This thesis is an exploration of professional behaviour in health care settings, using a Model of Treatment Engagement that is developed as a tool for ethics critique. The Model is tested and refined using data on: a psychiatric ???treatment??? carried out on over 1,127 occasions in a 15 - 40 bed non-acute hospital during the period 1961-1979; the problematic withdrawal of all life-support from a 37 year old man who had suffered acute brain trauma some five days previously, in a tertiary hospital in March 2000; and a clinical experiment recently proposed for the emergency setting and intended to encompass five hospitals and the NSW Ambulance Service. In each case, the Model proves useful in identifying the shift from the treatment paradigm and the ethical imperative of ensuring the patient (or his/her agent) appreciates the difference between what is proposed and what would normally be done. It reveals how doctors who dealt with the patient but did not decide on treatment contributed to ethically troublesome practice. It clarifies how having multiple doctor players in the treatment situation gave rise to the need to suppress dissenting views. Doctors who were close enough to the action to comprehend its nature, by not dissenting, reinforced the problematic choice for the actor and validated it in the eyes of observers. The lack of dissent at the level of doctors working under supervision, appeared to be a function of institutional arrangements. At the consultant level, there was evidence of pressure to concur from other consultants and indirect evidence of a fear of ostracism. The public responses in the two modern cases point to there being a strong idea in Sydney???s medical community that dissent should not be publicly displayed once a decision on how to treat has been made. I conclude there are two steps to reviewing ethically problematic treatment situations. The first consists of identifying the shift from the treatment paradigm. The second consists of establishing why the problematic choice is translated into action. The Treatment Engagement Model is put forward as a useful tool for both these analyses.

This thesis is an exploration of professional behaviour in health care settings, using a Model of Treatment Engagement that is developed as a tool for ethics critique. The Model is tested and refined using data on: a psychiatric ???treatment??? carried out on over 1,127 occasions in a 15 - 40 bed non-acute hospital during the period 1961-1979; the problematic withdrawal of all life-support from a 37 year old man who had suffered acute brain trauma some five days previously, in a tertiary hospital in March 2000; and a clinical experiment recently proposed for the emergency setting and intended to encompass five hospitals and the NSW Ambulance Service. In each case, the Model proves useful in identifying the shift from the treatment paradigm and the ethical imperative of ensuring the patient (or his/her agent) appreciates the difference between what is proposed and what would normally be done. It reveals how doctors who dealt with the patient but did not decide on treatment contributed to ethically troublesome practice. It clarifies how having multiple doctor players in the treatment situation gave rise to the need to suppress dissenting views. Doctors who were close enough to the action to comprehend its nature, by not dissenting, reinforced the problematic choice for the actor and validated it in the eyes of observers. The lack of dissent at the level of doctors working under supervision, appeared to be a function of institutional arrangements. At the consultant level, there was evidence of pressure to concur from other consultants and indirect evidence of a fear of ostracism. The public responses in the two modern cases point to there being a strong idea in Sydney???s medical community that dissent should not be publicly displayed once a decision on how to treat has been made. I conclude there are two steps to reviewing ethically problematic treatment situations. The first consists of identifying the shift from the treatment paradigm. The second consists of establishing why the problematic choice is translated into action. The Treatment Engagement Model is put forward as a useful tool for both these analyses.