Contemporary Medicine: Applied Human Science or Technological Enterprise?
By Fortin, Sylvie Alvarez, Fernando; Bibeau, Gilles; Laudy, Danielle
Abstract This article takes as point of departure the quality of the doctor-patient relationship to consider contemporary medicine’s often compromising commitments to both technological enterprise and applied human science. The authors argue that this relationship is located within a tension at the heart of the clinic, between the demands of cutting-edge medicine (and ever-advancing technology) and the demands of a medical tradition long sworn to hold patient well- being in the highest regard. As members of a pluridisciplinary research team (anthropology and medicine), the authors carry out ethnographic research in a third-line pediatric hospital in Montreal, Canada. Involving interviews, informal exchanges, and observation with practitioners, patients, and families in clinical spaces, the ongoing research project broadly addresses humanism and medicine. Mainly drawing on interview material with clinicians and observation, we examine here the importance attributed by the specialists to human dimensions of the clinical encounter and the sometimes problematic relation between the cure and care aspects of medical practice. Technological and medical progress in recent years has given rise to tremendous scientific advancements that are engaged daily in the hospital context. But can knowledge in itself hold meaning beyond the life of the patient? Is medicine an applied human science or is it a technological enterprise? Is there necessarily an opposition between these premises? The authors call for the promotion of a humanist approach to medicine, in which relationships, involving multidimensional exchanges between different actors, may better serve patient interests.
Key words: doctor-patient relationship, pediatric hospital, technology, humanism, cure and care.
Introduction
As members of a pluridisciplinary research team (anthropology and medicine),1 belonging to both pediatrics and anthropology departments, we are currently carrying out an ethnographic study in a third-line pediatric hospital in Montreal, Canada. This university health center plays a prominent role in coordinating the network of pediatric and perinatal health services in Quebec and in the training of tomorrow’s pediatricians (and pediatric specialists). The facility counts more than 500 physicians and 18,000 patients hospitalized annually, 185,000 out-patients and 65,000 emergency consultations.2 A number of phenomena characterize this hospital setting, notably the diversity of its clientele, with a high rate of families born outside Canada using the services,3 along with the evolution of a clinical practice.
Our main argument here is that the response of patients to treatment is individual and depends on biomedical and pharmacologie case management. This response also depends on the consideration given to the social and cultural dimensions of any clinical encounter, and more widely on the humanization of healthcare conditions surrounding birth, illness, and death (2). Medical anthropology distinguishes between biomedical notions of being unwell in its pathological aspects (disease), in its subjective and experiential dimensions (illness), and the representations that these inspire or the social construction of health problems in a given milieu (sickness) .4 The clinic, taken as a place of care and of interaction between healer and patient, implies an incursion into this simultaneously biological, social, and cultural universe.
The quality of the human relation (often called “alliance”) between patients and their families on the one hand, and the healthcare team on the other, is central to the progression of an illness and the extent to which patients and their families follow or negotiate prescribed treatments (3; 4). This alliance enhances patients’ health outcomes and increases satisfaction for both patients and healthcare professionals (5).5 From this perspective, 1) the bond between clinician and patient becomes an active component in the therapeutic process; 2) in the pediatrie context, this relation is triadic, as it involves the patient’s family as an integral part in decision-making and the care trajectory; 3) this relation is located within a tension at the heart of the clinic, between the demands of cutting-edge medicine (and ever-advancing technology) and the demands of the project of medicine itself, i.e. the welfare of the patient and his/ her intrinsic confidence in this project (6).
