The Cartesian approach to knowledge has greatly enhanced biomedical technology by liberating the study of man from medieval theology. Legitimiz ing the study of the human body as a thing, that is, as a physical entity (res extensa), has made possible great technical advances that could not have occurred if anatomical dissections and other experiments that might have challenged the authority of the church were prohibited. However, when we refer to the study of man in the traditions of philosophical anthropology, we understand that to mean much more than the study of human physiology. The "soul" (res cogitans), which Descartes split off from the body, has all but lost any compelling significance in modern culture; even the word "spirit" barely conveys the more-than-physical concerns that are inevitably a part of the physician's concern for the patient.
Thus our culture, for all its diversity, experiences the full force of the Cartesian legacy in modern medicine. It is now possible to conceive of medicine as an almost totally impersonal, technological enterprise, or it is possible to conceive of medicine in very personal terms and quite broadly as concerned with suffering of human beings. Medicine and physicians are criticized both for being too impersonal and for being concerned with too broad a range of problems. It is a paradox of our culture that medicine should be denounced for being too concerned with human suffering, while any number of purportedly radical critics of medicine--including Ralph Nader, Ivan Illych, and Thomas Szasz,1 as well as members of the medical establish ment--hold that medicine should limit its concern to strictly physical matters. It is also paradoxical that just as medical technology has really been able to demonstrate prodigious accomplishment, public satisfaction with medicine has been rapidly declining. The paradox here is not that the public is dissatisfied with medical technology, but that technical virtuosity has led the physician to concentrate more on the physical aspects of disease with de creased concern for the patient who suffers. No one would wish a return to the turn-of-the-century physician, the "horse and buggy doctor," romantically remembered as sitting all night at the bedside of the dying patient, to whom he could offer little but compassion, but we might wish for more of the humane concern manifested by physicians of old.
It is one of the tasks of medical ethics to deal with this dichotomous view of medicine. Medical ethics is both the vehicle for transmitting professional tradition and the vehicle for calling those traditions into question. Recalling Chauncey Leake's distinction between matters of ethics and matters of eti quette, we may now paraphrase his concern as follows: While medical ethics is properly concerned with the ultimate conduct of physicians toward their patients and toward society as a whole, the consideration of the will and motive behind this conduct involves matters of etiquette and manners in medical practice. It is possible for ethics to avoid such personal, historical, and cultural considerations and to achieve explicit clarity on abstractly formu lated questions, but it does so at the risk of further impersonalizing medical practice. Or to reformulate the problem: In order for medical ethics to achieve the kind of conceptual clarity that the Cartesian outlook requires, it must sacrifice any awareness of a whole, integrated, historical human being living in a cultural situation in favor of the Cartesian split personality. The Cartesian legacy in our culture leads us to either mentalistic or materialistic formulation of our problems, and this is especially the case in medicine.
Just as the appreciation of technology in our culture is ambivalent, so also is the appreciation of medicine. And herein lies the confusion, for medicine as an institution consists of individual physicians and patients, each unique by virtue of unique historical experiences, whatever experiences they may share as citizens of a particular culture. Physicians do not act in a cultural vacuum devoid of the expectations of their patients. Indeed for all the standardization of practices that medical technology has accomplished, the physician's prac tice starts with an assessment of the needs of each patient who appeals to the physician for help. It is often held that the so-called "medical model" entails certain values of a technological sort, namely, an approach to the body as thing as opposed to the patient as person, when in fact this may not be the case at all. What the medical model entails is ambiguous as is the scope of medical concern and the definitions of health and illness. The extremes may be distinguished by what Dr. Otto Guttentag calls "the biological medical model" and "the anthropological medical model" to avoid conceding that medicine is just concerned with physiological matters and, correspondingly, that doctors are unconcerned with people.2
Thus we see two basic ways in which Cartesian dualism can deter modern medicine: (1) through treating the body as a machine (res extensa) and (2) through the concept of discarnate mentality (res cogitans). The former is overly materialistic; the latter is overly rationalistic.3 In all these chapters I have been discussing the limitations of an approach to ethics that attempts complete specifiability. In this chapter I attempt to demonstrate that this approach to ethics, depending as it does on an impersonal view of man (the person) and relying on the Cartesian mind-body dichotomy, contributes to the dehumanization experienced in modern medical practice.
