著者

道又 利 黒澤 美枝

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.20, pp.109-122, 2002-11-10 (Released:2018-02-01)

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Evidence-Based Medicine (EBM)can be defined as a procedure to evaluate objectively the clinical efficacy of treatment from the viewpoint of a statistical appropriateness. It can also illustrate guidelines for diagnosis and treatment, make the most sophisticated up to date system of medical applications shared by medical professionals beyond individual and cultural difference, and finally, aim at standardization of medicine. As an ethical viewpoint, EBM may be able to provide more positive and essential informed consent by showing better evidence of the treatment to patients. EBM also meets social needs by allocating medical resources effectively, for it can supply, from the very beginning, the most effective treatment. Even in clinical cases, in which the etiology or pathology is unknown, or symptomatology is too complex or multidimensional, EBM can give an active guideline for the treatment to physicians, concentrating only on the efficacy of clinical application, temporarily neglecting the etiological factors. As the only principle to justify medical intervention is the risk/profit ratio, it is extremely important to evaluate usefulness of treatment objectively before introducing the treatment method. Concerning this point, EBM can provide the foundation for medical ethics. Especially in psychiatry, because of difficulty in identifying etiological factors, EBM has a very important role in ethical consideration. However, on the other hand, the popularization of EBM could possibly offer various problems. We must take note of the easy use of EBM as a manual-book, overconfidence or misunderstanding of its "objectivity", neglecting the notion of "Comprehension" (Jaspers K) and related psychopathology, and alteration of patient-physician relationships evoked by a preponderance of objective data.

著者

岡本 珠代

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.20, pp.80-94, 2002-11-10 (Released:2018-02-01)

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Something is called a placebo when it is used to cause a favorable effect on an unknowing patient, even though it is known to have no pharmacologically effective action. A favorable effect, if any, is called a placebo effect and is referred to in a non-medical context as well, where an act of comforting or pleasing with verbal or non-verbal expressions or gestures is found successful. This latter case may be quite innocuous and need no particular justification. Ethical problems arise when placebos are used either in a clinical setting or in medical experimentation. Clinically a placebo is given to a patient at the medical practitioner's discretion without informing him/her about its use. In 1955 Henry Beecher published a study on the placebo effect. He believed he could prove the existence of a placebo effect in the 30 to 40 percent of all patients. Two camps seem to have formed differing assessments of Beecher's thesis. One literally believes a placebo is effective as a result of the mysterious process of the human mind-body relationship, while the other camp wants to dismiss the whole thesis as groundless. For the latter, placebos are a form of deception or manipulation and should not be taken seriously or used at all. Physician-ethicist Howard Brody tries to make sense of the placebo effect philosophically. He shows that a reductionist approach cannot explain it, while giving credit to anti-positivist approaches that define a person in a culturally meaningful context. He states that a good medical practitioner can cause a placebo effect without using any placebos by engaging in simple good conversation. But as to the use of placebos in double-blind controlled studies, physicians, including Brody, are usually permissive and do not question the use of placebos or non-treatment for the research subjects, who are, at the same time, patients in need of medical care. The use of placebos or non-treatment for patient-subjects contradicts the idea and practice of informed consent. Only volunteers should take part in a medical experiment. What is puzzling is why things given to the control subjects are called placebos.

著者

伊東 隆雄

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.20, pp.30-42, 2002-11-10 (Released:2018-02-01)

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There have been many discussions, from various positions, about what kind of care is needed with regards to terminal care for the elderly with dementia. Although it is generally thought that extraordinary treatment and care are not necessary, in reality, there is a marked tendency for excessive treatment to be performed in our country, because most physicians have difficulty accepting natural death. This is due to many physicians' strong belief that the death of a patient means a defeat for medical treatment. The elderly with dementia will not die by the disease directly, but from a complication such as pneumonia. Therefore, keeping the patient from such a complication extends a patient's life for a longer period of time. The situation of the elderly with dementia is reminiscent of the Struldbruggs in "Gulliver's Travels". In this story, these immortals must live eternally and cannot die even though they age with dementia. Furthermore, endless life-prolonging is not the purpose of terminal care. Certainly, the intellectual faculties of the elderly with dementia weaken, but, they continue to be able to maintain their emotional faculties when interacting with others. Such coexistence and feelings of emotion are basic of care and are not invasive conduct. If the medical care provider accepts the patient's death and is sympathetic to them, it is thought that appropreate medical treatment and care should be carried out naturally.

