Unsung questions of medical ethics.

Official doctrines of medical ethics have become increasingly 'patient-centered': physicians are exhorted to respect patients' autonomy and to encourage patient participation in decision making; physicians in general medicine and primary care, especially, are urged to develop psychosocial competence, cross-cultural sensitivity and communications skills. These official values are undermined and contradicted, however, by the routines and assumptions that physicians use to organize their everyday work. These routines are taken so for granted as natural and required for the smooth, orderly practice of medicine that they escape evaluation for the implicit values they contain. Yet, they reinforce a particular view of appropriate roles and responsibilities for both physician and patient in the medical system, including the agenda and purpose of the medical interview; the level and amount of information to share with patients; and the power structure of the physician-patient relationship. These values, hidden in the routines of daily practice, are unsung questions of medical ethics. A fallacy in calls for greater patient participation in medical care is that this participation can flourish by simple addition, without reform of the ordinary structures of everyday practice. It is unlikely that these structures will change unless their normally invisible value commitments are drawn out of the obscurity of routine, and made subjects for public scrutiny and choice.