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Citation: 40 J.L. Med. & Ethics 359 2012
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Attendin to Patients Need n
tbe nfnoried Consent Process
&l Siegal,RichardJ. Bo
[ntroduction: Impediments to
Informed Consent
[n an explicit attempt to reduce physi
s<
bec
hea
a ft
infco
the inft
ter
iStics,6
h~
ISE
cel
ibodi the
s shoi be
>f decisions that relate to their bodies
Fh< corollary obligat ion of physicians - to
tor
ase
sent procec
However, there a
deliberation
the n
when hysi
alicy i7
health
ns ofter
ssft
tel
D LL.B., S.J.D.,
Virginia School Of
zlth Law and Bioel
r Researcher at the
d. Richard J. Bo
addressed
e is another
Dfthe inft
consent do(
Ssuccessf
bst
e very he
ick of pati<
flow of infc
th e infc
have
Physicians
vb
te<
ent prior to
0 trea
Thatever the sta:
rd the
LL.B.,
Srofessor of Medic
nd L(
>unda,
Sc
1P
ychia ry and
d
:-Policy, and B
,id Pu 5lic Polie
lum, M.
Ty, Medi
if these
isclosure of specifie info
ed
by the hysi
asonab1
S ome states have adlopted th
of
stand
ning tlhe
infor:
that
Eionshoul be
by
tors ("what wo
their
>able patie:
to make a deci
vhile others
to kn
("wha
EdardIfc
to the asonable physi cian" stain
h
ible physi
Isi
ift
sO sul
nd ab1
perso
ta me
af
Dnot.9 The acceptet
ft r this information
ractical
g physi
of facili
by thei
to live up to
Si
info
iake educated decis
isclosi
5E
aft
to patient self-deter
Gil Sil
and other beh
ial" decision-making? h~ave cast doubt
Iapacity to understand e disclosed inft
nake choices that acct tely reflect thei
he
Sf :ilitate patient au tonomy - is reflected
it have been crea ted to implement conofrelevant
to compreh<
ssary health literacy a
)hysicians' disclosures,
h~
car(
lbaum
5,andPaul S.A;
tion, the re,
4e
the informa
be in a posi
S.
id Law, and the
ychiatryin theD
,rsity andNew H :St
EGHT TO
ibl1
is rel
>f informati
sclosi
is that given
inforr
it will be ab1
rantto her ch
iake
, she
Eh
ify
e
E
hat to
h
if
her decisi
when pre.,
Eh
astive infoi
fer to this
assistance
rei
tei
inform
s - i.
bE
)rofessional <c itidence in tf
>ersonag
that is relevan
cess. As a r( 11t, some phi
ft ffvaueo tconfet 5
les the Irature o
heloft
bombardin, their patieni
Fhis is on Sreasoi
ation ("overl "), which sti
obst
wh
ch
f gei tine "informed asent"i
atient's neecd or despairirn
valueinofmtin
the
et
cess
rather
tha
t.
fp
At fen earacterize
ng such an <( -:ensive discle
dictb
fity
andoshaki
ifortunately, th,
-rocess of inf
close some r aimal amoui
sto n-making is n<( Dften re
fE-actice. Instea(
thei elves to liabi
axposing
oeif information
a
rb
for reasons we dl ribe bE
s
retrospecti,
ngful dialogu
to be insufficient. Unc rtainty is als hl
be tween doctors
sh. initoo often bee n
A by
dis placed by a sty
)fr
'esentations
rbid
g and signing
for *M.
