Jonathan Banda Clinical Ethics Practicum August 16, 2013 Playing Doctor: Advanced Patient Autonomy and Self-Diagnostics

Seth makes an immediate appointment with his primary care physician, Dr. Anderson. He has an urgent matter to discuss. After waiting 30 minutes to see his doctor, Seth is ushered into the exam room. As the nurse takes his vitals, he is visibly agitated, and this shows in his elevated blood pressure. After another 10 minute wait, the doctor knocks on the door and enters. Mr. Adams, what brings you in today? she asks. Seth responds in a wavering voice: I have HIV. I need help. Dr. Anderson is taken aback there is no mention of an HIV test in Seths chart. Did you go to a testing center? she asks. No, Seth responds, I did it at home. The above scenario, though fictive, could happen today. On July 3, 2012, the US Food and Drug Administration (FDA), announced its first approval of a rapid home HIV test, OraQuick by OraSure Technologies. The antibody test works via a mouth swab and provides results in twenty minutes. The home HIV test, the first self-test for an infectious disease, in my opinion, is the vanguard of a new wave of self-diagnostics: one that implicates the testers and those around them. In a market-driven heath care system, patient autonomy and consumer choice are often conflated. In fact, some have suggested that the FDA would have been considered paternalistic (and thus unethical) if it had decided to limit patient choice by not approving the HIV self-test based on concerns about user error.1 However, we must recognize that these choices are not taken in isolation from other individuals; self-testing impacts families, partners, and providers. What is the responsibility of the physician in this case? What implications does this new informed patient have for the clinical encounter? What are the ethical principles at play here? Do consumers have the right to access any information about their bodies that they so choose? These are just a few of the questions raised by the growth in self-diagnostics.

Melissa Whellams. The Approval of Over-the-counter HIV Tests: Playing Fair When Making the Rules. Journal of Business Ethics 77, no. 1 (2008): 9.

2 These questions are not new. The home pregnancy test, which was the first home diagnostic approved by the FDA, stimulated intense debate among the public and health care professionals when it was released in 1976. While some praised the empowering aspect of the home test, others in the field of medicine doubted that women should receive the results of their tests without the support of a clinical visit. As one doctor noted in a 1979 news article concerning the debate: I have a fear that a person who doesnt want to be pregnant will just use the test when she needs immediate counseling and referral. These tests remove the patient advocate from the scene.2 While even the ads for these tests were controversial, it does not seem to me that the current wave of home diagnostics (e.g., the home HIV test) has stimulated such intense debate, at least in the public realm. What has changed since the 1970s? Have consumer choice and patient autonomy become so intertwined and considered a universal good that to question them is unthinkable? It is my conclusion that the advent of advanced patient autonomy in the context of self-diagnostics should be questioned on the basis that autonomy and choice are not universal goods, nor do they occur without implications for others, including the physician. In addition, they present unique challenges to shared decision-making, specifically because they shift the informational balance away from the physician, who may not have the expertise to interpret and recommend treatment based on the results. Advanced Patient Autonomy and Consumer Choice In the contemporary landscape of patient care, it seems that patient autonomy is valued above all else. Limiting patient rights and choice is tantamount to bad medical care. It is not my view that patient autonomy and physician paternalism are two sides of a coin; they can (and do) co-exist in clinical decision-making. The question I propose, however, is to what extent self2

Diane Elvenstar. Pregnancy Tests: Birth of a Controversy. Value of At-Home Kits in Dispute. Los Angeles Times. August 10, 1979: E1.