Urban Contexts and the Hospital
The hospital where we are conducting research and clinical work is located in a multiethnic neighborhood, with an immigrant population of over 43%. This is one of the most pluralistic areas in Montreal, a city where nearly 27% of the population is of immigrant origin (8). In fact, 90% of all immigrants who come to this part of Canada (that is, Quebec) choose to live in Montreal, where approximately 30,000 to 40,000 immigrants from 100 different countries land each year. This creates a cosmopolitan urban environment characterized by a multiplicity of languages and religions. The hospital, as “an open-door to the city” (9) is not immune to such diversity.6
In addition to this pluralist context, the hospital is affected by the evolution of clinical situations linked to the increase in complex chronic pathologies (10) and technological progress (11). While health care units are configured around ‘acute care’, complex patients require ‘chronic’, long-term care (what many call “chronic/ acute illness”). At the same time, because of the quality of care in specialized and superspecialized environments, the hospital tertiary care context promotes the proliferation of caregivers at the patient’s bedside, to the point that the notion of ‘treating doctor’ is often unclear. Furthermore, the reform of the Canadian public health care system has also transformed the space of treatment, most markedly by promoting patient care outside the hospital. This has had the effect of increasing “heavy burden cases” in the hospital, with the ” lightest cases” leaving the institution, making room for more complex and often heavier cases in terms of care. In turn, this divides the time allotted to a doctor-patient relation because the patient is rapidly redirected towards other health care services outside the hospital.
As a matter of fact, the doctor-patient relationship is frequently disregarded due to both structural constraints (and lack of resources), and the progress of medical science itself, which is sometimes detrimental to this relationship so central to the therapeutic process. And subsequently, several studies carried out in recent decades have identified deficiencies among healthcare professionals in regards to communication and relational competencies in clinical interactions (15). A patient’s illness and his or her vulnerability create a need for security as well as trust in biomedical knowledge, as confirmed by the concerns of the Royal College of Physicians and Surgeons of Canada (16) and the Accreditation Council on Graduate Medical Education (17). These organizations, through the development of a competencies program,7 are mandated to promote an approach to medicine that (re) unites expert knowledge, central to the classical biomedical model, and relational competencies (Figure 1). The latter, and more particularly doctor-patient communication,8 are at the foreground of a patient-centered approach to care.
Outline
Technological and medical progress in recent years has given rise to tremendous scientific advancements. These are engaged daily in the hospital context (for both research and education), where technical competencies and knowledge assisted by leading technology prevail. Every means is taken to advance and preserve expert biomedical knowledge. But what does medical knowledge signify beyond the healthcare link? What importance does the specialist attribute to the human dimensions of the clinical encounter? Is medicine an applied human science or is it a technological enterprise? Is there necessarily an opposition between these premises?
Drawing on ethnographic research underway, we will examine this relative dichotomy, and more generally, the complexification of the medical profession. After outlining the methodological approach of this study, and briefly discussing the relational aspects of the clinical encounter, we will examine this complexification with a focus on the growing importance of technology, which can at times be detrimental to a humanist approach to care. Examination of this ‘tension’ in the clinical environment promotes the exploration of diverse therapeutic approaches that often illustrate the prospective or budding relationship of expert knowledge with communication and inter-relational competencies, as put forth by the Royal College of Medicine. To conclude, we offer a reflection on the ‘medicalization of the medical profession’ and the humanism central to the medical project.
Methods
Ongoing since 2005,10 this research has taken place in different units, including hemato-oncology, palliative care, and two spaces dominated by pathologies that are referred to as complex,11 one offering curative care and the other longterm palliative care. It is within this setting that we examine clinical practices, particularly those of physicians, with a special interest in the caregiver/ patient/ family relationship. Our approach is ethnographic, comprising observation in pluridisciplinary clinical spaces and informal exchanges with diverse practitioners, patients, and families (spaced out over a one-year period); forty individual interviews with physicians (semi-structured, lasting between 90 and 120 minutes); and eighteen case studies with patients and their families. The latter were chosen according to the healthcare team’s availability, as well as on the basis of unfulfilled expectations by the healthcare team or the patient/ family, such as adherence to treatment, the involvement of parents, expressed therapeutic expectations, and so forth. For their part, the physicians of various specialties were initially recruited (but not exclusively) because of their presence in one or another of the observed units.12 We have chosen a triple investigative method in order to document physicians’ daily practices, and in parallel, those of the other healthcare professionals concerned; the world of the patients and their families; and the relational dynamics among clinicians, patients, and their families. We are interested in all that concerns the trajectory of care, decision-making processes, and the biographies of patients and clinicians. The present article draws on interviews and observation of the latter.
