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Chapter 1: Introduction 1

1.1.Background 1

1.2.Identifying the doctor and the patient in health service delivery 5

1.3.When does a doctor-patient relationship come into being? 9

1.4.Aim and methodology 13

1.5.Research question and underlying assumptions 16

1.6.Outline of study 17

1.6.1.Chapter 2 17

1.6.2.Chapter 3 17

1.6.3.Chapter 4 18

1.6.4.Chapter 5 19

1.6.5.Chapter 6 19

1.6.6.Chapter 7 20

1.6.7.Chapter 8 20

PART A 22

Chapter 2: The historical development of the doctor-patient relationship and the culture of medical care 22

2.1.The historical development of the doctor-patient relationship 23

2.1.1.Primitive society 25

2.1.2.The Greek medical tradition （± 600- 100 B.C.） 27

2.1.3.Classical, medieval and early modern societies （1200-1600A.D.） 29

2.1.4.Modern western societies （1700-1900A.D.） 31

2.1.5.Postmodern societies 32

2.2.The culture of medical care 34

2.2.1.Professionalism and the regulation of the medical profession 34

2.2.2.Social roles and the doctor-patient relationship 41

2.2.2.1.The physi?an’s role 42

2.2.2.2.The sick role 44

2.2.3.Professionalism, authority and the doctor-patient relationship 45

2.2.4.Power and the doctor-patient relationship 52

2.3.Conclusion 56

Chapter 3: Medical decision-making and the doctor-patient relationship in a paternalistic setting 58

3.1.Defining medical paternalism 59

3.2.Medical decision-making in a paternalistic medical setting 65

3.3.Autonomy, dignity, self-determination and beneficence in medical decision-making 71

3.4.Ajuridical response to traditional paternalism in medical decision-making 79

3.4.1.Informed consent 81

3.4.1.1.The origin of informed consent 82

3.4.1.2.The development of the doctrine of informed consent 88

3.4.1.3.The current status of the doctrine of informed consent 94

3.5.An evaluation of medical decision-making and the doctor-patient relationship 103

3.5.1.Standards of disclosure 105

3.5.2.Historical attributes 111

3.5.3.Practical considerations 112

3.5.4.The efficiency of the doctrine of informed consent 115

3.5.5.Recommendations 117

3.6.Conclusion 122

PART B 125

Chapter 4:The doctor-patient relationship in the medical marketplace 125

4.1.Definingthe business model in medical practice 126

4.2.The relevanoe of the business model to medical practice and the doctor-patient relationship 132

4.3.The business model and the power imbalances in the doctor-patient relationship 139

4.3.1.Informed consent 139

4.3.2.Patients’ rights, patient autonomy and the defiance of benefioence 146

4.3.3.The erosion of trust in the doctor-patient relationship 150

4.4.Conclusion 155

Chapter5: The fiduciary nature of the doctor-patient relationship 158

5.1.The doctor-patient relationship as a fiduciary relationship 159

5.2.The legal content of the fiduciary relationship between doctor and patient 167

5.3.The doctor as a fiduciary in the doctor-patient relationship 171

5.3.1.The duty of loyalty 172

5.3.2.The duty to act in the patient’s best interest 175

5.4.The patient as a beneficiary in the doctor-patient relationship 178

5.4.1.Right ore ntitlement to a benefit enforceable against the fiduciary 178

5.5.An evaluation of the doctor-patient relationship as a fiduciary lationship 182

5.6.Conclusion 188

PART C 191

Chapter 6: The doctor-patient relationship in an era of managed care 191

6.1.The history and development of managed care in health service delivery 193

6.2.The influence of managed care practices on the doctor-patient relationship 201

6.2.1.Access to health care 204

6.2.2.The new role of the physician in the doctor-patient relationship 210

6.2.3.Trust in the doctor-patient relationship and trust in managed care institutions 212

6.2.4.Informed consent in an era of managed care 217

6.2.5.Patient advocacy in an era of managed care 222

6.3.Conclusion 224

Chapter 7: Consumerism and the doctor-patient relationship 227

7.1.Consumer choice, patient autonomy and the ethical limits of consumer responsibility 231

7.2.Consumer protection in the doctor-patient relationship 235

7.3.Consumer empowerment and the doctor-patient relationship 240

7.4.Conclusion 242

Chapter 8: A proposed re-conceptualisation of the doctor-patient relationship to redress power imbalances 245

8.1.Are there power imbalances in the doctor-patient relationship? 246

8.2.Can the doctor-patient relationship be re-conceptualised, from a legal perspective, to redress the power imbalances inherent in the relationship? 250

8.2.1.The role of autonomy, dignity, self-determination and benefioence in the doctor-patient relationship 250

8.2.2.The doctrine of informed consent and the power imbalances in the doctor-patient relationship 252

8.2.3.The fiduciary nature of the doctor-patient relationship and the power imbalances inherent in the relationship 253

8.2.4.The role of trust in the doctor-patient relationship 255

8.3.Concluding remarks 258

Table of cases 260

Bibliography 264

Index 280