Principles of Healthcare Ethics, Exercises of Ethics

Download Principles of Healthcare Ethics and more Exercises Ethics in PDF only on Docsity! CHAPTER 2 Principles of Healthcare Ethics Jim Summers INTRODUCTION Chapter 1 of Health Care Ethics: Critical Issues for the 21st Century presented the major ethical theories and their application in health care as part of a foundation for the study of ethics. This chapter extends that foundation by showing how those theories inform the principles used in health care and apply to the issues in that field. The principles commonly used in healthcare ethics—justice, autonomy, nonmaleficence, and beneficence— provide you with an additional foundation and tools to use in making ethical decisions. Each of these principles is reviewed here. The concept of justice is presented last because it is the most complex. In addition, this chapter presents a model for decision making that uses your knowledge of the theory and principles of ethics. NONMALEFICENCE If we go back to the basic understanding of the Hippocratic ethical teaching, we arrive at the dictum of “first do no harm, benefit only.” The principle of nonmaleficence relates to the first part of this teaching and means “to do no harm.” In healthcare ethics, there is no debate over whether we want to avoid doing bad or harm. However, the debate occurs when we consider the meaning of the word harm. The following ethical theories come into play here: e¢ A consequentialist would say that harm is that which prevents the good or leads to less good or utility than other choices. A natural law ethicist would say that harm is that which is opposed to our rational natures, that which circumscribes or limits our potential. e A deontologist would say that harm is that which prevents us from carrying out our duty or that which is opposed to the formal conditions of the moral law. e A virtue ethicist—a person seeking eudaimonia, a person of practical wisdom—would find that harm is that which is immoderate, that which leads us away from manifesting our proper ends as humans. e An ethical egoist would define harm as that which was opposed to his or her self-interest. What Is “Harm” in the Clinical Setting? In the clinical setting, harm is that which worsens the condition of the patient. However, deciding what harm or worsen means is no simple matter. Much of health care involves pain, discomfort, inconvenience, expense, and perhaps 47 48 HEALTH Care Eruics even disfigurement and disability. Using the natural law theory of double effect, we justify harm because there is a greater good. A consequentialist would say that the greater good, the greater utility, occurs from accepting the pain or dismemberment as part of the cost to get the benefit the healthcare procedures promise. The due care standard to provide the most appropriate treatment with the least pain and suffering sounds almost like a deontological principle.* Most healthcare workers consider harm to mean physical harm, because the long history of healing has focused primarily on overcoming bodily disorders. However, harm can occur in other ways. For example, healthcare managers can cause harm by failing to supervise effectively. The result may be inadequate staff or a lack of equipment that is maintained or kept up-to-date. Either of these can lead to adverse patient outcomes. Harm also comes from strategic decisions that lead to major financial losses and jeopardize the ability of the organization to continue. At a different level of harm, making the decision to dispose of hazardous materials without taking proper precautions puts the community at risk. In another example, healthcare policy makers can cause harm by changing eligibility requirements that lead to patient populations being unable to afford or to access the care they need. The ways in which harm can occur are infinite. Harm as Negligence Given the vast number of ways in which harm can occur, healthcare workers have developed numerous protocols to protect patients, families, the community, and themselves. Failure to engage in these protocols is an act of omission, as opposed to directly doing harm, which is an act of commission. A substantial body of law and ethical understanding supports the view that such a failure is negligence (omission). The person has not exercised the due diligence expected of someone in his or her role. Healthcare financial managers also face a number of laws to ensure that they are not engaging in fraud and abuse, which also cause harm. For example, failure to follow the expectations of good financial management is essentially malfeasance. This term is very close to maleficence and represents neglect of fiscal responsibility. Medical professionals find a similar term with malpractice. Part of the education of all healthcare professionals concerns what it takes to avoid doing harm, to ensure that due diligence is followed. Part of the development of a healthcare professional is to create a person of integrity who would consider it a violation of self to put those who trust in him or her at risk. Persons who avoid this violation are persons of practical wisdom. They have achieved eudaimonia in their professions and in their lives. They can sit down together and discuss what they should do in a complex ethical situation. In the healthcare community, we believe that persons working within the healthcare ethic share a common understanding of the mission, vision, and values of health care. They are able to reason together, even if they get to their conclusions by different ethical theories and principles. The shared values of “first do no harm, benefit only” provide a foundation that is often lacking in ethical disputes outside of health care. Principles of Healthcare Ethics 51 avoid discussion of a sexually transmitted disease. Drug abusers may hide their condition for fear of job loss. An interesting approach to competence is the idea of specific competence, as opposed to general competence.