著者

宮坂 道夫

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.20, pp.67-79, 2002-11-10 (Released:2018-02-01)

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In this paper, I will inquire about justice theories with regard to the public policy of assisted reproduction (AR). In the first part, I will criticize the classic four-principle-based frameworks of American bioethics. Firstly, it is not all-embracing, because it rejects any "communitarian" argument dependent on substantial common values such as human dignity. Secondly, it is not neutral, because practical advantage is given to liberal argument that permits any kind of AR. These liberal points of view are further analyzed as follows. (1) They impose empirical demonstrations on the autonomy-based negation of AR, (2) They permit the harm/benefit-based argument dependent on medical habits which are basically affirmative for AR, (3) They have traditionally concentrated on distributiv e justice, that is, nothing is discussed about newly developed AR, until it becomes a social resource. I will then introduce categorical and methodological expansions of justice theory as follows: (1) When we establish another category, which I call 'resourcification justice', in justice theory by questioning 'on what basis the health care service is justifiable', it will allow us to identify the nature of the conflict over AR. (2) When we adopt the two Rawlsian principles of justice only formally, rejecting any material premise, they require us to identify justly who is the worst off in the context of AR. Furthermore, the only guiding principle of fairness requires us to adopt a methodological justice, which I call 'narrativejustice', in that identification. This does not allow us to take ourselves only in the public context of policy makers and the worst off. It requires us to take ourselves at the same time in the private context of the narrator and the narratee.

著者

井上 芳郎

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.218-222, 2001-10-20 (Released:2018-02-01)

著者

服部 健司

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.151-165, 2001-10-20 (Released:2018-02-01)

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Placing the family in the center of ethical judgements, John Hardwig has proposed a duty to die. In this paper his theory is critically examined. When we were a burden on our loved family memters, we have such a duty. We should die responsibly. If we were coward and ego-centric to prolong our life, we should be accused as immoral. In an anonymous society, egoism might be plausible. However, in a loving family it is to be abandoned. It affirms our sense of who we are and endows our death with dignity to die for the sake of our loved ones' future. We would see most critics opposed to Hardwig as insufficient or out of point. Their alternative propositions are scarce of reality. Some insist the East Asian principle of autonomy is based on family-determination. Some believe the concept and practice of informed consent must, when imported, be modified so as to fit in with the Japanese family-centered biomedical ethics. When considering a duty to die, it appears we should examine more deeply what family is, what love is, and what is the architectural matter of the Japanese biomedical ethics?

著者

伊藤 幸郎

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.213-217, 2001-10-20 (Released:2018-02-01)

著者

重野 豊隆

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.179-191, 2001-10-20 (Released:2018-02-01)

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Michael Tooley has argued that the only beings, who have a right to life, are those who can conceive of themselves as distinct entities existing over time, in other words, "person". Tristram Engelhardt distinguishes "a person in the social sense" from "a person in the strict sense" as moral agent. He assigns "a social sense of person" to certain severely damaged humans, who cannot interact in even minimal social roles. What is "a social role" with regard to a terminal-stage patient? A patient in a persistent vegetative state and a brain-dead patient are not treated as "a person in the social sense" by T. Engelhardt. I discuss terminal-stage patients from the viewpoint of their families' experiences. This viewpoint may considers the patient's body, in a sense, as the expression of the patient's intention. Such a comprehension of the patient's body should be taken into account by medical staff.

著者

ライター ヨハネス 盛永 審一郎

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.201-212, 2001-10-20 (Released:2018-02-01)

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Vor dem Hintergrund der medizinethischen Diskussion in Deutschland und den USA geht es in diesem Beitrag um eine Klarung des Begriffs Medizinethik sowie um die insbesondere in Deutschland derzeit aktuell debattierten Problembereiche Praimplantationsdiagnostik und Ziichtung und Verwendung menschlicher Stammzellen.

著者

服部 健司

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.223-230, 2001-10-20 (Released:2018-02-01)

著者

今井 道夫

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.231-233, 2001-10-20 (Released:2018-02-01)

著者

池谷 健

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.126-135, 2001-10-20 (Released:2018-02-01)