3 diagnostics promote good care. As Atul Gawande argues: Where many ethicists go wrong is in promoting patient autonomy as a kind of ultimate value in medicine rather than recognizing it as one value among others . . . as the field grows ever more complex and technological, the real task isn't to banish paternalism; the real task is to preserve kindness.3 My analysis here is not focused on a system level issue: I do not believe that physicians or other health care workers have the ability to extend or prevent the rights to self-diagnostic testing on their own. If anything, what we have seen is an assemblage of actors, including patients, medical associations, the US Food and Drug Administration (FDA), and biotech companies that are bringing these devices to market. The question, here, is not whether to limit or control these technologies across the board, but instead how they will transform the relationship between patients and the medical establishment. It is also not my argument that patient autonomy should be unequivocally restricted; instead, I argue that the use of the rhetoric of patient autonomy to promote these tests as desirable is itself flawed and that we should at least be skeptical of it. In line with this argument, Greaney, OMathuna, and Scott contend that the advent of advanced patient autonomy and its conflation with consumer freedom and choice does not suit health care policy or medical professionalism because (1) it mistakenly equates autonomy with the lack of constraints and (2) it does not take into account other considerations such as relationality and responsibility that may in the end provide better care to patients.4 Greaney and her colleagues tie the shift to advanced autonomy to the growth of consumerism in health care, where patients are expected to be active participants in their health. Such neoliberal tendencies

Atul Gawande. Whose Body is It, Anyway? in Complications: A Surgeons Notes on an Imperfect Science. Picador: New York, 2003: 223-224. 4 Greaney, Anna-Marie, Dnal P OMathna, and P Anne Scott. Patient Autonomy and Choice in Healthcare: Self-testing Devices as a Case in Point. Medicine, Health Care, and Philosophy 15, no. 4 (November 2012): 383395. doi:10.1007/s11019-011-9356-6.

4 should be critiqued in their own right, but the authors also argue that freedom of choice is not necessarily a pre-requisite for autonomy: we (patients) do not make autonomous decision in a vacuum, but in relation to society and other considerations. A model of autonomy based on freedom to choose, they argue, which fails to consider the notions of relationality, responsibility, and care does not provide the best means for increasing patient potential.5 This view of autonomy is essential for self-diagnostics, since (I believe) the relational aspect is often ignored in clinical trials, which, in order to secure FDA approval, focus on the efficacy and safety of new devices and often ignore the user experience and how such tests might implicate others. This is especially relevant in the case of self-tests for infectious diseases, such as HIV. For while these tests are conceived as individual, private matters, they implicate sexual partners as well, not only in the sense of notification of results, but also in that partners may be pressured to take these tests. These considerations too are part of the assessment of autonomy and the risk/benefit ratios of these tests. Other authors have offered alternative frameworks for conceiving good patient care, those that do not necessarily equate autonomy with choice. For example, medical anthropologist Annmarie Mol, in a study of diabetes clinics and diabetes self-care, argues that health care practices that ostensibly promote patient choice often hurt practices designed to promote patient care. Patient choice and good care may sometimes complement each other, she contends, but more often they clash.6 Integral to her analysis is the role of technology in diabetes self-care. Using self-blood sugar monitors as a case in point, she shows how the advent of this self-monitor has not only changed how diabetes is managed by patients, but also how it has led to new

Ibid., 392. Annemarie Mol, The Logic of Care: Health and the Problem of Patient Choice (New York: Routledge, 2008), 1.
6

5 problems (e.g., an increase in incidence of hypoglycaemia). The thesis of her argument (and integral to the ethical critique of self-diagnostics) is that while the logic of choice sees technology as an instrument, technologies themselves are unruly and often have unintended consequences that go beyond their intended purpose. On the other hand, the logic of care, Mol observes, does not take technologies to be mere instruments. Instead, good care involves a persistent attempt to tame technologies that are just as persistently wild.7 What implications does this argument hold for self-diagnostics? While blood sugar monitoring occurs after diagnosis (after one is already under physician care), new diagnostic tests like direct-toconsumer genetic testing and HIV self-testing provide information about ones own body outside of the clinical setting that could have serious consequences for how one lives his/her life and how one sees his/her future and responsibilities to others. They are truly unruly technologies, and should be viewed as such by physicians and other health care professionals. Kearns, OMathuna, and Scott (2009) provide the example of male fertility self-tests available in the United Kingdom. They question whether a man who takes such a test is ethically obligated to inform his partner about the results. Specifically they speculate about a situation where a couple is trying to have a child, and the male partner finds out in private whether or not he is infertile. They ask: What if he intends not to disclose the (perhaps divisive) results to his wife but wants to test only so that he knows privately who to blame? Does her autonomy place an obligation on him to inform her of the results so that she can know whether or not she has a physiological problem?8 The same question could be asked about any test for an infectious