erns
-ders,5concur
-reatments,I
Df symptoms, degri Ofmedical lite
hc lake
The Ritual of InformedConsent
stan dard disclosure (Suc
is tnose re(
dby
th
ifo
th
Most agree that the commonplace rituial
of informe
0nsent - focused as it is on the pr esentation an
has many flaws.12Viewe
s igning of a consent form ffrom the patient's perspective, what sh(ould be an ite
tive, personalized process of receiving and absorbin
nformation and seeking clarification oir further infor
nation has become standardized an d inflexible, a
hysicians attempt to comply with a du ity to inform a,,1
ible" r ininer. As a resul-t
s<
-inforr ie(d, while otherrs
be
from i rhcat is importan
be
te diffEreint than what a
them (w]hich
easonable pati
to0nt
k
3ble to
ercise a ri ght not to kno .One might sa
ponse,
IS
iat the int(erests of both )arties - phys
1patients - have to be t Lken into accoiunt in fori
ing rules for informatic a disclosure. ASrequirerr
for in
alized or "subjI
ed disclost
ephysicians w tho
woul,
3ictical wa )f
tbility for faili to
avoicd
vhat inforl
tion ,
-now. Ind(
5i
for ju
subj
hE
is
y
on in
of the
able
When the problem ais viewed in thus way,
ized disclosure migh,t be seen as a logical ft
Lst
lardf the
law's effort to formu late a predictable rul
the current approaclh has by no means elii amatect the
risk of physician liab ility for failure to obta i informed
consent. To the con atrary, many physicik is are still
instates
uncertain what is e xpected of them, eve .1
that accept the "reas onable physician" stal
dard. Even
when standardized disclosures have bee i endorsed
by professional bod lies or risk managem
courts have occasio nally ruled that the 1
fail-
entitled to other inft
ure to disclose inforr
in those cases amoui
consent, thereby cre
O
>fa
about t E patLient's wish
mportantly,
ns of in
1sent
Dspect, w b
to obtain infe
are mao
:come has al
d. A
vh
ha
to
0der
ascer
)f sp
h re altered the patient's decision, t1
1t for physic -iansto counter pat
1ients
would h
ave chosen a differer
if nly the infor mation had been ava
juries, like e,,ver,yone else, are influe
"hindsight bias""- i.e., the tendent
t
since a risk 1
the patient w
sition of liabi
consecluence
to laintiffs
to
0 a given p
to a fa
onstruct
ith
rejected
-ethat foci
for infori ation in fi
of disclosi
st
uate
0applicable
profeassional associc .ons)
e time of the rn lical teraction.
sum, obtainir the ttient's inft
hE ended to beco
zet
an eth
in which physi ,ians are obey
legal
to inft
ee of uncertain
cer
("be
ucope
your
rhich
nt"), and ofter acting deferE
y,and
>f infoi
,nts lack conti 1 over the f
leaving them
ift
both for be
relative to thei .decisional new ds and of receivin
nf
information t1 an they need i r desire. This su . f
unwanted infe rmation can di tract them fromI
evant issues, 16 leave them urn luly worried aboxu
iscule risks,7 nd possibly le, id to decisions c(
to their real -*A fshes. This is all the more dist -bi
>f
because preoc cupation with the "legal sufficit
the disclosurE 'makes physi -ianscvnical abc
th
whole exercise (often awkwar
cons(
a
hi
quate inform(
r the unwante
this stage, it
-ificationwou
is making it d'if-
nts' claims th
course of actic
Able. Judges ai
ced by a stroi
to believe th
terialized, if told ab
it it in advant
Idhave chosen differi -itly.19 The imp
Tin these cases has si fificant financi
both
enages award(
the subsequemiums.
rs msurance,
ssed in this
.m of inforr
OURNALOf
vhethE
Sie al.ABonnie, andAi
1hi
L's
vhi
Is(
hysicians.
between the flow of inft
ift
tection for
:er
rs, the physi
he consent f
of
hysi
:es
isclosure pr
rivey the re
ended course of tr
ssion and hand thE
significant
tei
th<
staff membE
Ter the form. What we are pro
compatible with - and sh
ove the consequences of -
a
>s-
>f
seauences.
this
or r
whic
ft
ssesf
SE
st
>a
st
chieving Personali ed Disclosure
e aim to shift genuine ontrol over the informationa
ocess to patients, an I to facilitate a personalize(
ocess by overcoming both the information asym
bl
th relevance problem. By per
ceiving inforthe processoffonalizing
SE
nation, our proposal woul
rts to specify
heir desire for information
his approach rests on re
iffe
n their level of risk aversit
to
sug
Aintroduced to
<(
1sent to medical
ss or
fi
if
d written consent. Howe,
to be useful in this contex
be modifie<
te<
>f h
:a:
kkey feature of <(
it from patient
,nee for informa
his
is to
ulqn
h
for specificity.
ar's seat, rather
S1l
how much to
certed effort to
>f ir overall prefsponsibility of
Iting in either
disclosure (oft
if
Lion of.
