. F. Tannock, “Treating the Patient, Not Just the Cancer,” New England Journal of Medicine 317 (1987): 1534–35; A. Coates, V. Gebski, J. F. Bishop, et ai, “Improving the Quality of Life During Chemotherapy for Advanced Breast Cancer,” New England Journal of Medicine 317 (1987): 1490–95.
M. D. Sullivan, “Placebo Controls and Epistemic Control in Orthodox Medicine,” Journal of Medicine and Philosophy 18 (1993): 213–231.
H. Brody, Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical Issues (Chicago: University of Chicago Press, 1977).
A. M. Garber, “No Price Too High?” New England Journal of Medicine 327 (1992): 1676–1678.
J. F. Burnum, “Medical Practice A la Mode,” New England Journal of Medicine 317 (1987): 1220–1222.
R. Weiss, “Medicine’s Latest Miracle,” Hippocrates 9, no. 1 (1995): 53–59.
Wilk v. American Medical Association, 895 F. 2d 352, 363 (7th Cir. 1990) (cert. denied 111 S. Ct. 513(1990)).
In re Guess, 393 S. E. 833 (NC 1990). Interestingly, there is some scientific evidence that homeopathy is effective. See C. Bayley “Homeopathy,” Journal of Medicine and Philosophy 18 (1993): 129–145. Similarly, an Indiana court issued an injunction against a woman practicing iridology. She examined eyes for clues and hints to detect physical conditions-unlawfully making a “diagnosis” without a medical license. Indiana v. Stetina, All N. E. 2d 322 (Ind. App. 1985).
D. M. Eisenberg, R. C. Kessler, C. Foster, F. E. Norlock, D. R. Calkins, T. L. Delbanco, “Unconventional Medicine in the United States: Prevalence, Costs, and Patterns of Use,” New England Journal of Medicine 328 (1993): 246–252; E. W. Campion, “Why Unconventional Medicine?” New England Journal of Medicine 328 (1993): 282–283.
Walker v. Superior Court (People), 763 P. 2d 852 (Cal. 1988); State v. McKown 461 N. W. 2d 720 (Minn. App. 1990); S. D. Robinson, “Commonwealth v. Twitchell: Who Owns the Child?” Journal of Contemporary Health Law and Policy 7 (1991): 413–31.
Custody of a Minor, 434 N. E. 601 (Mass 1982); Matter of Hamilton, 657 S. W. 2d 425 (Tenn. App. 1983).
V. E. B. Kolder, J. Gallagher, M. T. Parsons, “Court-Ordered Obstetrical Interventions,” New England Journal of Medicine 316 (1987): 1192–1196; G. J. Annas, “Protecting the Liberty of Pregnant Patients,” New England Journal of Medicine 316 (1987): 1213–14; J. L. Nelson, N. Milliken, “Compelled Medical Treatment of Pregnant Women: Life, Liberty, and Law in Conflict,” Journal of the American Medical Association 259 (1988): 1060–66. Note that the reciprocal does not occur: medical physicians are never prosecuted for failing to use spiritual approaches when their own remedies are clearly failing.
“The GUSTO Investigators. An International Randomized Trial Comparing Four Thrombolytic Strategies for Acute Myocardial Infarction,” The New England Journal of Medicine 329 (1993): 673–682; “The GUSTO Investigators. The Effects of Tissue-Plasminogen Activator, Streptokinase, or Both on Coronary-Artery Patency, Ventricular Function, and Survival after Acute Myocardial Infarction,” The New England Journal of Medicine 329 (1993): 1615–1622; K. L. Lee, R. M. Califf, J. Simes, F. Van de Weft, E. J. Topol, “Holding GUSTO up to the Light,” Annals of Internal Medicine 120(1994): 876–881.
F. A. Lederle, W. A. Applegate, R. H. Grimm Jr., “Reserpine and the Medical Marketplace,” Archives of Internal Medicine 153 (1993): 705–706.
M. Chen, S. Landefeld, T. H. Murray, “Doctors, Drug Companies, and Gifts,” Journal of the American Medical Association 262 (1989): 3448–3451.
J. Avorn, M. Chen, R. Hartley, “Scientific Versus Commercial Sources of Influence on the Prescribing Behavior of Physicians,” American Journal of Medicine 73 (1982): 4–8; R. I. Shorr, W. L. Greene, “A Food-Borne Outbreak of Expensive Antibiotic Use in a Community Teaching Hospital, Journal of the American Medical Association 273 (1995): 1908; R. K. Schwartz, S. B. Soumerai, J. Avorn, “Physician Motivations for Nonscientiflc Drug Prescribing,” Soc. Sci. Med. 72 E. Haavi Morreim 28 (1989): 577–582.