* Competence can be understood as the ability to complete a task. This may mean you are able to do and understand some things, but not others. For example, a person with a transient ischemic attack might be unable to balance a checkbook. However, that same person might be able to understand the consequences of medical procedures and thus assent to them or not. This is an example of specific competence. A person may be inter- mittingly competent owing to his or her medical condition. Thus, the person is competent to assent to treatment right now, but was not two hours previously, and might be unable to do so two hours in the future. At this point, we have seen the importance of nonmaleficence, beneficence, and autonomy as principles of healthcare ethics. Now we move to the last of the four principles of healthcare ethics: justice. THEORIES OF JUSTICE In general, to know something is unjust is to have a good reason to think it is morally wrong. We can ask, “What sorts of facts make an act unjust rather than simply wrong in general?” Several reasons are available. People use the term injustice to mean unfairness in treatment. Injustice in this sense occurs when similar cases do not receive similar treatment. Following Aristotle, many believe that we are required, as a formal principle of justice, to treat similar cases alike except where there is some relevant or material difference. The equity requirement in this 2,400-year-old principle is critical. Now I shall break down the concept of justice into its components. Justice usually comes in two major categories: procedural and distributive. Procedural justice asks, “Were fair procedures in place, and were those procedures followed?” Distributive justice is concerned with the allocation of resources. In some cases, both of these issues will be in play at the same time. Both justice principles start from the idea that in the distribution of burdens and benefits the allocation should be equal unless there is a material reason to discriminate. Procedural Justice Procedural justice can be defined as “due process.” For example, in the legal system, we speak of being equal before the law as a part of procedural justice. In the legal sense, then, procedural justice or due process means that when you get your turn, you receive the same treatment as everyone else. One can apply this concept to health care. For example, if you are waiting to see your primary care physician, did others get to go ahead of you without any clear medical reason? Procedural injustices occur in health care, but they are more common when dealing with employees. For example, if a healthcare manager has to terminate employees due to economic considerations, are the procedures for determining who will go applied without bias? In such cases, the issue is not. so much whether what happened was in itself just or fair, but whether the method used followed the stated procedures. No one would claim that it is 52 HEALTH Care Eruics fair to terminate good employees with long careers of service who have done nothing wrong. However, if economic circumstances dictate that there must. be terminations of employees, the procedural justice question emerges as to whether there were standards and procedures for making the selection and whether they were followed. Failures of due process can also occur in the health policy arena, and those participating in policy making carefully watch for these failures. For example, suppose that at a public hearing, the time limit for speaking is 3 minutes. You will not think justice is done if some are allowed to speak 10 minutes, whereas others are constrained to 3, or perhaps told to sit down after only 1 minute. We now turn to a review of the principles of distributive justice. Distributive Justice The concept of distributive justice relates to determining what is fair when decision makers are determining how to divide burdens and benefits.° Kaiser Family Foundation data suggest the extent of the resource allocation disparity in healthcare demand and spending.