elves in medical infe
cal
f3
Yal defe
o her (oft(
ter
rs to
s of self-efficacy, anc
to
Rec
zing that
sr
Lh
Eeimportant decisions,
fa
nt a fully in(
11 bE ab1 e to imph
iffe nees may be embedc1
st
cultural inf lu
cess
imme
tely, we sugge
>syncratt
r
ences (be th,
-based).21 The S eddbsr
the goal of o
ans of whi
nsent sh
be sh tped to reflect
law of inforr
dslsr
opte -ts can be h ieved.
ther thai
them.22 C 011these variati,
sider, for exa
ges
tgeI
r sitional St( p Forward
the
of a proposei
si
:a
Se first1: stageffraof i
7e-The
th
written desc:
tered
model of inft
isclosure is,,
-I
come or, to t]
>h
dshift
ster
rni
Zal
sicians shoul, d not be reqt
by
o
>f patic
ste<
d for inforrr
.e patient and shoul
if
IS(
formula for obt,
d from the ]
him- or herself. The
take their
ted to signal his or E rdesire for inforbe
approach
,are proposi
ght be described, ir
lude to the disclosur process. It might
i on demand" (IOD)
shorthan ft rm. as "infor:
>fwalking through
be helpful to consi
The fund:
tients should be able
There passengers
self-idenl ify their status by se
the aisle through
if
which th ev -pass: reen (no th
is
:es
a%,,ge
sigmti
nust be paid).
(carrying items on which customs
as and speo
;arclmg the ways n
mong physi
Asi tional phase
Similarly, patients during this
sent is integrate(
vhich the foa ility of obi
I for informabe
to pronounceI
te
i
aisle (basic inf<
s offered such
hysi
>ss
the nature >f procedure/tre
the reasons it
arse of
ter
can return to
being perff rmed, when thE
iscl oSu:
befc
bE
Lea to
th
fe
EGHT TO
fl
'slifE
blue aisle (where mo
iding major/significa
information is
risks of the p:i >SE
,nt defined by severil
and frequency
tbout alternat
aisle (extensii ve info )rmation is p
items that onliy a sm all number of
Fb
relevant).
Standardized,
Stratification cof
will require dilffE
medical procE
might choose.
ing task, it sh<
the material ir ic
ing consent ft
roposea
isclosure
t stanaaraize
bl
te contel
ipproach
-for each
Dl
itinuity with exist
eflect what mos t patients probab1
that can be testLed).
One temn on the list of disclos ures (alternatives
seems specially th(orny. As indica ted in Table 1, th
"basic" lisclosure ( the green aisle I)would include
on of the pr(oposed procedu re, the reason for i
I consequences, but would not ini
zer
entation of alte rnatives to the ret
be described in th
cedure, which
sclosure (the bl
1S1
atients who ch<
>Sa
rst (green) tl
e informati<
would be asked if
if so,
Ibe describe
about alternatives a
>ffers
Prompting this opti
teE
ren if
if
tence of alternative
LU
hensioi
nuatibi
he
WO~L11
personanizei process can bE
made by th
these th
Disclost
eaccording
be embodi 1in physici
written or her materisent form: is well. Of
of disclosur
o
rse
ibout a top
disclosure for the "
ha
ns the nhysi
she has selected. When th
must provide accurate infor
to the question, irrespective of thl
SE
Ut11U
hysician's stan
to advise ab
si
apatient should be told this a
:hoice to as k for more (red) c
his
for each "ai
that th
Fugh
this is a
ittedly a ch
10t be too bi
e to extract
from existation mneach categ
Seen as a collaboi ve effort to
be involved
11 stakeholders sho
Lgmedical professic
to
0sprovide
itient advocates to
ure accessi-
isl
ible patient" star
ssentially th
efault, bu
uld be
legally sensible to make th
patient regan
are binding -
ST
h
being retrot
has stated his
fe
:es and th
taken place he
informed ci
s
failed to provide hi
Ifc
h
hat
his
pers
tHe cal it claim im retrospect
version is different fr
lm that sign
choice for information disc'
>sure he ha
Df risl<
f procedure/
I. Basic description of alternatives
t
2. Major/significant risks of proposed
about thE
treatment and alternatives, defined
by severity and frequency