How is medicine to be conceived? What is the legitimate purview of the physician? Unquestionably the physician is to be concerned with physical illness: an infection, a myocardial infarction, a neoplasm. But what about "mental illness"? Should the physician be concerned with emotional prob lems, anxieties, depressions, psychoses? These concerns might once have been in the spiritual realm, the subject of religious counseling or advice. Does their legitimacy as medical problems stem from a demonstrated organic etiology, or do such mental problems stemming from "problems in living" legitimately belong in the medical purview? What about those patients who perceive themselves to have physical problems, but problems for which no organic etiology can be demonstrated? The polite term for them is "hypo chondriacs"; they are sometimes disparagingly called "crocks" out of frustra tion; technically they are "conversion hysterics" if their symptom masquerade is unconscious, "malingerers" if it is conscious and willful. Should the physi cian be taking care of these people, or should they be refused admission to our hospitals and clinics? What about matters of preventive medicine, fluori dation, nutrition, sanitation, environmental pollution, industrial safety, family planning and birth control, abortion, nuclear energy and war, homosexuality, child abuse, and lifestyle including "bad habits" such as reckless driving, not using seatbelts, smoking, drinking, overeating, and underexercising? Should these matters be of no more concern to the physician than to any other citizen? Medicine is criticized for being both too much concerned and too little concerned with many of these areas.
There is no general agreement about these questions. There is a tradition of broad concern for the well-being of the patient that inclines the physician to adopt a broad definition of medicine. Notable in this tradition is Dr. Otto Guttentag, who defines medicine as "the care of health of human beings by human beings" to stress the physician's fellow-concern for another human being.4 Also in this tradition is the World Health Organization definition of medicine, which stresses physical, emotional, and social well-being. Yet there is another tradition that says the physician should tend only to matters of physical disease. Many of today's young physicians and medical students are defensively adopting this posture in response to the more hostile of medi cine's critics. "Why take unnecessary risks, which aren't appreciated anyway? Better to specialize narrowly in an area where I can be sure of my compe tence," they are saying. Others, sensing a growing resentment of medical paternalism, will say, equally defensively, "Patients are responsible for their health; if they want to kill themselves by smoking, I can't stop them. I will help those who ask for my help."
These are issues that no physician escapes. Whether or not they are presented in an ethical context, they are dealt with as physicians make choices about how they will practice medicine, as well as how they will handle each encounter with each patient. Inevitably there are differences in expectations in any human encounter, no less so in the doctor-patient encounter. Often patients will come to physicians expecting something other than what the physician is prepared to offer. Undoubtedly clarification of expectations should be very much part of the negotiations between physician and patient and involve them together in planning a treatment upon which both agree. A frequent problem is that physicians do not adequately ask patients to clarify their expectations or do not adequately explain the treatments they recom mend, just as it is a problem that patients are often surreptitious about stating what they want. A patient may complain of back pain, for example, leading the physician to believe that the patient wishes to be relieved of the symptoms when in fact they are tolerable, and the patient's conscious desire is that the physician aid in gaining monetary compensation in a legal dispute; uncon sciously the patient may want dependency gratification, but not cure.
One way of clarifying these differing expectations is to distinguish be tween disease and illness. Though disease and illness are practically synony mous in everyday usage, they are not necessarily the same thing, and herein lies the confusion. Illnesses are experiences of disvalued changes in states of being and in social function; diseases, in the scientific paradigm of modern medicine, are abnormalities in the structure and function of body organs and systems. To state the distinction tersely: Patients suffer illnesses; physicians (in the Cartesian paradigms, which reduce life to physics and chemistry) diag nose and treat diseases.5
Disease and illness may not always occur simultaneously. A patient may complain of symptoms for which the doctor can find no organic explanation, or conversely the doctor may make a diagnosis of disease that the patient does not experience as illness. In the former category are conversion hysteria and malingering; in the latter are hypertension and asymptomatic diabetes, which may subsequently become illnesses if the patient does not comply with the doctor's prescriptions. The following chart (Figure 5) illustrates some of the dichotomous possibilities and the value choices that must be made by both physicians and patients in determining the role of medicine in their lives.