® One percent of the U.S. population consumes 23.7% of healthcare resources. Half the U.S. population consumes only 3.4% of healthcare resources. The other half consumes 96.6% of health- care resources. This is an extraordinary mismatch in the use of healthcare resources. Is it fair? When it comes to distributive justice, several questions can emerge. Why are so many using so little? Are they healthy or simply unable to access the system? Are we seeing an improvement in the lives of that 1% who are taking up nearly 25% of the spending, whether measured by the patients or by the medical community? Are there less expensive ways to achieve healthcare goals? Do the healthcare goals, whatever they are, make sense relative to the world in which we find ourselves? Such questions are debated endlessly; however, they will not sidetrack us here. The point is to see the difficulty of the task of distributing the burdens of healthcare costs while seeking the holy grail of affordability, availability, and quality all at the same time. To understand distributive justice, you must first understand that resource allocation issues occur at all levels. For example, a physician has to decide how much time to spend with each patient. Busy nurses have to decide how quickly to respond to a call button relative to the task they are engaged in when it sounds. Nurse managers have to allocate too few nurses to too many patients. Healthcare managers hire employees. If they are going to increase pay, they must decide what method to use. Should the increase be across the board or by merit or seniority? If by merit, then who decides whether employees deserve it, and is the method fair? The latter question is one of procedural justice. This is an example in which the two types of justice often occur together. Organizational leaders have to decide whether to spend scarce money on cap- ital improvements on buildings and equipment, new employees, more money for the current employees, new services, or advertising, or whether to save the money. In health care, allocation of scarce resources can be a matter of life and death. For example, in Texas, persons with AIDS and HIV infection pleaded at a Texas Department of Health public hearing that funding not be cut. On the line Principles of Healthcare Ethics 53 was a drug-assistance program facing budget cuts. The drugs for this treatment cost $12,000 per year, and the state was considering only allowing coverage if income levels were not in excess of $12,400. If a person made $13,000 a year, he or she would have only $1,000 on which to live. Desperation prevailed, as people told the panel to look them in the eye so they would know who they were killing. Attendees promised “not to slip quietly into their graves.” Regardless of the outcome of that policy decision, in the midst of such emotions the need for the reflective equilibrium (discussed later in this chapter) is high. Decisions are difficult when you are facing people who claim they are in such a crisis. One can explore many related issues to understand why decisions are made with regard to distributive justice. Material Reasons to Discriminate The basic principle of distributive justice is that each person should get an equal share of the burdens and benefits unless there is a material reason to discriminate. What are the reasons to discriminate?* The multiple reasons to discriminate typically boil down to two different concepts: that the person deserves it or the person needs it. Society believes that those who work hard and do well deserve their success. That is the common morality in the United States. In contrast, a person who breaks the law and hurts people deserves prison. Health care shares this common morality but also includes a more complex element—need. The following list includes the most common candidates for material reasons to discriminate, all of which are subsets of need or being deserving. 1. Being deserving or worthy of merit includes one’s contribution or results and effort. 2. It also includes the needs of individuals or groups, such as the following: ¢ Circumstances characterized as misfortune ¢ Disabilities of a physical or mental nature or, more generally, unequal natural endowments e A person’s special talents or abilities ¢ The opportunities a person might have or might lose e Past discrimination against a group that is perceived as having negative effects in the present. Structural social problems perceived as restricting opportunity or even motivation In the larger society, there is also a need to discriminate based on material need. One of society’s views of distributive justice is that you get what you deserve or merit. Your results or contribution is what counts the most in getting what you deserve. The most common form of getting what you deserve in the larger society comes from the market. Therefore, if you are good at what you do, the market rewards you. If you are not, the market does not reward you, or even punishes you. For example, the physician who sees the most patients is some- times the one with the higher income. Healthcare managers who meet revenue or productivity goals should get higher pay than their peers who fail to do so. 56 HEALTH Care Eruics legal rights. When someone makes a claim that something is a right, the typical reaction of the other party is to consider the basis of the claim. Is it a legal one? Is it moral? Alternatively, is it simply a wish or a statement of a preference? Ways of Categorizing Rights The diagram in Figure 2-1 shows the types of rights and their relationships. One can find all the rights within the circle of ideal rights, which are rights we wish we had. Rights that are within another circle are subsets of that right. Rights that are partially within one or more other circles are rights that share common characteristics with their shared circles. For example, natural rights include elements of substance rights and negative rights. Some of the sub- stance rights and negative rights have become legal rights. A positive right is a certain type of thing or social good to which you have a legal right. All positive rights are a subset of legal rights. The size