procedur
2. ExtensivE
being recommended
swithout treatment
af
ces
if
h
th
bv
1. ExtensivE
tient can resume
ife activitie
about alt
:ivE
Extensive into
about possibl
ife
abe
Irnatives
ves the "right
ifil
be
the
Mil
:he risks of trc
Scontent of thi
tible with
nbli
idard or th
abli
thcit are designed
ze liability exp<
cl
OURNAL O
cive IC
Siegal. Bonnie. andAl
s. It bears
nsent transe
ag both par
itional excha
phasis, thou; 3h,
ess should
thE
,while pro
urrent infc
b1
fr
be person
surance t1
,the patiel
ie interact
of switchi
th
'sob1
as a physi
informatii
ible if
("Just tell me wha
h
to
t's 1
se
chooses to
oposed tre;
this ch
tails the r(
comfort th
to
n
Stage oft
sun
atient's desig
tionship
b
tage 2: Fully Individualized Disclosure
dvances in information t(echnology will eventually
f acilitate
lEm
a highly personal ized solution to the prob-
nsent disclosure throug
software.2 For Example, once a physicia
of individualizing co
to an agen
ir nteractive
ority to con
h as proposed a particular c ourse of treatment to the
has explained th
ft
ys
terms, the physie
the
believe thE
confront th
with makin
ide informa
iseauences
)al cos1
lst
is
se
bi
ther tha
pose
with p ossib1
hysicia:
tai
ations for th
ted td positive
S
aw
is
'fe
physi
Eto
dc
al
rtant ste]
is
Lai
ift
face if
5sclosur<
rst
ffers
ife rmed consel
lnt's right to
ving such wa
to delegate decisi
ces of
and the alter
hvsician.
to the p
to
sent to
it's de:
to the conset
th th
h
If the p
o
Secist
ter
L's
ft
by
gate
esponsibili
iscomfort
og
should be
or, if th
eclines, to
gent. We ackn< vledge that
has ecognized a
Eaditionally
isclosure of infc nation. Bui
b,ased on the ide that some
choosE t to
J be
rbi
o
set of in
A
ike to
ofRight to Be Info? od
t be permissible t oE
Sthe right to be in for
hear that stuff. Ji
)? Although stron tE
the
sides.
sbth N be'
1,such
no positioy
Tor by radiotherapy, with sin ilar survi il rates
90%), but with very differer t impact on the
t's life.
it choose to del-
si
iacha.
to tel
LOuue pm
cates pers
is in
tryngeal cancer, which ,an be tr tted by
L's
bl
to
Isle is so
burden is shift
rhere the cht
that the phy sician
of I
1a CD, flash drive
bsi
abc
link toa
ter-
ed info
nd altei
present purposes, we
>se
),C1
hE
atient physicall
vill lose
have babies) -
sed to p
ved by s(
isclos ure of which ca
In ais le. We are also i
to includ
agent designated by th Patient or acting on behalf
af Lpatient lacking decisi
of al ternatives to the
tE
nimum disclosi
capacity) has
Eal the cogni-
ability to navigate he way through an interactive
Ehine nroram. The t hing (software) program
iduals to specify their level
thosE
[GHT TO
)finter
formation, but would pro-
vide hypertext link,els of sp
at
that would enable
tients to obi ainforn
demand (IOD), bc d on their : ividual
Much as museum sitors who
it an au
can elect whether
Fhear more tail abc
number of topics
to the
Fated:hibitioi th
oFwould hav
,similar
>f
viewing, patients t
flexibility and cont
Use of informaation technology
trol over the flow, of information as
opportunities to recview the informat
a substal
comprehension. Additionally, there
tmine
the
applicati<
Af develo
exa
to
opportunity
technologies to the understanding sid,e of
A software prograrm can be written in suc
after completing tthe educational miodul associateo
with the disclosur re, patients could takel a mini-tes
(readability at an, 8th grade level) t( o ass .sswhethe
they had sufficien-t understanding of th procedur
(and possibly the r -isks, benefits, and; alter iatives). If,
e
patient consistentl ly "fails" such a tes-t, it I aight signo
a need for legallyE effective decision-r maki g authorit
to be assumed by an adeauately inf(orm( J surrogat
decision maker.