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Compared with the first Kochi case in March 1999, information about two other cases, the second case in Tokyo in May and the third case in Miyagi in July, decreased drastically. This restriction may be due to the infringement on privacy in the first case. It is important to discuss at the time of the transplants, whether their brain death was unavoidable, or was there some way to save the patient. It is indispensable not only to promote organ transplantation from brain dead persons, but also to advance emergency treatment procedures for the people who first administer treatment. In these 3 cases, as for the persons in charge of emergency treatment of the donors, ant the persons who diagnosed the preceding clinical and legal brain deaths of the donors, we have no information except for the first case. As for the details of the donorcard, it was reported only in the second case. The background diseases were explained immediately only in the third case which was a traffic accident. The family's comments about the organ-donation and each transplant result, weren't reported except in the second case, one year later. Perhaps the coordinators of the Japan Organ Transplant Network (JOTNW) could not establish good relations with the families. The mass media, JOTNW, and the MHW (Ministry of Health and Welfare) must put these problems in order, disclose them, and entrust the result to the good sense of the national public. Without accurate information, the donor families cannot freely talk about their thoughts to the public. Now the MHW has enforced a new committee in a perfectly locked room to verify organ transplantation, as if the leakage of the information were the problem. As a result, the right of the people to know, to discuss, and to decide is deprived, and donor's families cannot express their thinking about the process of organ transplantation.

著者

阿保 順子

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.42-56, 2001-10-20 (Released:2018-02-01)

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The life that people with schizophrenia experience in the acute stage is so different from ordinary people that the reality of their lives is beyond our imagination. The author presented a paper on the psychiatric nursing framework for understanding people with schizophrenia in 1995. The framework consists of two concepts. The first is the concept relative to mental-structure, the other is the process of illness. The aim of this paper is to re-construct mental-structure from the viewpoint of 'self and 'ego'. First, the construction of initial mental-structure will be described. Then similar concepts around 'self and 'ego1 are discussed. Second, the issues of 'self and 'ego' that have been described in the area of philosophy or psychology are discussed. Next 'self and 'ego' are discussed from the viewpoint of psychiatric nursing. Finally, mental-structure is re-constructed as follows; (1) 'ego' is located in the center of 'self. (2) 'self is a functional vessel that has many points of mutual effects connected with external circumstances as well as those dependent on the human body.

著者

宮脇 美保子

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.72-82, 2001-10-20 (Released:2018-02-01)

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Until recently, the western scientific methods have been viewed as the major and only valid and reliable ways to approach knowledge and understand people. Western science has developed a worldview which is in sharp contrast to that of the Far East. From the second half of the 17th to the end of the 19th century, the mechanistic Newtonian model of the universe dominated all scientific thought. Nature was viewed as not a mere machine, but in fact a very large machine. Such mechanistic philosophy was embodied in industrial society. However, the first three decades of the 20th century radically changed the whole situation in physics. At that time, Western science finally started to look to the eastern philosophies. In contrast to the mechanistic Western view, the eastern view of the world is organic. Incidentally, nursing science is a new intellectual activity. Established as recently as 50 years ago, it has occupied only a short span of time in the history of science. In the mid-1800s, Florence Nightingale called for nurses to develop an in-depth understanding of man and nature as interacting wholes. After one hundred years, Martha Rogers emerged as one of the most original thinkers in nursing. According to her "human beings are not disembodied entities, nor are they mechanical aggregates... human being is a unified whole possessing his/her own integrity and manifesting characteristics more than and different from the sum of its parts". Her model has had a significant influence on current scientific inquiry and professional nursing practice, including serving as a basis for the explication of other nursing theorists, including those of Newman, Parse, and Watson. Thus in the last part of the 20th century, the new world view has become more evident in nursing science.

著者

石井 誠士

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.83-98, 2001-10-20 (Released:2018-02-01)