Results and Discussion
Clinicians and clients sometimes draw upon different referential frames in order to understand illness and deal with the therapeutic (and decision-making) process. Many healthcare practitioners admit that an approach centered a priori on the organic or biological aspects of a disorder is limited in its ability to discern the diversity of the Other_(19). And in fact, it is worth noting that, after several years in practice, a number of physicians, confirmed specialists, have come to declare that listening to and being present for the Other is now, for them, the foundation of all clinical encounters: “ft’s more through, listening that confidence is established, less in what we say” (physician, pediatrie specialist, 20 years professional experience). This vision enhances an approach guided by the sole evidence of measure in the alignment of the care trajectory: “Madam, you can think what you like, you can say what you like, [but for] me it’s written there” (physician, pediatrie specialist, 6 years professional experience). Can knowledge in itself hold meaning beyond the life of the subject?13
The Complexification of Medicine
Medicine is becoming increasingly complex, as knowledge, pathologies, and treatment offer diverse alternatives for care. This Complexification is dual, linked to both technological progress and its resulting expertise. An ever-increasing body of medical knowledge is generating a specialization and division of medical practice into specific fields of expertise. In neonatology, for example, while technology allows for the eventual detection of certain foetal anomalies, and as such the prevention of stillbirth or morbidity, prematurity may entail a series of so-called complex pathologies (successive, multi-systemic, or chronic…). These require a multiplicity of expertise, since general pediatrics alone cannot meet all the healthcare needs of these patients. Numerous healthcare professionals become involved, each offering expertise on a very specific aspect of treatment, according to the institutional structure of healthcare itself, and often without knowledge of the problem as a whole:
[...] the team is mainly oriented towards scientific things, protocol, it’s more of an assembly-line-there are a lot of patients. It keeps going and going and going. There are a lot of doctors. It’s sometimes difficult to know which doctor is involved in a given situation [with a particular child] (physician, pediatrie specialist, 10 years professional experience).
This Complexification of knowledge and specialties stands as a measure of the undeniable evolution of medicine. This progress seems, nonetheless, to shape its own alterity, to the detriment of the ‘human’ dimension of healthcare, troubling generalist and specialist alike, all the while legitimized by its positive effects.
Tensions within the Clinic
This search for humanism translates into willingness on the part of certain clinicians to include or to reaffirm the social and cultural character of the medical vocation and its relational and qualitative aspects. Technology, then, elicits reflections regarding the growing absence of these dimensions from medical practice. When asked about current challenges in clinical practice, many of the physicians interviewed affirmed the existence of a dichotomy between cure (scientific competence, knowledge, expertise, technical skill] and care (attitudes, as well as personal, relational, and communicational qualities).14 This preoccupation conveys a core interrogation of biomedicine:
I find that medicine has become detached from the very idea of health, with respect to life and other daily preoccupations that can be political, economic, and social in nature. It has become something entirely separate (physician, pediatric specialist, 4 years professional experience).
“Evidence-based medicine” in the clinic is the guarantee of expertise based on experience and scientificity, fundamental characteristics of biomedicine (22). “That’s medicine,” some clinicians would tell us. Expert knowledge is first and foremost:
[In my area of practice, we find] the sickest patients. We treat everything, the liver, intestines, lungs. What interests me is basic science, [...] the medical side, the investigation more than the relationship” (physician, highly specialized , 13 years professional experience).
More popular in units where technological investment is important, this approach to medicine is described by some, nevertheless, as homogenizing, both for medical practice and for the patient who must conform to it:
You’ve got to understand that when we’re facing a patient, all this ‘evidence-based medicine’, it’s just one of many chapters in our head, there’s a lot more than just that. And [convincing data] supply us with ideas for specific treatments but that’s all…. Medicine goes a lot farther and is much more vast than simply diagnoses and treatment [...]. [...] even in groundbreaking specialties, such as my own, we don’t have an enormous need for techniques or science for the care of patients, because there are no medications, or at least not at the moment. Often [what is important] is communication, establishing confidence (physician, paediatric specialist, 30 years professional experience).
