Surrogacy in the Market of Desire

The State of Florida has spilled no small quantity of ink outlining the legal confines of gestational surrogacy (see particularly sections 742.13-742.17, here).  Legally permitted gestational surrogacy in Florida does not include “bringing in and harboring aliens, sex trafficking of children, forced labor and furthering slave traffic,” however; these charges were leveled against Esthela Clark in 2015. Clark had held a Mexican woman in her one-bedroom apartment, repeatedly inseminating her with semen from Clark’s boyfriend. When the woman failed to become pregnant, she was forced to have sex with two strangers, and placed on a diet restricted to beans.  On 29 March 2017, the 47-year-old Clark from Jacksonville, FL, pled guilty to one count of forced labor. The woman had been forced to clean Clark’s apartment. (See story here.)  What happened to the issues surrounding the smuggling of the woman across the border in order to be a surrogate for Clark and her boyfriend?

On the other side of the globe, India is arguably the world’s leading provider of surrogate mothers, with the industry estimated several years ago as “likely worth $500 million to $2.3 billion.”  India legalized surrogacy in 2002, and is now considering reining in its surrogacy situation:

     The Surrogacy (Regulation) Bill, 2016


  • The Surrogacy (Regulation) Bill, 2016 was introduced by Minister of Health and Family Welfare, Mr. J. P. Nadda in Lok Sabha on November 21, 2016.  The Bill defines surrogacy as a practice where a woman gives birth to a child for an intending couple and agrees to hand over the child after the birth to the intending couple.
  • Regulation of surrogacy:  The Bill prohibits commercial surrogacy, but allows altruistic surrogacy.  Altruistic surrogacy involves no monetary compensation to the surrogate mother other than the medical expenses and insurance coverage during the pregnancy.  Commercial surrogacy includes surrogacy or its related procedures undertaken for a monetary benefit or reward (in cash or kind) exceeding the basic medical expenses and insurance coverage.
  • Purposes for which surrogacy is permitted:  Surrogacy is permitted when it is, (i) for intending couples who suffer from proven infertility; and (ii) altruistic; and (iii) not for commercial purposes; and (iv) not for producing children for sale, prostitution or other forms of exploitation.

In their 2012 Journal of Medical Ethics article, Deonandan, Green and van Beinum formulate eight “Ethical concerns for maternal surrogacy and reproductive tourism

Robustness of informed consent

Custody rights

Quality of surrogate care

Limits of surrogate care


Multiple embryo transfers and abortion

Medical advocacy

Exploitation of the poor

Of the eight ethical concerns Deonandan et al found in the Indian experience of surrogacy, at least five of them were present in the Florida case described above –and that would-be surrogate was not even pregnant! It seems that India is not the only entity that should reconsider commercial surrogacy.


— D. Joy Riley, M.D., M.A., is executive director of The Tennessee Center for Bioethics & Culture.

The Gift of Finitude

I’ve been thinking a lot lately about finitude. About limits. Incompleteness. Even failure.

Like the friend of a friend who is dying and has just been admitted to hospice, whose young teenaged daughter is facing the prospect of a life without her mother.

Like the colleague who is grieving the loss of both a spouse and a parent within a month of each other.

Like my power wheelchair that keeps breaking down, making everyday activities significantly more challenging.

Like the never-ending “to-do” list that seems to be anything but finite, and never quite seems to get any shorter.

Life is, in a word, full of limits. Boundaries. Unavoidable stopping points.

Or is it?

What if we could transcend our limits, as recent developments in genetic and related technologies (e.g., CRISPR) seem to promise? What if, through genetic manipulations of various sorts, we could significantly reduce our limitations—eliminate specific diseases and disabling conditions, improve cognitive function, “select” for desired physical traits, and so on?

If we could do these things, should we do them?

Of course, as anyone who has followed the field of bioethics for even a short period of time knows, these questions are neither new nor hypothetical. In many ways, the “future” is already here: we “enhance” ourselves, “transcend” limits and boundaries, and otherwise seek to “overcome” finitude in a myriad number of ways, on a daily basis. And much of this is salutary.

Still, it’s always worth pausing to consider: supposing finitude could be eliminated entirely from our lives (which seems extraordinarily doubtful), is it the sort of thing we ought to try to eliminate? Put differently: is there anything good about finitude, such that we ought to embrace it (even if in a qualified way)?