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Die europaische Medizin 1st seit der Mitte des 19. Jahrhunderts eine sich auf die mechanistische Anschauung stiitzende angewandte Naturwissenschaft geworden. So gross wie die Errungenschaften der modernen fortgeschrittenen Medizin sind doch dabei auch ihre Defizite! Viktor von Weizsacker schrieb 1926: "Es ist eine erstaunliche, aber nicht zu leugnende Tatsache, dass die gegenwartige Medizin eine eigene Lehre vom kranken Menschen nicht besitzt." Sicher lehrt heute die Medizin Erscheinungen des Krankseins, Unterscheidung von Ursachen,Folgen,Heilmitteln der Krankeheiten, aber nicht den kranken Menschen. Das grosse Defizit der modernen Medizin ist also "Abwesenheit des kranken Menschen". Wie der letzte Mensch in "Die frohliche Wissenschaft" von Nietzsche den "Gottestod" kundgab, so verkiindete Weizsacker im 20. Jahrhundert den "Krankentod". "Abwesenheit des kranken Menschen" bedeutet.dass wir nicht kranken kbnnen, dass wir das Kranksein nicht erfahren konnen. Die Krankheit ist nicht als Abnormalitat, nicht als blosse Abweichungen von einer statistisch zu erfassenden Norm, sondern als ein Geschehnis des Menschen auf dem Weg zu seinem Ziel, d. i. "eine Abhaltung von der menschlichen Bestimmungin Wachstum, Wandel, Reifen, Altern, Tod" anzusehen. Und"das wirkliche Wesen des Krankseins ist eine Not und aussert sich als eine Bitte um Hilfe" Die Not ist fur Lebende unausweichlich, denn jedes Lebende ist ein Objekt, dem ein Subjekt schon innewohnt. Es ist die Existenz, an der ihr das In-Not-Sein immer fur sich selbst fraglich wird. Ein Hautptweg, sich der Bestimmung des Menschen in seiner Not zu nahern, ist fur Weizsacker die Krankengeschichte, die Erfahrung in der Krankheit und in ihrer Geschichte. Geschichte ist "ein Zusammenhang, in dem ein Zustand aus dem, welcher ihm vorherging, nicht kausal abgeleitet werden kann". Das Kranken eines Menschen bedeutet dann nichts anderes als ein Vollzug der Selbsterschliessens der Wahrheit des Lebens. Die Biographik zielt darauf bin, die eigentliche Krankengeschichte in der Lebensgeschichte zu entdecken und umgekehrt die eigentliche Lebensgeschichte durch die Krankengeschichte hindurch sprechen zu lassen. Diese Geschichte wird nur in der "erfahrenden Einsicht in die geistbestimmte Wirklichkeit des Menschen" erfahren. Zu dieser eigentlichen Erfahrung kann "die Weggenossenschaft von Arzt und Kranken" fiihren. Die Begegnung und das Gesprach von beiden schliesst die "intensivste.ausserste, wahrste und wirklichste Wirklichkeit fur das Leben dieses Menschen oder den Tod dieses Menschen" auf. Weizsacker erblickt das Wesen dieser Weggenossenschaft eben in der Beriihrung in der Erfahrung, die "die via regia zur wirklichen Welt" ausmacht. Die Aufgabe der Medizin liegt dann darin, "dass, was im kranken Menschen geschieht, im Arzt geistig wiederholt und so seiner letzten Bestimmung zugefiihrt wird".

著者

石崎 智子

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.115-125, 2001-10-20 (Released:2018-02-01)

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Since the middle of the 20th century, the medical work site has been presenting a. rapid change brought about by rapid progress of the medical technology on the basis of modernization of western medical science or biological science. The development of such medical science has put the present medical care in the change of tide. This medical situation has forced us to ask ourselves what identity of nursing. I have thought as follows. Conventionally, those who have been engaged in nursing tended to think it being in "the place of nursing" to attend at a clinical work site. The behavior for nursing care of such "work site" has been unconsciously done as premise. However,is the true "place" of nursing there? Is the identity of nursing secured only by it being in such "work site of nursing"? A main subject is the trial which is going to reconstruct the identity of nursing by reflecting upon "the place of nursing". Because, I want to offer the true nursing care which has being a patient and has respected his after being. The practice of nursing is created through human relations between those engaged in nursing and patient. Although, this place is not produced from the manualized work site of nursing. One over, this place is constructed from the both-direction - this vivid relation -, between a person engaged in nursing and patient. It could be caught as "a place of the relation as the present existence" which has just lived. In order to recatch of the conception of the identity of nursing, it must be concerned with this "place of the relation as existence" in consciousness with "the intelletual practice of nursing". It is important that the identity of nursing is based on this "place" of nursing.

著者

中澤 務

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.31-41, 2001-10-20 (Released:2018-02-01)

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This article investigates a new ethical basis for prohibiting human cloning from the point of view of a child's rights, and examines the limitations of human cloning in special cases. My approach appeals to two new points. (1) We must distinguish between two intentions of human cloning. One is the intention to duplicate the same genotype as the donor for the purpose of duplicating the same phenotype of that person (the intention of duplication). The other intention is to make a baby who is related to the parent by blood, in which case human cloning is not a means to the genetic duplication (the intention of non-duplication). (2) A child has a special right, "the right to an open future" (J. Feinberg), which is the collection of autonomy rights that are in trust until the child grows up. We should prohibit human cloning done with the intention of duplication, because in this case cloning will violate the cloned child's right to an open future. However,it seems there is no clear ethical ground for prohibiting human cloning when it meets the following conditions, (1) when it is done for the purpose other than duplication (the intention of non-duplication), (2) when it is in accordance with the normal reproductive rights, (3) when there is enough reason to choose cloning. Human cloning for infertility treatment seems to meet these conditions. Regarding human cloning, we must reexamine the total ethical framework of reproductive medicine.