of the circle also indicates the relative importance of each type of right within the common morality of the United States. For example, in the United States our common morality puts more emphasis on negative rights than on substance rights. Some other nations place a greater emphasis on the collective welfare as opposed to individual opportunity. In these cases, the substance rights category would be larger, and more of it would fit inside the legal rights circle. The list of rights here is by no means exhaustive. The following discussion of the types of rights in Figure 2-1 provides a synopsis of the issues involved. | Legal Rights Rights Positive \ } / “E Rights Ideal S Figure 2-1 Types of rights and their relationships. Principles of Healthcare Ethics 57 Major literature exists on the topic of rights and includes others that are not part of Figure 2-1.! The best of all rights, from the point of view of the claimant, are enforceable and legal rights. Legal and Positive Rights Margaret Mahoney notes that positive rights used to be called “social goods,” which society may or may not provide. The change to calling them “rights” was part of a rhetorical technique to give them a greater sense of legitimacy to the public. A legal right means that someone has a legal obligation to fulfill your right, whatever it happens to be. A positive right is a narrow example of a legal right, because it is a specific social good. For this reason, it is shown in the diagram in Figure 2-1 as a circle completely within the set of legal rights. These rights are written into the law and are described as entitlements. However, a legal right can include more than simply entitlements. For example, the legal system protects the right to due process, but it is not the provision of a good. One could say the same of the legal right to privacy under HIPAA (Health Insurance Portability and Accountability Act) laws. Thus, like due process, a right to privacy is not a positive right even though it is a legal right. When rights are under pressure because of budget shortfalls, political pressure to cap government spending, or the like, the real meaning of a legal right is that you can go to court to get it enforced. Legal rights are not as strong as they were once thought to be in protecting the person with the right. For example, you may have a legal right to abortion or to Medicare and Medicaid, but if no one is providing it, your right has little value. Apparently, even the strongest version of a right does not mean that you will be able to exercise whatever rights you have. Substance Rights Substance rights can be legal rights or not. They are rights to a particular thing, such as health care, housing, a minimum wage, welfare, food stamps, safe streets, a clean environment, and the like. In this sense, they are similar to positive rights, but not necessarily legal, as with an entitlement. This is somewhat of a nuanced difference, because a substance right might imply that it is a right to something basic needed to maintain life. Nations, such as those in Europe, can be concerned with substance rights and attempt to guarantee an outcome or a basic minimum for their citizens. In those nations, the substance rights became legal rights. The positive legal rights noted earlier for health care also are substance rights, as would be the right in the United States to get treatment, or at least be stabilized, at an emergency department regardless of ability to pay. Negative Rights In Figure 2-1, based on the common morality of the United States, the circle for negative rights is relatively large and extends into the legal rights domain. The terminology used for negative rights comes from the British tradition and essentially means that you have the right to be left alone. You have the right to do anything not strictly forbidden by the law. 58 HEALTH Care Eruics Negative rights are clear and enshrine liberty. For example, the Bill of Rights is primarily a list of negative rights, such as that speech and assembly will not be restricted. The Bill of Rights also includes the idea that a state will not enforce a religion. It also reinforces the negative right that allows people to have weapons because “a well-regulated militia, being necessary to the security of a free state, [means] the right of the people to keep and bear arms shall not be infringed.” In the realm of health care, one major negative right is that we have the freedom to pursue our lives as we see fit. For example, motorcyclists claim they have a negative right to be free from having to wear protective helmets. Another negative right enshrined in law in some places is the right not to have smokers in your workplace, eating area, or public areas generally. Smokers maintain this is a major affront to their freedom. One person’s negative right to be free of smoke is the cancellation of another person’s negative right to be free to smoke. Other legal protections that ensure you are left alone involve the protections against sexual harassment and hostile work environments. The privacy protections in HIPAA are yet one more legal negative right. Your medical information cannot be accessed unless you authorize it or for medically necessary reasons related to your care. As in the case of positive substance rights, the costs on the part of those who must honor or take responsibility for ensuring you are free of these