Havighurst, “The Changing Locus,” 700.
As Donald Light has noted: “The best observers of American medicine have described in detail how the monopoly established by the medical profession earlier in this century has led to its promoting the most profitable lines of work, organizational arrangements, and financing schemes while denigrating public health, preventive medicine, primary care, prepaid programs, and other approaches that have contributed to better health in other advanced societies.” Light, “Is Competition Bad?” 1316.
Virginia Pharmacy Bd. v. Va. Consumer Council, 425 U. S. 748 (1976).
Virginia Pharmacy Bd. v. Va. Consumer Council, 425 U. S. 748, 768–770 (1976).
Virginia Pharmacy Bd. v. Va. Consumer Council, 425 U. S. 748, 770 (1976).
Bates v. State Bar of Arizona, 433 U. S. 350 (1977).
Bates v. State Bar of Arizona, 433 U. S. 350m 368 (1977).
Bates v. State Bar of Arizona, 433 U. S. 350, 379 (1977). In National Society of Professional Engineers v. United States, 435 U. S. 679 (1978), engineers made a similar case on behalf of their rule forbidding engineers to engage in competitive bidding or in negotiating on price before a client had selected an engineer for a particular job. As in the pharmacy case, the engineers painted a dismal picture of their clients, as people who will almost invariably award contracts to the lowest bidder, regardless of quality or other factors. And they painted a dismal picture of themselves: if permitted to bid competitively, engineers may begin providing a poorer product, submit deceptively low bids, or the like (694, 696). Again, the Supreme Court rejected the arguments, favoring competition.
L. A. Weithorn, “Mental Hospitalization of Troublesome Youth: An Analysis of Skyrocketing Admission Rates,” Stanford Law Review 40 (1988): 773–837.
A. J. Barsky, “The Paradox of Health,” New England Journal of Medicine 318 (1988): 414–418; M. A. Rodwin, “Patient Accountability and Quality of Care: Lessons from Medical Consumerism and Patients’ Rights, Women’s Health and Disability Rights Movements,” American Journal of Law and Medicine 20 (1994): 147–167.
Weithorn, “Mental Hospitalization,” 785–798.
R. J. Bonnie, “Soviet Psychiatry and Human Rights,” Law, Medicine & Health Care 18 (1990): 123–131.
D. Callahan, “The WHO Definition of ‘Health’,” in Contemporary Issues in Bioethics, ed., L. Walters (Belmont: Wadsworth, 1982, 2nd ed.), 51.
In Tennessee, for instance, misuse of drugs features in 5 of the 18 explicit reasons by which the state’s Board of Medical Examiners can deny, suspend, or revoke a physician’s license. T.C.A. §63-6-214. The Office of Inspector General in the federal Department of Health and Human Services has reported that “approximately 75 percent of all disciplinary actions were based on drug and alcohol abuse by the physician or for inappropriate prescription for drugs.” Cited in Furrow et. al., The Law of Health Care, 53–54.
M. Angell, “Breast Implants: Protection or Paternalism?” New England Journal of Medicine 326 (1992): 1695–1696.
M. J. Underwood, J. S. Bailey, “Coronary Bypass Surgery Should Not Be Offered to Smokers,” British Medical Journal 306 (1993): 1047–1048.
A. Moss, M. Siegler, “Should Alcoholics Compete Equally for Liver Transplantation?” Journal of the American Medical Association (1991): 1295–1298.
L. Stell, “The Noncompliant Substance Abuser,” Hastings Center Report 21 no. 2 (1991): 31–32; J. LaPuma, C. K. Cassel, H. Humphrey, “Ethics, Economics, arid Endocarditis,” Archives of Internal Medicine 148 (1988): 1809–11.
P. D. Kramer, Listening to Prozac, (New York: Viking Press, 1993). The concept of “pharmacological Calvinism” is attributed to Richard Schwartz: See Chapter 9, 250 ff. Kramer notes that “Jean-Paul Sartre wrote his last books while on amphetamines, fully believing he was hastening his death but preferring his version of Achilles’ choice: the short, productive life. In the United States, we do not grant the individual this option” (244–45). Because amphetamines cause addiction and paranoia, U. S. laws only allow them to be prescribed for very narrow indications. Hence, an “American doctor would have to say to Sartre,’ The choice is not yours: the book goes, you stay; we are caretakers for a whole society, not potentiators of your work’” (245).