|Disease||Congestive heart failure||Hypertension|
|Conversion reaction following whiplash|
|No Disease||Conversion reaction, Malingering|
|Masturbation in 1900||Masturbation in 1980s|
|Homosexuality in 1970
("Sexual orientation disturbance" in 1980s)
|Homosexuality in 1980s?|
|Child abuse in 1980s||Child abuse in 1900|
Just as the perception of a problem as an illness or a disease may change from time to time in any given individual, so also may the perception in a society change. Masturbation, for example, was widely considered an illness around the turn of the century. Now, with recognition of its statistical "normal ity," it is no longer considered a medical problem, even though many people still experience feelings of shame and guilt about masturbation, perhaps not so much about the act itself as about the fantasies that accompany masturba tion.6 Many forms of behavior that were once considered moral problems or "perversions" have been humanistically appropriated into the medical realm, relabeled as illness or perhaps even as diseases, and given the supposedly value-neutral status of "deviations." Alcoholism and sexual perversions might fit in this category. Homosexuality was formally reclassified in 1974 by the American Psychiatric Association and removed from the Diagnostic and Statistical Manual of Mental Disorders Second Edition, being replaced by "Sexual Orientation Disturbance (Homosexuality)." This move presumably was made because not all people who claimed the identity of homosexuality considered themselves to be ill. Thus what was recently a moral problem, a "perversion," was demoralized and medicalized as a "deviation" and then partially demedicalized as an "elective form of sexual behavior." The process works the other way too, as exemplified by the situation of child abuse, which is now viewed as a medical problem. This change reflects in part the new ability of psychotherapists and community agencies to identify the problem and then intervene and offer "treatment."
Value choices reflecting cultural attitudes are made at a most fundamental level concerning "sickness" (disease and/or illness). Not only in the examples discussed to illustrate the scope of possibilities, but in any number of situa tions that come to the physician's attention, decisions must be made as to what should be the physician's best response to the request for help. Often in our culture the problem is perceived to be either a physical or a mental problem, the latter being the province of the psychiatrist as the specialists who deals with functional or nonorganic problems. Thus there is confusion about the relationship of mind to body. This can be understood by considering the relationship of psychiatry to the rest of medicine. Cartesian dualism creates something of an identity problem for psychiatry, depending on how one perceives the medical model. Some adherents of "biological psychiatry" hold that psychiatry's legitimate place in medicine is derived from its treatment of mental problems with a biological basis, "biological" being understood to mean "physical-chemical." This view accepts the supremacy of the biological medical model. Alternatively, others such as George Engel argue that the medical model must be understood to encompass not only biological phe nomenon but bio-psychosocial problems, broadly conceived.7 The dichotomy itself is spurious, but focusing on it provides a useful context for understand ing some of the debates in medical ethics, which take the Cartesian epistemo logical outlook for granted.
Questions of ethics lead to questions of philosophical anthropology: How is a human being to be conceived of in medicine? Since Cartesianism splits man into mind and body, conceived dichotomously, we have been led to consider the place of psychiatry in medicine and in relation to the rest of medicine. The physician is often presented with the question as to whether a certain problem is physical or emotional, "mental" or some variant of a nonphysical problem. Faced with such dichotomous alternatives, we may say medicine should be limited to the strictly physical, or we may say that medicine should be broadly defined to include mental or emotional problems. I have been arguing for the more-encompassing and personal approach. Thomas Szasz takes exactly the opposite approach: He argues that medicine's only proper concern is physical illness and that mental illness is a myth.
Szasz is aware of the impact of Cartesianism on medicine and accepts it as proper and inevitable. Without imagining alternatives, Szasz does not face the question of how to conceive of medicine; but rather in accepting the Cartesian dichotomy, he faces the questions of how to conceive of moral problems, problems in living, and problems involving human ambiguity in a system that insists on conceptual clarity. Says Szasz, "Strictly speaking, disease or illness can affect only the body; hence, there can be no mental illness."8
Since we are prepared to consider alternatives to the Cartesian system, which Szasz is not, we must consider the full import of Szasz's statement for our conception of medicine. "Myth" itself has many possible interpretations. In the Cartesian system and as Szasz uses it, "myth" refers to a nonreality, something that is not to be believed. Alternatively, to a cultural anthropologist or to a theologian a myth is a system of belief, which organizes the way reality is to be understood in a particular culture or religion. Thus we may under stand the myth of mental illness to mean a nonreality in which we should not believe or a reflection of the organizing beliefs of our culture, a way of understanding reality. As Polanyi points out, "if we equate the real with the tangible, then minds may not seem real, even though they are in a sense more real than stones, which are tangible." Similarly if we expect illnesses to be tangible in order to be real, then we may easily conclude that mental illnesses are not real, though they are real indeed to those who suffer from them.