;h suc h
After the patient
ized disclosure proicess, til
ip-t" of the patient's
mation
be(
avail,able to both
cauld
inforr
for
requests
Ln.
th(
and
A
patient
p(
the
Lephysi
a-nsona.l interaction
with the physician regar ig any aans,-wered questions can then enssue, fo1 red by th e formal indication of consent. Th iis appi ch is in te nde d to preserve
atient- phaysic- 1ian relationthe personal qualitty of th
,rves
ar
sei
also
it
but
ship,
aportai ntlega'tl purpose. If
n
action afFter tthe fact that
ii
a
claims
leg
a patient
"I should have rec -eived
litional Sil nfor mation," the
ill
show
wheth(
er his ( lafim iis backed by
w
script
h ictual b(ehavior. If it sh ows thcit he ddid not open
cl
:ified hyl
links Ir
tobthe risks
Fertext
thrat mater lized whim giver
nity to do so,
t he misma -h betwe en his
informatio and his :
ces would s
hat the info
stLrong infe mnce that the
wTas not re 1vant to hir and (if unrebutted
>f
s ever the c usal link ne 3sary fo:
.cein informed con S( litigati<
i
Lappears that expi
-e for informed co
wever, a fully deve
modality for achie
sort is probably st
be r
0equired
assure t]
to
to r educe the risk that I
info
0rmation,
op
and to
tel
rses of
will need to be available to allow physsici
to
ine-t une" the disclosures, and the substant ial ba
rs to use IT in medical practice will have to be
In the meantime, however, the "trainsi tio
I si
so
Dn" outlined above - admittedly a sn
ie that 0reflects a serious effort to achiev Tegreater
bi
t control over the flow of information diuring the
at process - can be implemented.
Lisms
Addr essing Possible Objections
The p ersonalized process enables the patient Lto iden-
tify an d select the informational sets she car res about
(for el' vcample, inevitable consequences as op-)posed to
poten tial risks, frequent side effects as op posed to
more, remote chances of complications), and t to receive
answ( rs to her individual concerns. Unde r a welldesig ned computer-assisted process, the "relevance
probl em" is solved completely by the patie ,nt's continuir g opportunity to demand and probe t he availto ascertain
its applicabili
ity to her
able i formation
situat
it
i proposal, is solved
lb
categ<
,tely. Thus, the content
of eac hcatep
of information (mainly about risks or
altern iatives) ft every proceduri,ewould have to be formulatLed for
hree aisles.
Ske
ht claim that,, particularly during
the tr
harbors the
stage, what w( e
ft
urrecting
or
rei
nforcing
(as
many feel
poten
it ney
medical patern alism - i.e., by allowing pa als to s elect options sh iort of "full disclosure,"
we wi II
be encc iraging them to rely on the judgment
of theair plhysic ans by renderi,.ng them incapable of
indep ende .ntchoice. This c -zern is exacerbated by
-seeking behavior will
the pirospeact that informat
be str ongl y related to soci s tatus and education:
patie nts w,ho are relatively
le ducated, uninformed,
unsop)histii.cated, poor, socia Llly vulnerable, and
Sby tlhe medical systerm are likely5 ,to rece
ant of informati(on, while patients th
yree of health liteeracy and socio-ect
hF
>f
osi
vill seek and rec-eive the highest 1I
afo
)n.
these concerns vTery seriously, but v >ffer
Fses.
First, our proposal offers abetter ,tion
irrent ritualized ppractice which is no aally
promote choi ce. Moreover, it do( not
ients wi Fth
soft
at are a
ee
disparities in praiLctice any worse thce they
ad inf ormation techn
ad, to the contrarry, provides a platft i for
>f
5
closing
the health literacy gCap in the long run t. ugh
xpers onalized disclosi
ifo
. technolog.6
11 advances i
rs away. Researc
d, bro
carram is user-frie
cts for patient E
werme.
y, doubts abonF
ul
ted transforma
it overlook t
that h
>f )f already oco
rst
th acquisition of i
-al info
h, I- mation by
powered health
e
ou
i
OURNAL O
Siegal. Bonnie. andAl
f
s consumers of othe
rs
so
entify
herefo
atients are frequently
f information they ne<
nteraction that we eny
Lively to specify the inft
Second, we envision
levelovping the standal
cess for
ag both
should
I disclosui
)bout professi
or about bridging thE
chs should be
Standardized disclos
fr<
high(
ducators, and ot Yher stakeholders. Ther
at educational task to be
isno material ison foi
andertaken so
ical profession or heald
by the
.s. Such
effort wouh
are organizal
b
whether our pro
sal ne
or-patient relati
ishis.
eserve patients' opportt
of "ais les" as they proceed ar
Frcess with multile b
that reac
tF
cai
>ssibility th so
we suspect th the numbe will not be large
would encou e attentio to this possible
2ffect as thesi ipproache Lre tested. Of cc
thei
Fllinganxiety, some
3,way of corn
d exc-
rse, as
Fht to obt
As
o0
Will personalized d isclosure
sent litigat
for
elimi
ft
if
tation of a
rst
ing disclosi
n some states to"
1of disclosure is wh
t is possible tb
demented by t]
refinemen t of existin
and respec
aft -mation. Moreover, ft
five lecact
)sal could be
a
i
te inft
:edly be a ch
yal octrine that h
ge, since it would refr
Isi
Fh
EGHT TO
genuine preferences.
