interests without the patient's knowledge or consent. To treat without consulting a patient is to assume that a patient does or should share one's own assessment of the risks, benefits, and burdens of treatment. But current hospital specialists, it is said, rarely know their patients(or themselves) well enough to make this assumption without serious risk of ignorant arrogance. Given hospital hierarchies, such paternalistic physicians are seen to resemble Victorian patriarchs Some physicians reject such criticism as intervention by lawyers, philosophers, feminists, and other social critics ignorant of the realities of medical and hospital life. But the"neo-paternalists admit that physicians should attend more carefully to a patient's desires and to give them greater weight in arriving at a treatment of choice. Unmollified critics, however, continue to insist that dent, and not to the physician, however attentive and knowing to curb Hippocratic paternalism they define a range of patients' specifie rights to be told about, and choose among, alternative treatments, including a right to refuse all even life-saving treatment These rights confer adult status on patients whom paternalists regard as children, replacing quasi-familial with quasi-legal relations. A patient's "free and informed consent"reflects an implicit therapeutic contract, defined and reviewed as treatment proceeds. a physician who treats without such consent is not a patriarch, but a batterer. Less litigously, these rights define a principle of autonomy"traced to Kantian notions of respect for persons and inherent human dignity. Attempts to apply this principle have raised questions of scope: Is a patient's"free and informed consent"needed for routine procedures with slight or rare risks? Is consent required if a patient would, in the physicians judgment, be"medically harmed"by information about diagnosis and prognosis? Are refusals to be honored even if patients risk death, as do surgical patients religiously opposed to blood transfusion? Does the principle(contra Kant) cover voluntary euthanasia? Can children or mentally ill patients give informed consent at least for some procedures? Can parents or refuse"substituted"consent when a patient is too ill to consider the tions or to speak Whatever the scope of a principle of patient autonomy, this challenge to paternalism has shifted the categories of concern. Physicians power, not their character, has become the issue Consequently, "Who is to decide? has become more pressing than"What is to be done? " Proper rocedure has become as important, in medical ethics, as correct conclusions Physicians and Institutions These shifts reflect changes in medical practice from home and office to hospital and clinic Physicians have become members of teams treating patients in institutions governed by internal routines and external guidelines from government, insurers, and corporate owners(and secondarily, religious authorities in some instances). Increasingly decisions are delegated to bioethics committees"which include nurses, lawyers, social workers, chaplains, philosophers, citizen representatives, patient advocates, and other non-physicians. Even if physicians dominate2 interests without the patient's knowledge or consent. To treat without consulting a patient is to assume that a patient does or should share one's own assessment of the risks, benefits, and burdens of treatment. But current hospital specialists, it is said, rarely know their patients (or themselves) well enough to make this assumption without serious risk of ignorant arrogance. Given hospital hierarchies, such paternalistic physicians are seen to resemble Victorian patriarchs. Some physicians reject such criticism as intervention by lawyers, philosophers, feminists, and other social critics ignorant of the realities of medical and hospital life. But the "neo-paternalists" admit that physicians should attend more carefully to a patient's desires and to give them greater weight in arriving at a treatment of choice. Unmollified critics, however, continue to insist that treatment choice belongs to the patient, however imprudent, and not to the physician, however attentive and knowing. to curb Hippocratic paternalism they define a range of patients' specific rights to be told about, and choose among, alternative treatments, including a right to refuse all, even life-saving treatment. These rights confer adult status on patients whom paternalists regard as children, replacing quasi-familial with quasi-legal relations. A patient's "free and informed consent" reflects an implicit therapeutic contract, defined and reviewed as treatment proceeds. A physician who treats without such consent is not a patriarch, but a batterer. Less litigously, these rights define a "principle of autonomy" traced to Kantian notions of respect for persons and inherent human dignity. Attempts to apply this principle have raised questions of scope: Is a patient's "free and informed consent" needed for routine procedures with slight or rare risks? Is consent required if a patient would, in the physician's judgment, be "medically harmed" by information about diagnosis and prognosis? Are refusals to be honored even if patients risk death, as do surgical patients religiously opposed to blood transfusion? Does the principle (contra Kant) cover voluntary euthanasia? Can children or mentally ill patients give informed consent at least for some procedures? Can parents or other surrogates give or refuse "substituted" consent when a patient is too ill to consider the options or to speak. Whatever the scope of a principle of patient autonomy, this challenge to paternalism has shifted the categories of concern. Physicians' power, not their character, has become the issue. Consequently, "Who is to decide?" has become more pressing than "What is to be done?" Proper procedure has become as important, in medical ethics, as correct conclusions. Physicians and Institutions These shifts reflect changes in medical practice from home and office to hospital and clinic. Physicians have become members of teams treating patients in institutions governed by internal routines and external guidelines from government, insurers, and corporate owners (and, secondarily, religious authorities in some instances). Increasingly decisions are delegated to "bioethics committees" which include nurses, lawyers, social workers, chaplains, philosophers, citizen representatives, patient advocates, and other non-physicians. Even if physicians dominate