Szasz rightly deserves to be criticized for his overreliance on the Carte sian outlook, his overly narrow conception of medicine, and most especially for his absolute opposition to involuntary commitment of mental patients. But I cite his work not just to discredit it, for he is among the most prominent contributors to medical and psychiatric ethics, discussing many issues with a nuance of understanding and a sensitivity that is uncommon. Rather I cite Szasz to demonstrate how, even with the kind of sensitivity he shows, it is possible to come to some very rigid conclusions that may actually make matters worse rather than better--and do so in the name of ethics.
Particularly to Szasz's credit and indispensable for our understanding of contemporary medicine's dilemmas is his analysis of hysteria, which he uses as a prototype of the myth of mental illness, but which we might use equally well as a basis for understanding medicine in personal rather than physical terms. He cites Freud's account of Charcot's pioneering work on hysteria:
Charcot explained that the theory of organic nervous diseases was for the present fairly complete, and he began to turn his attention almost exclusively to hysteria, thus suddenly focusing general attention to this subject. This most enigmatic of all nervous diseases--no workable point of view having yet been found from which physicians could regard it--had just at this time come very much into discredit.... First of all Charcot's work restored dignity to the subject; gradually the sneering attitude, which the hysteric could reckon on meeting when she told her story, was given up; she was no longer a malingerer, since Charcot had thrown the whole weight of his authority on the side of the reality and objectivity of the hysterical phenomenon.9
Thus by virtue of his authority, according to this account, Charcot re stored a modicum of human dignity to those who suffered from nonorganic illness. It remained for Freud himself, initially in collaboration with Breuer, to further dignify the illness by explaining how and why the hysteric suffered and by offering a method for treating the hysteric's symptoms. Breuer discov ered that the symptoms disappeared if the patient recalled under hypnosis the time when the symptoms first appeared. Freud later found that hypnosis was unnecessary and substituted the method of free association, by which analyst and patient working together could come to understand the origin and meaning of the symptoms and possibly find alternative ways of dealing with heretofore unconscious conflict.
Observing these historical "facts," a value judgment must be made. Was what Freud did good or was it bad? Szasz makes an interesting observation in this regard. He notes that,
Although Freud regarded hysteria as a disease, he clearly understood it far better than his language allowed him to express it. He was in a sort of semantic and epistemological straitjacket from which he freed himself only rarely and for brief periods. The following passage is an example of description in plain language, unencumbered by the need to impress the reader that the "patient" is truly ill and a genuine patient.10
Szasz then goes on to quote Freud's account:
Here, then, was the unhappy story of this proud girl with her longing for love. Unreconciled to her fate, embittered by the failure of all her little schemes for reestablishing the family's former glories, with those she loved dead or gone away or estranged, unready to take refuge in the love of some unknown man--she had lived for eighteen months in almost complete seclusion, with nothing to occupy her but the care of her mother and her own pains.11
Szasz is entirely correct that Freud relied heavily on scientific or mecha nistic paradigms in explaining his theories, perhaps in order to make them intelligible to the scientific community. He used those paradigms metaphori cally to explain the suffering of hysterical persons (usually women) who presented themselves to physicians (originally neurologists, then psychia trists) asking for help. Freud was thoroughly scientific insofar as he relied closely on his observations to draw his conclusions, but not in his reliance on mechanical terminology to explain emotional and moral phenomena. Use of such terms as "forces," "determinants," "impulses" and the like have left Freud open to the criticism that he was "reductionistic," though it should be acknowledged that he wisely decided not to publish "Project for a Scientific Psychology" (1895), where he speculates on the physiological determinants of behavior.12 Thus a critic such as Szasz might well go on to reinterpret the moral dimension of the suffering hysteric, but instead he himself remains locked in the same Cartesian straitjacket that he claimed was shackling Freud. Szasz, faced with the same moral dilemma that Freud faced and faced with the same "facts," arrives at a different value judgment; namely, that it is not the physician's place to help these people because they do not suffer from "real" illnesses.