Ibid., 50. Alan Kearns, Dnal P OMathna, and P Anne Scott. Diagnostic Self-testing: Autonomous Choices and Relational Responsibilities. Bioethics 24, no. 4 (May 2010): 202. doi:10.1111/j.1467-8519.2008.00711.x.
8

6 disease: does the self-tester have the obligation to inform others who may have contracted the disease about his/her result? These cases not only show that the promotion of autonomy and choice can actually cause harmful unintended consequences, but reinforces the conclusion that choice does not always equate to care. The home HIV test could also have unintended consequences if consumers pressure their partners to take such tests. Besides the additional stress this may cause, what consequences might these tests have for patient privacy and confidentiality? What if one of the partners finds out that he or she is positive? The immediate effects of finding this out are traumatic enough, but while before results were disclosed by a clinician or health care worker bound by law to patient confidentiality, the general public does not have such an obligation. There is also the possibility of false results from these tests. While inaccurate results are a risk of any test, it is possible that self-diagnostics could produce higher false negatives or positives as a result of user error or, in the case of home collection kits, lower quality assurance and monitoring of labs that do the testing. In such cases, extending choice does not necessarily coincide with providing good care. Self-Diagnosis and the Clinical Encounter In observing clinical encounters in the pediatrics wing of a teaching hospital, I have seen how integral the process of diagnosis is in medicine, not only in the instruction of medical students, but also to patients. I overheard a physician comment that even if the presenting symptoms had resolved, the parents of the patient would not leave the hospital happy without a definitive diagnosis. Diagnosis is essential to the patient-physician encounter. As one researcher commented: Diagnosis is at its [doctor-patient relationship] heart: providing a rationale for the consultation, delegating the responsibility for labeling an illness, and in our contemporary era, providing access to a range of resources. The diagnosis is generally a prerequisite for treatment,

7 an imperative for reimbursement, an authorization to deviate from expected behaviors, in sum, a legitimating force.9 But if diagnosis has historically been a legitimating practice and exercise of power held mostly by physicians, the advent of internet sites like webMD, as well as new home diagnostic technologies, has troubled that notion. While early sociologists of medicine like Talcott Parsons (1951) viewed the patient in a passive role in need of the technical expertise of the physician, as one researcher noted, common sense and experience make clear that patients in a medical encounter bring their own thoughts, feelings, experiences, and sense-making practices (diagnoses) to bear on whatever ails them.10 If indeed contemporary emphasis on patient autonomy has shifted the standard to shared decision-making in the clinical encounter (which sees the patient as a collaborator or partner), the advanced informed patient who has done a clinical test on his/her own is the epitome of the independent patient. However, this new power conferred onto the patient does not untether him or her from the medical establishment. In fact, it would (and should) bring the patient into the clinic at the earliest point possible for treatment or intervention. The question remains how doctors and other healthcare workers should view and handle this type of patient presentation (the self-diagnosed patient). Literature on the physician perception of diagnostic self-tests (specifically those that involve the testing of biological specimens) is scarce. However, literature on self-diagnoses from internet health information can shed some light on the matter. Several studies have been conducted to assess how physicians view patients who present with opinions about their conditions based on their independent internet research. One Canadian study based on focus

Annemarie Jutel, "Self-diagnosis: a discursive systematic review of the medical literature," Journal of Participatory Medicine 15 (2010): e8. 10 Richard M. Frankel, Clinical Care and Conversational Contingencies: The Role of Patients Self-diagnosis in Medical Encounters, Text Interdisciplinary Journal for the Study of Discourse 21, no. 12 (January 12, 2001). doi:10.1515/text.1.21.1-2.83.