A Diversified Practice
Biomedicine and its practitioners do not make up a homogeneous body (23; 24). In spite of a relatively consistent medical ethos, intensive care and the oncology department are areas that generate a different kind of praxis than that of general paediatrics or the field of long-term complex pathologies. Be it acute or chronic care, curable illnesses or those under constant supervision, treatment techniques, teams of specialists, biomedical practice and treatment situations are equally variable. This said, the different ways of being a doctor are tied to the context of institutional politics and more broadly, of systems of care (25). This is similarly the case of interdepartmental and inter-specialty practices.
A number of doctors call for a clinical approach in which theoretical and relational competencies intersect, but actual practice is often otherwise. With the exception of palliative care, in which relationships among healthcare professionals and between them and their patients are regularly discussed topics, team meetings involving clinicians in other units usually discuss treatment choices and pharmacological needs-the more technical aspects of care. Several physicians evoke the double standard of a care structure wherein the acquisition of ‘scientific’ competencies and the effective practice of medicine are valorized, but wherein humanization of the field is also advocated. Relational qualities translate into transversal capabilities. Recognized by the Royal College of Doctors and Surgeons of Canada (the Canadian medical accreditation institute), they become explicit issues in professional training. The quality of the therapeutic relationship, of patient/physician communication, and more broadly, the clinical encounter, become objects of study that “add to” an already exhaustive degree program. For some, they are welcome, for others, superfluous.
Many of the clinicians interviewed recognize (to different degrees, depending on field of work, training, and the dynamics of service) the need to have both scientific and humanist competencies in a context where the human dimension is more easily relegated to an individual preoccupation. Yet, fundamental knowledge (so-called ‘hard’ knowledge) is as central to training as it is to clinical practice. It constitutes an essential element of medical prestige. But as physician and ethicist Pellegrino (26) reminds us: “Who does the physician serve-the good of the patient, the success of the team that pays his salary, or his own infatuation with athletic success?”
I am becoming less and less comfortable with the way medicine is evolving. It is evolving very poorly. It has lost its symbolic function. It is no longer an art. [Before, there was] a scientific side and a very important human side. The evolution of medicine gives primacy to the scientific and technological side in relation to the other side. Medicine has fallen in with this technological evolution to the detriment of the human evolution of people. More and more, it’s computers, robots, technology. People (patients) no longer come to see a doctor, they come to see a guy to find out if he will use a laser or (…). We haven’t mastered the technological evolution… in any case, we haven’t put it to the service of humanity. Universities have also been excessively impressed by scientific and technological development and have put a lot of energy into it, to the detriment of human development. As physicians, we are increasingly becoming technicians, scientists and less and less a human consultant who has decisions to make. (physician, highly specialized, over 30 years in professional practice).
Conclusion
Social research in healthcare, along with an increasing number of clinical experiences, reveal the need to reunite medicine’s dimensions of cure and care under a single banner, or, as some would say, to promote the humanist approach central to medicine’s initial project.15 The “medicalization of medical practice” is a product of the refinement of biomedical knowledge. These advances generate a proliferation of competencies and the categorization of knowledge, sometimes to the detriment of biomedicine’s initial project in which care and competence are complementary. Such care implies a relationship, a context of multi-facetted exchanges among the various actors, in all their complexity.
If physicians were at one time powerless to fight disease due to insufficient means, today they are sometimes powerless because of these means. They are also often faced with choices that some years ago did not yet exist.
So long as we have no clear sign from society, setting our limits, we must do everything (physician, highly specialized paediatrics, 15 years professional experience).
Or again:
One of our biggest challenges today is, in 2006, to know how to use technology properly and [the question of] the allocation of resources. [...] What should we do when many patients are left waiting? [...] Because ultimately, this is also a challenge… to come back to the patient and decide… how far should we go with… this or that technology? And even when potential criteria are present, is it reasonable? Is it correct? Are we really making the best decision for the patient? (physician, highly specialized paediatrics, 5 years professional experience).