hazards can be large. Process Rights Given the Bill of Rights, many laws relate to ensuring that due process is followed, at least for most people. As noted in the discussion of the layout. of the diagram in Figure 2-1, process rights do overlap with natural rights. In the United States and in most developed nations, process rights also are legal rights. Natural Rights Natural rights have a long history. The concept of a natural right means that we should respect attributes that humans have by nature." For Aristotle and St. Thomas Aquinas, these features would be those that best support. our achievement of our highest good. The appeals to natural rights within our common morality that are most well known go back to the Founding Fathers. Drawing heavily on John Locke, Thomas Jefferson proclaimed in the Declaration of Independence “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty, and the pursuit. of Happiness.” One practical advantage of the natural rights approach to determining a person’s rights is that people from very different perspectives use the same language. Thus, even if their views are philosophically inconsistent, they can agree that someone has a natural right. For example, many will say that there exists a natural right to that which is necessary to move toward one’s full potential, and health is important to this. To the extent that health care is related to health, one should be able to sustain the argument that morally one Principles of Healthcare Ethics 61 As discussed earlier, ethical principles include advancement of liberty, respect for autonomy, and acting out of beneficence to advance welfare. They also include ensuring that we do nothing to cause harm by following the principle of nonmaleficence. We try to do this all fairly by upholding principles of justice. The typical portrayal of the healing ethic—first do no harm, benefit only—captures at least two of these principles: nonmaleficence and beneficence. The questions become just what to do. In the midst of all the decision making, the people involved are unlikely to consciously draw on ethical theories or principles. They have internalized these foundations for making decisions and simply do so. This is what it means to be a person of practical wisdom, a person exhibiting eudaimonia as described in Chapter 1. The term reflective equilibrium describes this back-and-forth process of coming to a coherent solution. John Rawls has described this method,'® and its hallmark is its lack of dogmatism. The person involved in making the decision revises the decision as new information becomes available. The person may choose to draw on one principle or ethical theory more heavily than he or she did in previous decisions. Such movement back and forth among competing ethical theories and the quick reweighing of the importance of ethical theories and principles can sometimes look like incoherence or arbitrariness. However, people making healthcare decisions are not as troubled by the requirements of doctrinal purity as they are by the need to come to a decision. They need to have a sound ethical basis to explain that decision, get action on that decision, and get on to the next task. Ethical theories and ethical principles can help them to reach those decisions, explain them, and motivate others to act decisively, urgently, or passionately on them. With this foundation, the outcome is better, assuming the decision was sound. If not, the reflective equilibrium begins again. For this reason, the author chose the toolbox approach to better equip healthcare decision makers with an understanding of the principles and theories of ethics, so they can better decide, better explain, and better motivate. As Beauchamp and Childress put it, disunity, conflict, and moral ambiguity are pervasive features of moral life. Thus, it should be no surprise that untidiness, complexity, and conflict should be part of the process, too.'® SUMMARY The principles of healthcare ethics complete the elements necessary for the reflective equilibrium. The primary principles of healthcare ethics are autonomy, beneficence, nonmaleficence, and justice. Justice is by far the most. complex principle, because it includes various conceptions of rights and there is greater dispute about what justice is and how to achieve it. Understanding the various nuances of rights and justice is of considerable importance in making resource allocations at the bedside, at the organizational level, or at the health-policy level of government. In using the reflective equilibrium model, a person will have to use reason to pick from among the principles, the theories, the common morality, and the considered judgments to apply them to the issue at hand. In health care, 62 HEALTH Care Eruics we have a great advantage over most organizational approaches to dealing with ethical issues. Given the tradition of ethics committees and consults, a group of persons who are skilled and experienced in applying the reflective equilibrium is more likely to reach a decision that is reasonable than is a single person. This process will be messy; it will be error prone. That is the human condition, and there seems to be no way around it. Ethics is a complex field. Over thousands of years, humans have yet to develop an ethical theory that will satisfactorily handle all the issues. Nonetheless, some approaches have proven more satisfactory than others and have led to the development of principles. You might ask, “Now what?” Are there any final answers for healthcare issues now and in the future? The answer is “no.” However, the important role of the study of ethics and ethical issues and the use of the reflective equilibrium model is to keep the inquiry going. The process matters as much, or even more, than the products. Although there was acceptance of certain beliefs for relatively long periods, the process eventually leads to a change. Let us hope the changes will result in improvement to our lives and an increase in the good. It is the job of each of us to keep the process going. QUESTIONS FOR DISCUSSION 1. What do you think is the most important principle for clinical healthcare professionals? Explain. 