8 groups with 48 family physicians found that in general they perceived health information gathered online as problematic when patients brought it up in the clinical encounter.11 Doctors in the study generally felt that such information often led to misinformation, confusion, or negative self-diagnosis or treatment on the part of patients. In addition, they felt that this introduced a new role to their clinical duties for which they were unprepared: to interpret medical information from third-party sources that they had not solicited themselves. These findings suggest that physicians may be ill prepared to handle situations in which the patient presents with findings from clinical tests conducted in the home or via a direct-to-consumer service. The physician might feel that his/her role has been challenged since the tests were not ordered personally. Or perhaps the question is not about the appropriateness of the test, but instead accuracy. Perhaps the physician will question whether the patient has accurately performed the test, or whether the lab that did the testing was compliant with clinical standards. Whatever the case, it is probable that the physician will express some level of skepticism, which, in my opinion, could disrupt the pattern of trust that may have characterized the doctor-patient relationship. However, there is not universal skepticism among physicians about self-diagnosis. In a discursive review of medical literature on self-diagnosis, Annemarie Jutel found that the body of literature on the principle of self-diagnosis (38 articles she reviewed via a search in PubMed) was actually fairly balanced in favor of and against the idea.12 The concerns mentioned in her review were similar to the Canadian study referenced above: there were concerns about inaccurate diagnoses, which could lead to delays in treatment, and articles expressed concern that

Farah Ahman, et al., Are Physicians Ready for Patients with Internet-based Health Information? Journal of Medical Internet Research 8, no. 3 (2006): e22. doi:10.2196/jmir.8.3.e22.
12

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Jutel, Self-Diagnosis.

9 self-diagnosis would challenge the authority of medicine and the ideal of the compliant patient. However, self-diagnosis was also seen as a positive development of self-care and in filling in where physicians or clinics were not readily available or accessible. One of the concerns voiced in some of the articles was that the push for self-diagnostics was not driven by patients or physicians, but instead by pharmaceutical companies in hope that patients would advocate for their diagnosis and request the branded drug. In a study of symptom checklists promoted by drug companies, Mary Ebeling argues that this is a rhetorical sleight of hand by these pharmaceutical firms. She notes: Through the pharmaceutical promotion of the instruments of self-diagnosis, diagnostic power is removed from the exclusive purview of medical authority and placed by marketing into the hands of patients. Self-diagnosis has the potential to redistribute power within medically mediated relationships, such as the relationship of power and trust between a patient and her doctor. Yet in this subversion of power, the pharmaceutical marketing ideologies are distributed seamlessly while appearing to put decisions and determinations about health and optimized action into consumers hands.13 Biotech firm representatives have also called any reservation about direct-to-consumer tests as appallingly paternalistic. As one director of a direct-to-consumer genetic testing firm claimed: People can understand statistics about baseball, and I think they ought to understand statistics about genetics.14 It is not the intent of the essay to critique the structural role of private interests in the production of patient desire for self-diagnosis. However, if we are to consider the ethical implications for self-tests, it is possible that physicians might sense that this shift in patient interaction is in some ways driven by pharmaceutical websites and biotech marketing. If so, this

Mary Ebeling, Get with the Program!: Pharmaceutical Marketing, Symptom Checklists and Self-diagnosis. Social Science & Medicine 73, no. 6 (September 2011): 830. doi:10.1016/j.socscimed.2011.05.054. 14 Andrew Pollack, Is a DNA Scan a Medical Test or Just Informational? Views Differ, The New York Times, March 19, 2010, sec. Business. http://www.nytimes.com/2010/03/20/business/20consumergenebar.html.