著者

佐藤 拓司

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.136-150, 2001-10-20 (Released:2018-02-01)

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How should we treat intersexual individuals? It has been standard pediatric practice to recommend surgery for infants with ambiguous genitalia or loss of panis. In females, any large clitoris is to be reduced or removed. In males with less than an adequate penis, the preferred surgical approach is sex reassignment. This management philosophy is based on 2 beliefs: (1) individuals are psychosexually neutral at birth and (2) healthy psychosexual development is dependent on the appearence of the genitals. This philosophy was strongly supported by the classical and well-known "John/Joan" case. But reports of the success of John/Joan were premature and wrong. Diamond and Sigmundson recently reported that John failed to identify as a female, and she had in fact chosen to resume life as John. They conclude that the evidence seems overwhelming that humans are not psychosexually neutral. If they are correct, we need a new philosophy for dealing with intersexual individuals. I propose that we have to realise that there are several limitations in our capacity to clinically manage intersexuality. At first.it appears impossible to draw any distinct, line between males and females. And we are unable to predict with confidence the gender that an intersexed newborn will settle into during adulthood. And finally, it is unlikely that surgical reassignment will ever truly "normalize" an individual. In accordance with these limitations, we have to be more careful when undergoing gender reassignment for infants with traumatized genitalia.

著者

永田 まなみ

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.19, pp.57-71, 2001-10-20 (Released:2018-02-01)

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In the 21^<st> century, as we face an unprecedented increase in the number of elderly people and a high-welfare society, care and nursing will become more important. In this article, I review the coming role of nursing specialists from the viewpoint of patient autonomy. Firstly, I propose that the trend of mutual support, while maintaining individual autonomy, will continue to spread. Thus, it is essential to respect others' lives as well as one's own for a "comfortable relationship". This is the core meaning of the concept of "Caring". "Caring", the basis of nursing, also includes interrelationship and interdependence. This should make nurses reflect on their own lives often cared for by patiants while caring for them. Secondly, while reviewing the development of nursing theory, I stress the support of patient autonomy. In clinical nursing, respect for patient autonomy in their daily lives is the most important factor in patient "comfort", although more attention is normally paid to radical problems involving life or death such as terminal care. Lastly, I mention the possibility of integrating the "ethics of justice" and the "ethics of care". When nurses deal with "patient autonomy" as professionals, the problem of "bad paternalism" (or intrusive nursing) can arise. In considering how clinical nursing ought to be, the "ethics of care" and the "ethics of justice" must be integrated. This idea may be more suitable for the age of care. "Practical knowledge" in nursing may contribute to the theoretical integration of the "ethics of justice" and the "ethics of care".

著者

松島 哲久

出版者

日本医学哲学・倫理学会

雑誌

医学哲学 医学倫理 (ISSN:02896427)

巻号頁・発行日

vol.18, pp.182-188, 2000-12-15 (Released:2018-02-01)

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In this paper, I first argue from the viewpoint of philosophy that the patient's body cannot be sufficiently comprehended by the logic of the biological mechanism. In order to make this point clear, I criticize the philosophical stand of the biological mechanism. Firstly, the position of the biological mechanism views a patient's body as an object of the world, so it cannot comprehend the reality lived by the body of patient. The patient's body, the biological mechanism reveals, is an anonymous body, not the proper living body of the patient. The biological mechanism lacks the perspective of individuality. Secondly, the understanding of disease of the biological mechanism is that of being-already-objectified, so it always remains in the past aspect of time. It lacks historicity and timeness and thus ignores the life history of the patient. Following the critical argument of the biological mechanism in modern medicine I propose a new comprehension of illness. It considers the patient's body as the milieu of the auto-expression of the patient's existential suffering. The comprehension of the patient's body should be that from the viewpoint of the unity of mind and body. Moreover, taking into consideration the relationship between medical staff and the patient, the patient's body should be understood as the body-aspair (interbodility). The patient's body reflects the body of medical staff, and reciprocally the latter reflects the former. They both form the intersubjectivity and then make themselves open into the world. So we should also understand the patient's body in the socio-cultural context. Thirdly, I propose the understanding of the body as sign/metaphor. It represents the semantics of illness. I insist upon the necessity of the hermeneutics of illness to understand the meaning the patient's body auto-expresses. The metaphor of the body bears both the meaning of discrimination and the religious-symbolic meaning. So the medical staff should transcend the discriminative meaning of the patient's body to its sacred meaning. Lastly, I argue the importance of the stand of ethics. The medical staff should constantly come face to face with the patient. We need to realize the patient's rights in accordance with the patient's actual body.