And here we can ask: Is technology an asset to medical practice or is practice at the service of technology? However, room must be left for nuance, as our research site is a leading-edge institution, removed from preventative medicine and primary healthcare services. As well, we must take into account the cultural heterogeneity and diversity of care perspectives within a given specialty or a same departmental unit.
Anthropologist, Margaret Lock (27) affirms that it would be an error to locate the current medicalization of biomedicine solely among physicians, pharmaceutical corporations and their private interests. Undoubtedly, many scientists are motivated by the ever- retreating technological horizon, but patients (clients) are also buying into it…16
In the words of one medical colleague, a paediatric specialist with thirty years professional experience:
The challenge in years to come, from the paediatric point of view, is to try to strike a balance between action and reflection, between science, technology and humanism, and what is individual and collective. I think we are far from such a balance. [...] Society itself fluctuates like a pendulum, swinging from back and forth. Rarely does it stop in the middle.17
Endnotes
1. With the exception of D. Laudy, ethicist, S. Fortin, F. Alvarez and G. Bibeau are members of the Inter-Cultural Pediatric Unit at Sainte Justine Hospital.
2. The hospital also has 1,300 nurses, 970 professionals, 160 researchers, 400 paraprofessional employees, 400 volunteers, and over 2000 interns and students from all fields [for 2005). It comprises eight departments: Anaesthesiology and Resuscitation, Biochemistry, Ophthalmology, Pathology, Pediatrics, Pharmacy, and Psychiatry.
3. In a pilot study, Gauthier et al. (1) found that more than 40 % of the institution's clientele were of immigrant origin. These were mainly Arab, Caribbean, South-American, and Asian populations.
4. See Kleinman (7).
5. This alliance also decreases risk for malpractice litigation (5).
6. Elsewhere we address challenges posed by pluralism in the medical milieu and the diversity of norms and values in the clinical context (12; 13; 14].
7. As an initiative to improve patient care, the “CanMEDS’” framework (for those in the Canadian program) insists on the following competencies needed for medical education and practice: medical expertise (central to the physician role); communication; collaboration; management; health advocation; scholarship; professionalism (see Figure 1).
8. “[As Communicators}, physicians enable patient-centered therapeutic communication through shared decisionmaking and effective dynamic interactions with patients, families, caregivers, other professionals, and other important individuals. The competencies of this role are essential for establishing rapport and trust, formulating a diagnosis, delivering information, striving for mutual understanding, and facilitating a shared plan of care. Poor communication can lead to undesired outcomes, and effective communication is critical for optimal patient outcomes" (16).
9. Source: http://rcpsc.medical.org/canmeds/index.php
10. The research team for this study includes S. Fortin, G. Bibeau (anthropologists), F. Alvarez (pediatrician), D. Laudy (ethicist) and research assistants M.E. Carle, G. Davis, E. Laprise and N. Morin. Funding has been granted by the Canadian Institute for Health Research (2005-2008) and the Inter-Cultural Pediatric Unit of the Sainte Justine University Hospital Centre (18).
11. By complex pathologies, we mean illnesses that are serious, chronic, evolutive, eventually debilitating, and sometimes fatal.
12. All participation was voluntary. More widely, the study protocol was peer reviewed and met the requirements of the Ethics Research Committee of the Hospital where our research is underway.
13. See Le Blanc (20).
14. Good and DelVecchio Good (21) also tackle this theme.
15. The Hippocratic Oath promotes a medicine that serves the sick, practiced benevonently. It avows to achieve the patient's well- being, and in order to do so, the maintenance of expert competence.
16. Due to limited space, we do not address this question here. It remains that the evolution of the role of patients is just as pertinent, as it is a question of relational dynamics in the midst of the clinical exchange.
17. Funding for this research has been granted by the Canadian Institute for Health Research (2005-2008), the Fonds de Recherche en Sante du Quebec (2004-2008) and the Int er-Cultural Pediatric Unit of the Sainte Justine University Hospital Center.