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10 may be another way in which pharmaceutical and device companies are inserting themselves into the patient encounter, an intervention that may not be welcome. Hence, if providers sense that there is a threat to the profession by self-diagnostics, it may not be a threat from patients, but instead from private corporations seeking profit. Jutel argues that the any attempt to mediate access to self-diagnostic information or control its delivery would be an infringement on patient autonomy, returning the patient to the paternalistic care of the omniscient physician.15 On the other hand, she argues, allowing patients to consumer self-diagnostic information freely without sufficient comprehension results in individual vulnerability for both patient health and the doctor-patient relationship.16 I find this dichotomy to be a somewhat reductionist approach to doctor-patient decision-making. As noted earlier, I do not see patient autonomy and physician paternalism as two ends of one spectrum. In line with Annemarie Mols argument on the logic of choice and the logic of care, ethicist Rebecca Kukla argues that unequivocally promoting self-determination in health care is not a universal value.17 Instead, she shows how health care is inherently fraught with surveillance and medical management of individual behavior by professionals. Those who deliver health care cannot reduce their responsibilities for protecting and promoting patient autonomy to merely offering relevant information while trying not to influence decisions, she argues, continuing: Rather than trying to reduce the influence of their authority, they need to find ways to use it to foster a conscientious relationship to appropriate health care practices hopefully, practices that not only promote health, but also express respect for the integrity,

Jutel, Self-diagnosis, 6. Ibid. 17 Rebecca Kukla. Conscientious Autonomy: Displacing Decisions in Health Care. Hastings Center Report 35, no. 2 (2005): 3444. doi:10.1353/hcr.2005.0025.
16

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11 dignity, and identity of their practitioners.18 Kuklas argument is central to the critique of the claim that self-diagnostics, in the name of patient autonomy and choice, should be made available to those who desire it (and can afford it). While the physician cannot prevent patients from using self-diagnostics, s/he has an integral role in promoting or discouraging their use when patients present with results or ask for advice. It would not be a violation of patient autonomy for a physician to advise a patient not to self-test (and instead to test in a clinical setting) if the physician feels that it would cause more detriment than benefit, for example if there is doubt that the patient will be able to properly conduct the test or interpret the results on his/her own. In line with Kuklas argument, appropriate practices of self-care and management may mean that patients would better receive care if tested in the clinic. While this may seem like a return to paternalism, in my opinion it is instead protecting a form of mediated autonomy that better respects the patient and promotes health. As Kukla notes, It is not the amount of medical management that determines how respectful a set of health care practices are, but rather the shape and meaning of those practices.19 Self-diagnostics and the Physicians Role While the literature is limited, there are some indications that physicians might tend towards skepticism about this new wave of home diagnosis that seems to have emerged with little participation from the profession. As early as 2001, the FDA Consumer published an article discussing the growing trend of consumers playing doctor with home test kits (e.g., cholesterol, glucose, illicit drugs, etc.).20 The term playing doctor, which appears in other articles, is not a rhetorically neutral reference. Instead, it suggests that consumers are not to be Ibid., 43. Ibid. 20 Carol Lewis. Home Diagnostic Tests: The Ultimate House Call? FDA Consumer 35, no. 6 (December 2001): 1822.
19 18

12 truly trusted to test themselves on their own, and that they are conducting a procedure that in actuality should be done by a health care professional. The article quotes several physicians who express concerns about accuracy, misinterpretation of results, delay in treatment, user error, and lack of counseling. As one expert in the article states, home tests are best used only by those who are well-educated about the disease, and who are in touch with their emotions and have a good support system around them.21 Of course, such sentiments are not universal, but it is probable, as in the case of online health information, that physicians and other health care professionals are ill prepared to effectively handle situations where patients arrive with test results in hand. If, as some have observed, the clinical encounter consists basically of (1) the presenting complaint, (2) inquiries both about the problem and unrelated to it, (3) review of systems/patient history, (4) physical exam, and (5) delivery of diagnosis and treatment plan, then the possibility of self-diagnosis with a consumer clinical test could severely disrupt that process.22 Others have identified three specific diagnostic stages in the clinical encounter: first, the initiation phase, which can consist of the patients hypothesis; second, refinement, which consists of further assessment and ruling out/recognition of probable condition; and third, definition of final diagnosis, which can consist of diagnosis and further confirmation testing.23 A clinical self-test can also transform this process, since, while patients often have an idea of what ails them, historically they have not had a clinical test they could perform at home. In discussing how physicians should respond to patient self-diagnosis, a 2010 article in the BMJ recommended the following:

21 22

Ibid., 19. Frankel, Clinical care and conversational contingencies, 98. 23 Clare Goyder, A. McPherson, and P. Glasziou. Self Diagnosis. BMJ 339 (November 11, 2009): b4418. doi:10.1136/bmj.b4418.

13 Doctors should acknowledge the patients self diagnosis, but what they say will depend on the probability of the suggested diagnosis being correct. If the self diagnosis is likely to be right we could say That sounds likely, but there are a few other things we should check first. For less likely suggestions we could say That sounds possible, but there are other diagnoses that might be more likely. This approachlistening combined with verificationshould enable the self diagnosis to be explored but should prevent premature closure of the diagnostic process.24 While such advice may be helpful in the case of self-diagnostics with less definitive results, it may not fully capture situations where the patient presents with certainty that he/she has a positive test result, even thought such results must be confirmed by further clinical tests (e.g., for HIV). I would recommend that medical institutions and professional bodies develop guidelines to assist physicians and other health care professionals in effectively communicating with selfdiagnosed patients, whether they be expert patients or not. Separate guidelines may need to be developed for different tests which may have very diverse implications, but there are several integral aspects for any guidance for physicians in this regard. First, it is clear that physicians have the responsibility to treat or refer patients who have been diagnosed outside of their consultations or advice. For example, Kier and Molinari discuss the implications for physicians of do-it-yourself tests for mental illness. They ask: What responsibility does the clinician have for further testing and/or treatment when presented with DIY test results?25 The authors conclude that physicians should counsel and treat results of consumer tests even if they were not recommended. Second, physicians will need to be educated about the reliability of selfdiagnostic tests (which may be lower than those conducted in the clinical setting) so that they can better assess the probability that the patients self-diagnosis is accurate. Third, physicians should

24

Ibid.
25

Kier, Frederick J., and Victor Molinari. Do-It-Yourself Testing for Mental Illness: Ethical Issues, Concerns, and Recommendations. Professional Psychology: Research and Practice 35, no. 3 (June 2004): 265. doi:10.1037/0735-7028.35.3.261.

14 be able to assess whether self-diagnostics are appropriate for their patients and discourage their use if needed. This would not be an infringement on patient autonomy, but instead a promotion of better care. Lastly, while it is not the intent of this paper to recommend whether selfdiagnostics should be restricted at the population level, I believe that the medical profession as a whole should be able to advocate against tests that do not promote good care. This of course, runs the risk of enabling the perception that medicine is resorting to paternalism. But if we can separate consumer choice from autonomy, it is clear that choice is not necessarily a universal good, nor does it always promote autonomy or good care. Conclusion From a social science perspective, self-testing and diagnosis promote a specific kind of ethic, one that Nikolas Rose calls a somatic ethic, which concerns itself with the selftechniques by which human beings should judge and act upon themselves to make themselves better than they are.26 I turn to this sort of ethic because I believe it characterizes how most patients negotiate their utilization of medical services and technologies. On the ground, however, the challenges that physicians face in making sense of the tools that are available to patients outside of the clinic are myriad and constantly evolving. The perception that patient choice and advanced patient autonomy should always be promoted is a significant challenge to providing good care. Yet social science and philosophy may have been complicit in this perception. Annemarie Mol contends that our theoretical frameworks lend themselves well to critique. They unmask, she writes. They tend not to explore or build ideals but to undermine

Nikolas Rose, The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the Twenty-First Century (Princeton: Princeton University Press, 2007), 27.