E. H. Morreim, “Profoundly Diminished Life: The Casualties of Coercion,” Hastings Center Report 24, no. 1 (1993): 33–42.
H. T. Engelhardt, Jr., The Foundations of Bioethics 2nd ed., (New York: Oxford University Press, 1996), 227.
Foundations, 375.
Foundations, 205.
For further discussion of these varying standards of care see E. H. Morreim, “At the Intersection of Medicine, Law, Economics, and Ethics: The Art of Intellectual Cross-dressing,” in Perspectives on Philosophy in Medicine, eds., Ronald A. Carson and Chester R. Burns, Philosophy and Medicine Series 50 (Dordrecht: Kluwer Academic Publishers, 1996), forthcoming.
“How Do Non-physician Providers Function in HMOs?” HMO Practice 8, no. 4 (1994): 151–156.
J. P. Kassirer “What Role for Nurse Practitioners in Primary Care?” New England Journal of Medicine 330 (1994): 204–205; C. D. DeAngelis, “Nurse Practitioner Redux,” Journal of the American Medical Association 271 (1994): 868–71; E. S. Sekscenski, S. Sanson, C. Bazell, M. E. Salmon, F. Mullan, “State Practice Environments and the Supply of Physician Assistants, Nurse Practitioners, and Certified Nurse Midwives,” New England Journal of Medicine 331 (1994): 1266–71.
Eisenberg et. al., “Unconventional Medicine”; E. W. Campion, “Why Unconventional?”; R. Weiss, “Medicine’s Latest Miracle,” Hippocrates 9 no. 1 (1995): 53–59; P. Long, “The Naturals,” Hippocrates 9 no. 5 (1995): 30–35; T. L. Delbanco, “Bitter Herbs: Mainstream, Magic, and Menace,” Archives of Internal Medicine 121 (1994): 803–4.
Delbanco, “Bitter Herbs,” 803–804.
H. T. Greely, “The Regulation of Private Health Insurance,” in Health Care Corporate Law: Formation and Regulation, ed., H. A. Hall, (Boston: Little, Brown, and Company, 1993), 8–32.
Furrow et. al., The Law of Health Care, 190.
J. C. Goodman, G. L. Musgrave, Patient Power (Washington DC: Cato Institute, 1992); P. DuPont, “The Free-market Health Proposal,” Wall Street Journal, (July 1, 1994): A-10; P. Gramm “Why We Need Medical Saving Accounts,” New England Journal of Medicine 330 (1994): 1752–53; M. S. Forbes, “Health Care: Trust the People,” Forbes (May 23, 1994): 23–24; J. C. Goodman, “A Plan to Empower Patients,” Wall Street Journal, (May 2, 1995): A-20; E. H. Morreim, “Lifestyles of the Risky and Infamous: From Managed Care to Managed Lives,” Hastings Center Report 25, no. 6 (1995): 5–12.
For further discussion, see E. H. Morreim, “Diverse and Perverse Incentives in Managed Care: Bringing Patients into Alignment,” Widener Law Symposium Journal 1(1995): 89–139.
M. R. Gillick, “Common-sense Models of Health and Disease,” New England Journal of Medicine 313 (1985): 700–703.
Roughly half of reported deaths in 1990 could be attributed to factors such as tobacco, diet and activity patterns, alcohol, microbial agents, toxic agents, firearms, sexual behavior, motor vehicles, and illicit drugs. J. M. McGinnis, W. H. Goege, “Actual Causes of Death in the United States,” Journal of the American Medical Association 270 (1993): 2207–2212.
Morreim, “Lifestyles of the Risky,” 5–12; A. J. Slomski, “Maybe Bigger Isn’t Better After All,” Medical Economics 72, no. 4 (1995): 55–58.
American College of Physicians, “Physician Assistants and Nurse Practitioners,” Annals of Internal Medicine 121, (1994): 714–716, at 715.
For further discussion of the pros, cons, and consequences of managed care, see: K. Davis K. S. Collins, C. Schoen, C. Morris, “Choice Matters: Enrollees’ Views of Their Health Plans,” Health Affairs 14, no. 2 (1995): 99–112; D. G. Safran, A. R. Tarlov, W. H. Rogers, “Primary Care Performance in Fee-for-service and Prepaid Health Care Systems,” Journal of the American Medicine Association 271 (1994): 1584; K. Grumbach, T. Bodenheimer, “The Organization of Health Care,” Journal of the American Medical Association 273 (1995): 160–67; P. D. Gerber, D. S. Smith, J. M. Ross, “Generalist Physicians and the New Health Care System,” American Journal of Medicine 97 (1994): 554–558; E. J. Emanuel, N. L. Dubler, “Preserving the Physician-Patient Relationship in the Era of Managed Care,” Journal of the American Medical Association 273 (1995): 324–25.