2. Why is beneficence a more complex principle than nonmaleficence? 3. Why is respecting autonomy so important to the future of health care? 4, Why is justice in health care more complicated than just doing what is fair? 5. How can the reflective equilibrium model assist you in making practical ethical decisions in the future? FOOD FOR THOUGHT Today’s healthcare system presents and will continue to present ethical challenges. Consider what Summers teaches us about the principles of ethics. How can you make these principles part of your day-to-day practice of medi- cine? Will you have to make some difficult choices to remain an ethics-based practitioner? NOTES 1. See E. E. Morrison, Ethics in Health Administration, 2nd ed. (Sudbury, MA: Jones and Bartlett, 2011), 48. 2, J.J.C. Smart, “Distributive Justice and Utilitarianism,” in Justice and Economic Distribution, ed. J. Arthur and W. Shaw (Englewood Cliffs, NJ: Prentice Hall, 1979), 103-115, esp. 103. In contrast, Richard Hare, also a consequentialist, specifically disavows that intuitions are 2 o eo ~ 10. 11. 12. 13. 14, 15. 16. 17. 18. 19. Principles of Healthcare Ethics 63 a sufficient base for an ethical theory; R. M. Hare, “Justice and Equality,” in Justice and Economic Distribution, ed. Arthur and Shaw, 116-131, esp. 117. D. Goleman, “The Roots of Compassion,” New York Times, December 19, 2006. Retrieved from http:/happydays. blogs. nytimes.com/2006/12/19/the-roots-of-compassion/?8ty&eme=ty. Accessed November 29, 2011. The author of the article surveys brain research and finds that humans may be hard wired to have empathy, compassion, and thus beneficence. T. L. Beauchamp and J. F. Childress, Principles of Biomedical Ethics, 5th ed. (New York: Oxford University Press, 2001) point out this early history on page 166. This approach was pioneered by Beauchamp and Childress, Principles of Biomedical Ethics, 5th ed., who point out this history on pages 70-72. Robert Nozick, in Anarchy, State, and Utopia (New York: Basic Books, 1974), 149-150, argues that the very language of “distribution” implies a central organization deciding who gets what and why. To him this improperly frames the discussion to imply a state and its attendant mechanisms when the problem is the state itself and its inevitable oppression. Kaiser Family Foundation, “Illustrating the Potential Impacts of Adverse Selection on Health Insurance Costs in Consumer Choice Models,” November 2006. Retrieved from http://www .kff.org/insurance/snapshot/chcm1 11006oth2.cfm. Accessed November 29, 2011. M. A. Roser, “Don’t Cut State Drug Funds, AIDS, HIV Patients Plead,” Austin-American Statesman, January 17, 2003, B1, B6. Arthur and Shaw, eds., Justice and Economic Distribution, 1-11 was helpful here. World Health Organization, “About WHO.” Retrieved from http:/hwww.who.int/about/en/ index.html. Accessed November 29, 2011. L. Armstrong, It’s Not About the Bike (New York: G.P. Putnam’s Sons, 2000), 108-109. For a sampling of complaints, see K. Hausman, “Mentally Ill Workers Rarely Prevail in ADA Discrimination Claims, Survey Finds,’ Psychiatric News 37, no. 16 (2002): 6. See also M. Weiss, “Study Finds Discrimination Against Disabled Patients,” ABCNewsHealth.com. Retrieved from httpy/abenews. go.com/Health/story?id=2633 167 &page=1&CMP=OTC-RSSFeeds0312. Accessed November 29, 2011. See also R. Longley, “Disabled Face Discrimination in Rental Attempts” About.com. Retrieved from http:/Aisgovinfo.about.com/od/rightsandfreedoms/a/disablerents. htm. Accessed November 29, 2011. See L. Wenar, “Rights,” Stanford Encyclopedia of Philosophy, 2011. Retrieved from http:// plato.stanford.edu/entries/rights/. Accessed November 29, 2011. M. E. Mahoney, “Medical Rights and the Public Welfare,” Proceedings of the American Philosophical Society 135, no. 1 (1991): 22-29, especially 23. Wenar, “Rights,” was helpful here. See especially section 6.1 on status rights. Retrieved from http:/plato.stanford.edu/archives/fall2006/entries/rights/. Accessed November 29, 2011. Associated Press, “Veterans Lose Health Care Suit Against Pentagon,” Washington Post, November 20, 2002. Retrieved from www.americasveterans.org/news/112002.html. Accessed November 29, 2011. For a sample of unhappy commentary, see M. Marquez, “Government Must Honor Promises from the Past,” Austin-American Statesman, January 21, 2003: A11. J. Rawls, A Theory of Justice (Cambridge, MA: Harvard University Press, 1971), 47-48. Arthur and Shaw, eds., Justice and Economic Distribution, 10. Rawls, Theory of Justice, esp. 20-21, 48-51. Beauchamp and Childress, Principles of Biomedical Ethics, 5th ed., Chap. 9, especially 389-390.