Sf-1
hysi
the
ing depersonalization of
n(
the
stress
we
eed for a personal n
)nship,
the
Fning
consent f
1prior to formally sig
rs
its should be having t'Fe
h
th
th
ed position,
to ft
vhat is importa
afa
being flooded
af mation.
accept this approach
>f
a protective star
Dfinformationa
Lag
to
ana to assui
to alter their ch
At the choice
the concerr st
',
The Path Ahead
:se
the risk-a, rse default pos
' choices
information co
rid medical infc
is also importaifferences bearii
hat icare decisions in parti
>sure in dis-
rba
ractice se-
se
:ar provide reli-
lost
flec
at
ing st re that the bodies of kn
differ ent categories of standa
tinue to reflect updated sciei
mratic n in an accessible fash .
to col duct research on indivi
rl
ac
Pt
Pa
m
a bi
b
is
lisclosures a
rsonalizes d
sire for information ger
ntal process
able demonstratis
th 2r point of concern c<( 1d be that p
b( defeated, rather tha empowered by the
erst
ized approach - i.e., tlhey might bEe overvhel
even in the transitior I stage by ha .ving to
:hoice about the level :f informatio n that
t. Implementation of a omouter-bas ed dis-
informa
he high,
hvpert
rfe
avoid the effort i
d professional commit
:f
our sugges
tempts to g ierate better
n for nPatiei
as physici
F,
concerns must bE
h collaborations
vh
1c1
>f
are whethe
isensus-b c
phases of implementa
tinct areas of sur,
with
the
Dur approach
hoices rather
counteract concerns
ment. We thereft
that allows the g
ase t
Dftel
As (
f failing to seek
ter-assisted modality fc
ibts abc
Iinforr
legal effet
Given th
S.
[us "4malpractice irefoi
ach eving the ,galcha es necessary to m Sake:h
pro osal wort -ay have rnore sanguine fu ture
anti -ipatedat rst sight. rhether such effor ts sh
be i indertake will del nd on "proof of
ugh subsi tial beh oral research. Ou r modest
is to lay d
vn a nev ,aradigm of informyaation on
2Ad
to em, wer patients, enha nce legal
,ertainty, and o hieve gr(eat er congruence betLween the
lients waant and the informa tion they
In o m tIto
is ]peeceive.
,ssible tI hat this approach c(ould also
promote more neaning]ful patient-physiciain iinteracLions mnmany cases, a de.,sir-able outcome that has been
lifficult to ach: ve by ot1 , means.
for Shar
Law & r redicine 32, no. 4 (2001
S. T. Bog irdus, E. Holmboe, ant
Possibilii es in Talking about M
(1999): 1 )37-1041.
P. H. Scl uck, "Rethinking Infoi
nal 103, 10. 3 (1994): 899-959;
Informed Consent i
reUniversity Press, 20(
Ashe v
3adiation Oncology As
1999).
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ple, Wilson-Toby v. L
N.Y.S.
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ag," American ,
29-501, at 493'.Jekel, "Perils, I
1 Risk," JAL4
Consent," Yale
3Manson and
oethics (Cambri
at 27.
9 S.W.3d 19
ag
13.
14.
39
cin, 72 A.D. 3c
ib1
Ref
abl1
S.
ab1
S.
AT-i
,35
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Sc
43-45
S. K. Si
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Surgeons, JAM4
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d
34
>3
St
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19E
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irs," Ne w E
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S3
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ATi
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,d Client De
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American Surg<
~,
HE
0
3
,tern Bic
idMA 2
11, no.
S.
3,
5
Sc
)9)
Social Sc
53-
~,
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es about Inforny
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he Navajo Reser
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S
A
IAl
I St
ib<
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t3-.
79
Si
rSi
/31
rnet,"
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34
31
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Se
. St
Health Ab
le
Sc
31, no. 4, Su
Hanusc
3.
28.Se
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333,
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