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15 them.27 Thus, she contends, questions about what made up good care were left to the ideals of market capitalism, such as efficiency. She concludes: Without a language to address these questions collectively, answering them was left to everyone individually. Let people choose for themselves. That the social sciences and philosophy did not seek to praise some version of good care created a vacuum. It is partly due to this vacuum that autonomous choice, an ideal that originally took shape in quite different contexts, so rapidly conquered health care.28 In my own experience, the social science critique, at times, does not coincide with the reality of what happens on the hospital floor. Whether or not patients and consumers should be able to make unlimited choices in health care is not the question. The question is whether choice actually leads to better care. In some cases it is clear that it does not. The fact of the matter, however, is that self-diagnostic tests will continue to proliferate as long as they are profitable. These clearly empowering technologies have the potential to produce better health outcomes for the population as whole. Unintended consequences, however, as I have outlined in this essay, can diminish the overall benefit of these tests. Hence, we should consider them carefully (and with a certain degree of skepticism), remembering that choice and autonomy are separate dimensions of what might constitute good care.

27 28

Annemarie Mol, The Logic of Care, 90 Ibid.

16 References Agarwal, Aakash Kumar, and Beth Brianna Murinson. New Dimensions in Patient-Physician Interaction: Values, Autonomy, and Medical Information in the Patient-Centered Clinical Encounter. Rambam Maimonides Medical Journal 3, no. 3 (July 31, 2012). doi:10.5041/RMMJ.10085. Ahmad, Farah, Pamela L Hudak, Kim Bercovitz, Elisa Hollenberg, and Wendy Levinson. Are Physicians Ready for Patients with Internet-based Health Information? Journal of Medical Internet Research 8, no. 3 (2006): e22. doi:10.2196/jmir.8.3.e22. Ebeling, Mary. Get with the Program!: Pharmaceutical Marketing, Symptom Checklists and Self-diagnosis. Social Science & Medicine (1982) 73, no. 6 (September 2011): 825832. doi:10.1016/j.socscimed.2011.05.054. Frankel, Richard M. Clinical Care and Conversational Contingencies: The Role of Patients Self-diagnosis in Medical Encounters. Text Interdisciplinary Journal for the Study of Discourse 21, no. 12 (January 12, 2001). doi:10.1515/text.1.21.1-2.83. Gawande, Atul. Complications: A Surgeons Notes on an Imperfect Science. Picador, 2003. Goyder, C., A. McPherson, and P. Glasziou. Self Diagnosis. BMJ 339, no. nov11 1 (November 11, 2009): b4418b4418. doi:10.1136/bmj.b4418. Kearns, Alan J, Dnal P OMathna, and P Anne Scott. Diagnostic Self-testing: Autonomous Choices and Relational Responsibilities. Bioethics 24, no. 4 (May 2010): 199207. doi:10.1111/j.1467-8519.2008.00711.x. Kukla, Rebecca. Conscientious Autonomy: Displacing Decisions in Health Care. Hastings Center Report 35, no. 2 (2005): 3444. doi:10.1353/hcr.2005.0025. Lewis, C. Home Diagnostic Tests: The Ultimate House Call? FDA Consumer 35, no. 6 (December 2001): 1822. Mol, Annemarie. The Logic of Care: Health and the Problem of Patient Choice. 1st ed. Routledge, 2008. Parsons, Talcott. The Social System. New York: Routledge, 1991. Pollack, Andrew. Is a DNA Scan a Medical Test or Just Informational? Views Differ. The New York Times, March 19, 2010, sec. Business. http://www.nytimes.com/2010/03/20/business/20consumergenebar.html. Rose, Nikolas. The Politics of Life Itself: Biomedicine, Power, and Subjectivity in the TwentyFirst Century. Princeton: Princeton University Press, 2007.