It could be argued that it matters little whether mental illness is considered a myth or a reality as long as one is sensitive to the value dimensions involved in making such a choice and as long as the value judgments are acknowledged as such. Both Freud and Szasz are exquisitely sensitive to such issues. But there is one problem that cannot be overlooked in this analysis and that is the possibility of moral inversion when moral ideals are held as absolute moral imperatives. I believe Szasz falls prey to this problem in his conclusion that involuntary commitment should be absolutely prohibited on the grounds that there is no such thing as mental illness. Consider the following example:
A 23-year-old mother was transferred from the obstetrics service to the psychiatry ward because of disturbing fantasies that she might harm her baby by stuffing rags into its mouth. Three days later she was released against medical advice when she insisted she had to take care of her baby. Two days after that she returned to the Emergency Room saying that she could not tolerate her baby and was afraid she might hurt it. She refused admission but was committed.
A team of civil liberties lawyers opposed the commitment and opposed efforts of the Social Services agency to take legal custody of the baby. They argued that she had a "right" to care for her baby, and that attempts to separate her from the baby would only make her worse. After several months involving several court appearances, she was arrested for creating a public disturbance. In jail she hanged herself, not deprived of her civil rights, but deprived of the psychiatric help she so desperately needed.
The dilemmas posed by this patient are illustrative of the kinds of concerns that must be dealt with, but that an absolutist approach fails to adequately consider. We see a very real conflict between opposing moral principles with a beneficent treatment offered in the patient's best interest on one hand and the abstract principle of liberty on the other, even though that may not be in the patient's best interest. Any action in such a situation will be less than perfect because conflicting ideals are involved. Were the patient perfectly rational, there would be no problem, but she says at one minute that she wants to be in the hospital; the next minute she does not. Her psychopath ology does not allow her to integrate her impulses over time. It is the very ambiguity of the situation that the civil liberties lawyers (and Szasz), expecting matters to be clear and distinct in strict Cartesian fashion, cannot tolerate. To clarify such ambiguity and to defend against the dreadful anxiety of trying to empathize with the schizophrenic turmoil, the civil liberties lawyer abstracts certain facts from the complexity and tenaciously insists on nothing less than moral perfection, which is determined a priori with no reference to the needs of the individual patient.
This may be considered moral inversion because the moral thing to do would be to provide this confused woman with a stable environment where her impulses could be controlled and integrated over time; that is, to insure psychiatric care for her, or, to translate this concern into the language of rights, to insure her right to treatment. What the schizophrenic woman needs is not an adversarial proceeding designed to obtain an abstract clarity at her expense, but rather a cooperative exploration of how her needs can best be met with all interested parties attempting to formulate a plan that guarantees her right to the best treatment available without violating her civil rights. Such an approach, admittedly novel in our judicial system, would properly be called fiduciary insofar as it would rest on trust and cooperation, rather than control and competition, between parties with different methods and out looks but with similar goals, namely, the interests of the patient.
An exhaustive analysis of all the legal, medical, and moral aspects of the issue of involuntary commitment is beyond the scope of this inquiry. My purpose in raising the issue in this context is to relocate the issue that I believe cannot be ignored--the conception of the person. A view that focuses on "freedom" as an absolute or on civil liberties, however desirable, without also accounting for the attendant limitations, such as the limitation of the mental patient to think rationally, is inevitably incomplete.13 What it means to think rationally is something which, of course, must be interpreted epistemo logically, and that is where the debate should be located. In the chapter on informed consent it is possible to say more about how these judgments might responsibly be made.
The person suffering from nonorganic "ills" is not always identified as a psychiatric patient. Many people come to the doctor with poorly defined symptoms, experienced perhaps as pains in the body. In areas where it may be possible to obtain psychiatric consultation, these problems may be trans lated into psychiatric problems and a treatment approach developed that attempts to get at the etiology of the problem. But in many instances the problems may be treated symptomatically, perhaps with a placebo medica tion. The patient may benefit also from the placebo effect of the encounter with the physician, someone who listens to the patient, does not criticize or demean, and "seems to understand."
Into these therapeutic encounters enter matters of clinical judgment for the physician, value judgments that can and should be subject to ethical reflection. As with so many ethical issues, care must be taken in asking the proper questions and keeping a clear distinction between matters of value and interpretations of fact. On the specific matter of placebos, for example, do we raise the issue as a matter of "truth-telling" or do we inquire into the best method for caring for the hysterical patient in a medical system that reflects a culture tending to maintain rather sharp divisions between problems of the mind and problems of the body?
