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By Max J. Charlesworth

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If physicians are helpless against such agencies, patients are doubly so. It will take larger changes in state and federal laws and financing mechanisms governing health care to restructure the system in ways that will benefit all patients, not just those with enough money, persistence and savvy to work the system. Without such reforms, health care will remain inefficient and inequitable, and patients' efforts to transform the doctor-patient relationship will have only limited impact. 46 -59All this is especially relevant to the question of making the hospital, and the health-care system generally, sensitive to the autonomy of the individual patient, particularly in the delicate but momentous area of patients making decisions about the manner of their dying.

Again, extra-hospital health-care contexts should be built up to provide genuine choices for patients. The hospice movement for the care of the terminally ill is a good example of what might be done here. As a US observer has argued: With health care becoming more bureaucratised, there are limits to what can be achieved at the doctor-patient level in structure, content and process. Increasingly medical care is being determined not by individual physicians but by large institutions that employ or reimburse them.

Thus, for example, the Akamba people of Kenya take the view that older males should be saved before younger males because the former usually have a larger and more complex network of relationships with others in the community and thus their death would damage more people. 25 Again, even within our own mainstream community there can be very deep differences about these matters between, for example, rural and urban people. 26 In a liberal society which has ethnic and religious minorities within it, these different views about death and dying and whether or not we have a right to die as we choose have of course -44to be tolerated, and physicians and health carers must be sensitive to them in providing appropriate medical treatment.

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