lenged these standards, claiming that even when a medical procedure is skillfully performed, physicians may nevertheless be liable for adverse consequences about which the patient was not adequately informed. The decisions in these cases combined features of negligence and battery theories into a new approach to informed consent in the medical setting that attempted a fairer balance between patients' rights to self-determination and the demands and complexities of both the physician-patient relationship and the legal setting (Faden and Beauchamp, 1986). Partly as a result of these decisions, the traditional model of medical practice, characterized by paternalism and authoritarianism, eventually gave way to a new model of informed consent, where the competent patient's decision-making authority became primary.

Ironically, the triumph of patient autonomy raised a new set of ethical quandaries. Many clinicians fear that strict observance of patient autonomy may override good medical judgment, encourage moral detachment on the part of the physician, and even work against the patient's best interests (Brock, 1991; Pellegrino, 1993). Patient autonomy also raises questions about increased public costs for expensive but not necessarily beneficial technologies, as well as about prolonging the quantity of life at the expense of quality of life. Empirical research in this area would enhance our understanding of the attendant ethical quandaries.

In addition to the changes in patient care engendered by a new emphasis on patient autonomy, the continuing technological revolution in medical diagnosis and treatment has further altered the delivery of health care and the relationship between patient and provider. Where the physician had once been viewed as omniscient, new medical technologies demythologized the individual physician's role. People began to view physicians less as personal therapeutic forces than as accomplished wielders of technology.

Coincident with the growth of new medical technologies has been an increase in specialization in the health establishment and the proliferation of health care delivery "teams" to administer specialized care. It is not always the physician who leads the team or has the initial or greatest contact with the patient or client. For example, health maintenance organizations (HMOs) might assign a nurse practitioner or physician assistant as a primary care provider or gatekeeper to specialized care, instead of a family physician. A cardiac surgeon may lead both the preoperative and operative teams, while a cardiologist and a cardiac nurse intensivist might lead the postoperative aspects of care. All of these caregivers share in the responsibilities for care of a patient, but each may be distant from total accountability for the patient's welfare.

This arrangement has contributed to a sense of isolation on the part of the patient. Sometimes, it seems that no one is in charge; that no one is



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