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Chapter 1: Introduction1

1.1.Background1

1.2.Identifying the doctor and the patient in health service delivery5

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

1.4.Aim and methodology13

1.5.Research question and underlying assumptions16

1.6.Outline of study17

1.6.1.Chapter 217

1.6.2.Chapter 317

1.6.3.Chapter 418

1.6.4.Chapter 519

1.6.5.Chapter 619

1.6.6.Chapter 720

1.6.7.Chapter 820

PART A22

Chapter 2: The historical development of the doctor-patient relationship and the culture of medical care22

2.1.The historical development of the doctor-patient relationship23

2.1.1.Primitive society25

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 societies32

2.2.The culture of medical care34

2.2.1.Professionalism and the regulation of the medical profession34

2.2.2.Social roles and the doctor-patient relationship41

2.2.2.1.The physi?an’s role42

2.2.2.2.The sick role44

2.2.3.Professionalism, authority and the doctor-patient relationship45

2.2.4.Power and the doctor-patient relationship52

2.3.Conclusion56

Chapter 3: Medical decision-making and the doctor-patient relationship in a paternalistic setting58

3.1.Defining medical paternalism59

3.2.Medical decision-making in a paternalistic medical setting65

3.3.Autonomy, dignity, self-determination and beneficence in medical decision-making71

3.4.Ajuridical response to traditional paternalism in medical decision-making79

3.4.1.Informed consent81

3.4.1.1.The origin of informed consent82

3.4.1.2.The development of the doctrine of informed consent88

3.4.1.3.The current status of the doctrine of informed consent94

3.5.An evaluation of medical decision-making and the doctor-patient relationship103

3.5.1.Standards of disclosure105

3.5.2.Historical attributes111

3.5.3.Practical considerations112

3.5.4.The efficiency of the doctrine of informed consent115

3.5.5.Recommendations117

3.6.Conclusion122

PART B125

Chapter 4:The doctor-patient relationship in the medical marketplace125

4.1.Definingthe business model in medical practice126

4.2.The relevanoe of the business model to medical practice and the doctor-patient relationship132

4.3.The business model and the power imbalances in the doctor-patient relationship139

4.3.1.Informed consent139

4.3.2.Patients’ rights, patient autonomy and the defiance of benefioence146

4.3.3.The erosion of trust in the doctor-patient relationship150

4.4.Conclusion155

Chapter5: The fiduciary nature of the doctor-patient relationship158

5.1.The doctor-patient relationship as a fiduciary relationship159

5.2.The legal content of the fiduciary relationship between doctor and patient167

5.3.The doctor as a fiduciary in the doctor-patient relationship171

5.3.1.The duty of loyalty172

5.3.2.The duty to act in the patient’s best interest175

5.4.The patient as a beneficiary in the doctor-patient relationship178

5.4.1.Right ore ntitlement to a benefit enforceable against the fiduciary178

5.5.An evaluation of the doctor-patient relationship as a fiduciary lationship182

5.6.Conclusion188

PART C191

Chapter 6: The doctor-patient relationship in an era of managed care191

6.1.The history and development of managed care in health service delivery193

6.2.The influence of managed care practices on the doctor-patient relationship201

6.2.1.Access to health care204

6.2.2.The new role of the physician in the doctor-patient relationship210

6.2.3.Trust in the doctor-patient relationship and trust in managed care institutions212

6.2.4.Informed consent in an era of managed care217

6.2.5.Patient advocacy in an era of managed care222

6.3.Conclusion224

Chapter 7: Consumerism and the doctor-patient relationship227

7.1.Consumer choice, patient autonomy and the ethical limits of consumer responsibility231

7.2.Consumer protection in the doctor-patient relationship235

7.3.Consumer empowerment and the doctor-patient relationship240

7.4.Conclusion242

Chapter 8: A proposed re-conceptualisation of the doctor-patient relationship to redress power imbalances245

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 relationship250

8.2.2.The doctrine of informed consent and the power imbalances in the doctor-patient relationship252

8.2.3.The fiduciary nature of the doctor-patient relationship and the power imbalances inherent in the relationship253

8.2.4.The role of trust in the doctor-patient relationship255

8.3.Concluding remarks258

Table of cases260

Bibliography264

Index280