Sissela Bok analyzes placebos as an issue of truth-telling, actually as an example of lying. Her analysis is informative not only on the use of placebos, but also on the pitfalls of ethical analysis based on the Cartesian assumption of a mind-body split. Bok quite correctly realizes that lying exacts a toll, namely an erosion of trust, as much for the liar as for the victim of the deception. But in her fervor to denounce lying, she overlooks the importance of a careful search to understand the truth.
Applied ethics, then, has seemed uncongenial and lacking in theoretical chal lenge to many moral philosophers even apart from any belief in epistemological priority and from muddles about the meaning of "truth." As a result, practical moral choice comes to be given short shrift, and never more so than in the case of lies.14
Her point is an important one, and her assessment that many epistemolo gical discussions lead to "muddles" about what the truth is should serve as a warning to fellow philosophers not to ignore urgent practical problems in favor of theoretical issues. Nonetheless, the theoretical questions remain, and an understanding of what the truth is remains indispensable to any decision about when, if ever, it might be acceptable to lie. Bok's arguments about lying are essentially valid, but she has difficulty applying them to the practical situation of deciding whether to give placebos because she does not ade quately settle the antecedent questions. She recognizes that the prevailing outlook is inadequate but immediately falls prey to its seductive familiarity.
Bok is a victim of our culture. Without awareness of accounts of knowl edge alternative to the Cartesian demand for explicitness, she understandably misperceives an epistemological issue as an ethical problem, as we are all inclined to do. When asked how we like the new necktie Uncle Joe sent, for example, we often understand the request as requiring an (objective) assess ment about the tie, rather than an invitation to say something about ourselves, our (aesthetic) values, our tastes, and our judgments. We lie and say the tie is lovely (a white lie, to be sure; maybe trivial), when in fact once again we so easily substitute a statement of fact for the disclosure of a judgment of value.
Ethically, a question even more difficult than whether to lie is how to understand and communicate the truth: how to understand what Uncle Joe really wants to know and how to tell him our feelings, not only about the tie but about himself. For the physician the question is how to understand the patient's human as well as physical needs and how best to serve those needs. To decide when and how to tell a patient he has cancer, the oncologist must understand more than cancer; he must know the patient as well.
Locked in the grip of Cartesian dualism, it seems only natural to consider the placebo a lie. It does not cause a direct physiological intervention in the body. It does something to the mind instead. This is problematic if one conceives of medicine as a technology intended to intervene in the body's mechanisms rather than a service profession intended to help people.
Medicine's identity as a profession fringes on our understanding of personhood. Is a person something more than a mind in a machine? Do we perceive ourselves as having any psychosomatic integrity, or are our bodies alien to ourselves? William Poteat in a startling new work, Polanyian Medita tions, coins a new conjoined word, "mindbody," to remind us how habitual the Cartesian split has become in our way of thinking about ourselves.15 The language of (w)holism might be useful here as a way of getting beyond the mind-body dualism. Certainly treating the whole person is a legitimate aim of medicine. Yet the concept of "wholistic medicine," however noble its aims, is often used as a reaction to mechanistic medicine and produces a reductionis tic spiritualism or "psychism" that is every bit as one-sided as the poison to which it is supposed to be the antidote.
The problems Bok attempts to deal with as ethical questions recur as matters of genuine perplexity for physicians in clinical practice. Those pa tients for whom placebos may legitimately be a more ethical option than using dangerously addicting analgesics may be called "hysterics" or "placebo- responders," but they must be recognized as fellow human beings in need of help and cannot be dismissed as moral degenerates by the physician, the medical profession, or critics of the medical profession, no matter how frustrating, time-consuming, or expensive their care may be. The mind-body problem recurs as the basis of so many problems in medical ethics and the practice of medicine in part because hysterics refuse to think of themselves and refuse to experience their bodies in the ways demanded by Cartesian notions of rationality. One of the differences between practicing medicine and reflecting on the practice of medicine is that the physician must actually deal with (often irrational) fellow human beings and not just idealized approximations thereof. The doctor-patient relationship, therefore, continues to be an important focus for understanding ethical dilemmas that issue from medical practice.