References
1. Gauthier A., Alvarez F, Bibeau G, Tapiero B, Turgeon J. Emergence d'une pediatrie inter culturelle a l'Hopital Sainte- Justine: penser la pluralite sociale et culturelle des familles. In: De Plaen S (ed). Soins aux enfants et pluralisme culturel, Collection Intervenir. Montreal: Hopital Sainte-Justine; 2004. p. 13- 30.
2. Bibeau G. Une anthropologie de l'enfant : cadre pour une pediatrie interculturelle. In : De Plaen S (ed). Soins aux enfants et pluralisme culturel, Collection Intervenir. Montreal: Hopital Sainte-Justine ; 2004. P. 107-37.
3. Haynes RB. Improving patient adherence : State of the art, with a special focus on medication-taking for cardiovascular disorders. In: Burke LE, Ockene LS, Armonk (eds). Compliance in Health Care and Research. New York: Futura Publishing; 2001. p. 3- 21.
4. Desmond J, Copeland LR. Communication with Today's Patient : Essentials to Save Time, Decrease Risk, and Increase Patient Compliance. San Francisco: Jossey-Bass; 2000.
5. Losh DP, Mauksch LB, Arnold RW. Teaching in-patient communiction skills to medical students: An innovative strategy. Acad Med 2005; 80(2):118-24.
6. Pellegrino E. From Medical Ethics to a Moral Philosophy of the Professions. In.Walter JK, Klein EP (eds). The story of Bioethics. Washington DC: Georgetown University Press; 2003. p. 3-15.
7. Kleinman A. The Illness Narratives : Suffering, Healing, and the Human Condition. New York: Basic Books; 1988.
8. Statistique Canada [homepage on the Internet]. Profil statistique : Statistiques demographiques pour Montreal (region metropolitaine de recensement) d’apres les donnees du recensement de 2001. Available from:ww21.statcan. ca/english/Profi101, 2005
9. Sainsaulieu I. Le malaise des soignants: le travail sous pression a l’hopital. Logiques sociales. Paris: l’Harmattan ; 2003.
10. Davis G. Pratiques cliniques, interdisciplinarite et complexite medicale a l’ere de la biotechnologie. Etude de la prise en charge des maladies chroniques dites complexes en milieu hospitalier pediatrique. These de doctorat en preparation, Departement des Sciences Humaines Appliquees, Universite de Montreal [forthcoming].
11. Lock M. Medical Knowledge and Body Politics. In: MacClancy J (ed). Exotic no more: Anthropology on the front lines. Chicago: University of Chicago Press; 2002. p. 190-208.
12. Fortin S. Les enjeux et defis d’une pratique pediatrique en contexte pluraliste: reflexions theoriques. In: De Plaen S (ed). Soins aux enfants et pluralisme culturel, Collection Intervenir. Montreal: Hopital Sainte-Justine ; 2004. p. 87-105.
13. Fortin S, Laprise E. L’espace clinique comme espace social : culture, competence, dynamique relationnelle. In Cognet M (ed). Les representations de l’Autre dans l’intervention : pour une ethique de Palterite. Quebec: Presses de l’Universite Lavai, collection Societes, Culture, Sante ; 2006 [in press).
14. Fortin, S. The Paediatric Clinic as Negotiated Social Space, (forthcoming).
15. Richard C, Lussier MT. La communication professionnelle en sante. Saint-Laurent : Editions du Renouveau Pedagogique Inc ; 2005.
16. Frank JR., Jabbour M & al. (eds). Report of the CanMEDS Phase IV Working Groups. Ottawa: The Royal College of Physicians and Surgeons of Canada; March, 2005. 17. Accreditation Council on Graduate Medical Education and American Board of Medical Specialties. General Competencies: Minimal program requirements language. ACGME and ABMS; September 1999.