For studies supporting the value of continuity of care, see, D. A. Barr, “The Effects of Organizational Structure on Primary Outcomes under Managed Care,” Annals of Internal Medicine 122 (1995): 353–359; J. H. Wasson, A. E. Sauvigne, R. P. Mogielnicki, W. G. Frey, C. H. Sox, C. Gaudette, A. Rockwell, “Continuity of Outpatient Care in Elderly Men: A Randomized Trial,” Journal of the American Medical Association 252 (1984) 2413–17; C. L. Shear, B. T. Give, J. K. Mattheis, M. R. Levy, “Provider Continuity and Quality of Medical Care: A Retrospective Analysis of Prenatal and Perinatal Outcome,” Medical Care 21 (1983): 1204–1210; D. S. Rubsamen, “3 Scenarios that Spotlight the Malpractice Hazards Pervading Managed Care,” Physicians Financial News: Managed Care Report (4/30/95), S-l, S-14, S-15.
E. L. Hannan, H. Kilbum Jr., M. Racz, E. Shields, M. R. Chassin, “Improving the Outcomes of Coronary Artery Bypass Surgery in New York State,” Journal of the American Medical Association 271 (1994): 761–766.
Morreim, “Diverse and Perverse Incentives.”
Havighurst, Health Care Choices.
Goodman, et al., Patient Power.
Morreim, “Diverse and Perverse Incentives.” Note that these changes would require courts to look quite differently on health care. In order to permit patients to contract for the level of care they want, courts would have to abandon their insistence that health plans are generally contracts of adhesion whose terms may be discarded any time they disadvantage the individual patient. If patients are to have the freedom to make contracts in the first place, those contracts must be enforced. Havighurst, Health Care Choices; P. E. Kalb, “Controlling Health Care Costs by Controlling Technology: A Private Contractual Approach,” Yale Law Journal 99 (1990): 1109–1126; E. H. Morreim, “Moral Justice and Legal Justice in Managed Care: The Ascent of Contributive Justice,” Journal of Law, Medicine & Ethics 23 (1995): 247–265. In like manner, increased access to alternate health care providers would require courts to place greater responsibility on these providers, and less on physicians. When nurses market their services directly to patients, physicians who no longer’ supervise’ others should not be held legally accountable for what the latter do. In Adams v. Krueger, 856 P. 2d 887 (Idaho App. 1991), a physician was held vicariously liable for the acts of a nurse practitioner employee, even though the nurse practitioner was not herself found liable. Such holdings may need reevaluation if allied health care providers gain greater independence, as proposed here.
Although this chapter argues that medicine’s monopoly should be mitigated, it is admittedly not clear just how far or how fast this should occur. One might argue, for instance, that it may be best to let physicians retain some control over prescription medications, if only for public health reasons. Instant public access to antibiotics, for instance, may contribute to the development of resistant organisms that pose a threat to everyone. On the other hand, perhaps physicians have contributed to the development of these resistant organisms as much or more than direct public availability might have. Physicians, wary of malpractice suits and sometimes concerned that they must please the demanding patient by writing a prescription, may have overprescribed common antibiotics over the years and thereby contributed to the rise of resistant organisms in conditions such as otitis media, for instance. See N. Joshi, D. Milfred, “The Use and Misuse of New Antibiotics,” Archives of Internal Medicine 155 (1995): 569–577. The question is empirical, and cannot be settled by reason alone. Suffice it here to conclude that, at the very least, we need to reexamine the notion of permitting one particular group of healers exclusive control over all access to such a broad array of powerful healing tools.
As Blumenthal notes, patients not only recognize an asymmetry of information and skill between themselves and their physicians-they want their physicians to know more than they do. D. Blumenthal, “The Vital Role of Professionalism in Health Care Reform,” Health Affairs 13 no. 1 (1994): 252–256.
E. Pellegrino, “Altruism, Self-interest, and Medical Ethics,” Journal of the American Medical Association 258 (1987): 1939–1940; E. Pellegrino, D. C. Thomasma, For The Patient’s Good (New York: Oxford University Press, 1988).
Blumenthal, “The Vital Role of Professionalism,” 253.
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Morreim, E.H. (1997). Medicine’s Monopoly: From Trust-Busting to Trust. In: Minogue, B.P., Palmer-Fernández, G., Reagan, J.E. (eds) Reading Engelhardt. Springer, Dordrecht. https://doi.org/10.1007/978-94-011-5530-4_4
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