18. Fortin S, Alvarez F, Bibeau G, Laudy D. Pratiques cliniques hospitalieres et pluralisme urbain : l'arrimage d'une pediatrie a la diversite de son milieu. Ongoing research funded by Canadian Institute for Health Research (CIHR) 2005-2008.
19. Lock M, Nichter M. Introduction: From Documenting Medical Pluralism to Critical Interpretations of Globalized Health Knowledge, Policies, and Practices. In: Nichter M, Lock M (eds). New Horizons in Medical Anthropology. London & New York: Routledge; 2002. p. 1-34.
20. Le Blanc G. Le conflit des medecines. Esprit. 2002; 284:71- 80.
21. Good BJ, DelVecchio Good MJ. Learning Medicine: The Construction of Medical Knowledge at Harvard Medical School. In Lindenbaum S, Lock M (eds). Knowledge, Power and Practice. The Anthropology of Medicine and Everyday Life. Berkeley: University of California Press; 1993. p. 81-107.
22. Lewis G. Double Standards of Treatment Evaluation. In: Lindenbaum S, Lock M (eds). Knowledge, Power and Practice. The Anthropology of Medicine and Everyday Life. Berkeley: University of California Press; 1993. p. 189-218.
23. Lindenbaum S, Lock M. Knowledge, Power, and Practice. The Anthropology of Medicine and Everyday Life: Comparative Studies of Health Systems and Medical Care. Berkeley: University of California Press; 1993.
24. Katz P. The Scalpel's Edge. The Culture of Surgeons. Boston: Allyn and Bacon; 1999.
25. Freidson E. Profession of Medicine. A Study of the Sociology of Applied Knowledge. New York: Harper & Row; 1988 [1st ed. 1970].
26. Pellegrino E. [homepage on the Internet]. Biotechnology, Human Enhancement, and the Ends of Medicine. The Center for Bioethics and Human Dignity. Available from
27. http://wwww.cbhd.org/resources/biotech/pellegrion_2004-11- 30_print.htm.
28. Lock M. Anthropologie medicale : pistes d’avenir. In: Saillant F, Genest S (eds). Anthropologie medicale: Ancrages locaux, defis globaux. Quebec: Presses de l’Universite Lavai ; 2005. p. 439- 67.
SYLVIE FORTIN, PHD, FERNANDO ALVAREZ, MD, GILLES BIBEAU, PHD, AND DANIELLE LAUDY, PHD
Sylvie Fortin, PhD, is an Anthropologist and Researcher in the Pediatrics and Anthropology Departments, Universite de Montreal, Montreal, CANADA.
Dr. Fernando Alvarez, MD, is a Pediatrician, Gastro-enterologist for the Centre hospitaller universitaire Sainte-Justine Hospital, and Full Professor in the Pediatrics Department, Universite de Montreal, Montreal, CANADA.
Gilles Bibeau, PhD, is an Anthropologist and Full Professor in the Anthropology Department, Universite de Montreal, Montreal, CANADA.
Danielle Laudy, PhD, is an Ethicist, Researcher (Department of Surgery), and Headmaster for the Trainees Ethics Curriculum at the Faculty of Medicine, Universite de Montreal, Montreal, CANADA.
Sylvie Fortin, PhD, is an Anthropologist and Researcher in the Pediatrics and Anthropology Departments, Universite de Montreal, Montreal, CANADA.
Danielle Laudy, PhD, is an Ethicist, Researcher (Department of Surgery), and Headmaster for the Trainees Ethics Curriculum at the Faculty of Medicine, Universite de Montreal, Montreal, CANADA.
Fernando Alvarez, MD, is a Pediatrician, Gastro-enterologist for the Centre hospitalier universitaire Sainte-Justine Hospital, and Full Professor in the Pediatrics Department, Universite de Montreal, Montreal, CANADA.
Gilles Bibeau, PhD, is an Anthropologist and Full Professor in the Anthropology Department, Universite de Montreal, Montreal, CANADA.
Copyright Bioethics Press Spring 2008
(c) 2008 Ethics & Medicine. Provided by ProQuest Information and Learning. All rights Reserved.