Gilbert Meilaender, a bioethicist and Distinguished Fellow of The Center for Bioethics and Human Dignity, suggests that there is something good about finitude. In a reflection on the “created duality” of our human nature—we are simultaneously both “free” and “finite”—Meilaender observes that this “two-sidedness” to our nature both opens up possibilities and imposes certain limits upon us. We are, he observes,

created from dust of the ground—finite beings who are limited by biological necessities and historical location. We are also free spirits, moved by the life-giving Spirit of God, created ultimately for communion with God—and therefore soaring beyond any limited understanding of our person in terms of presently “given” conditions of life…. Made for communion with God, we transcend nature and history—not in order that we may become self-creators, but in order that, acknowledging our Creator, we may recognize the true limit to human freedom. Understanding our nature in this way, we learn something about how we should evaluate medical “progress.” It cannot be acceptable simply to oppose the forward thrust of scientific medicine. That zealous desire to know, to probe the secrets of nature, to combat disease—all that is an expression of our created freedom from the limits of the “given,” the freedom by which we step forth as God’s representatives in the world. But a moral vision shaped by this Christian understanding of the person will also be prepared to say no to some exercises of human freedom. The never-ending project of human self-creation runs up against the limit that is God. It will always be hard to state in advance the precise boundaries that ought to limit our freedom, but we must be prepared to look for them.[1]

I am inclined to agree with Meilaender. Moreover, as I have shared in an autobiographical essay published recently,[2] my own experiences as a person with a physical disability have taught me valuable life lessons that, arguably, might not have been learned otherwise—lessons such as the value of patience and endurance, accepting my limits (an ongoing struggle, I must admit!), and even the importance of having a sense of humor at the (sometimes ridiculous) circumstances in which one finds oneself. Our limits shape our character, our career, and our life choices as much as do our “freedoms”—often in surprising and unexpected ways, and frequently for the better.

None of these reflections, of course, even begin to scratch the surface of the “what?”, “where?”, “when?”, “how?”, or “why?” questions related to the ethical permissibility (or lack thereof) of pursuing various genetic, reproductive, or other technologies. Nor do they, by themselves, tell us whether (and when) we ought or ought not to avail ourselves of abortion, physician-assisted suicide, euthanasia and the like.

They do, however, remind us of one very simple, yet all-too-often overlooked fact: finitude is, in many ways, a gift. Let us not neglect it.


[1] Gilbert Meilander, Bioethics: A Primer for Christians, 3rd ed. (Grand Rapids, MI: Eerdmans, 2013), 3-5.

[2] See “Why am I Disabled? Reflections on Life’s Questions and God’s Answers,” in the Beyond Suffering Bible (Tyndale, 2016), available at and

OB Potpourri

This month’s issue of the medical journal Obstetrics & Gynecology (O&G) has a review of the four best ethics articles that appeared in their journal in the last year. Here are my comments (in italics) on their review (in quotes).

Article title: “Clinical, Ethical, and Legal Considerations in Pregnant Women With Opioid Abuse.” O&G‘s bottom line: “Opioid abuse is a chronic medical illness, not a moral failing. Obstetricians should advocate for pregnant women’s access to opioid maintenance therapy and social services that support healthy outcomes for these women and their fetuses.” Some will quibble about whether the slavery that is opioid addiction should be defined as a chronic medical illness (and remember that some opioid addiction comes courtesy of us physicians who misprescribe opioid medications). However, whether you believe that these women are unable to stop their substance abuse (illness model) or somehow unwilling (moral failure model), from a medical standpoint, treating these women as criminals isn’t helpful for either them or their babies to achieve the best outcomes. We’re doctors, not the police, so acting judgmentally has no role; we should be helping these patients and their babies in any ethical way possible.

Article title: “Evaluation of Ethics Education in Obstetrics and Gynecology Residency Programs.” In this study, 57% of OB residencies had 0-5 hours of ethics training, and 64% of residency directors said their graduates are unprepared or only somewhat prepared to handle ethically challenging situations. O&G‘s bottom line: “Obstetrics and gynecology residencies are behind in creating and evaluating formal ethics education programs. Additional resources and support, including a standardized formal curriculum, are needed to provide all obstetrics and gynecology residents with an adequate baseline ethics education.” In a specialty that regularly comes up against some of the most ethically problematic issues in medicine, it is extraordinary that over half of residencies have a hard time finding even five hours for ethics education during the course of a four-year residency. I could write a lot more about forming professionals vs. training technicians, but space doesn’t permit.

Article title: “The Ethics of Access: Who Is Offered a Cesarean Delivery and Why?” O&G‘s bottom line: “The ethical principles of justice and respect for autonomy require obstetricians who provide cesarean deliveries on maternal request when medically appropriate to discuss this delivery option with all appropriate patients and not just with those patients who request the procedure.” Since I don’t think it’s good medical practice to offer a pregnant woman a cesarean section if there is no medical indication to do one, this article seems to me to be a futile exercise, giving advice on how to perform an unethical act ethically.

Article title: “Prenatal Consultation for Extremely Preterm Neonates: Ethical Pitfalls and Proposed Solutions.” This article addresses the situation of the patient who is at high risk for the imminent delivery of an extremely preterm infant, one whose survivability is doubtful. Often a newborn specialist is called in, who quotes statistics and asks the parents to make an immediate decision regarding whether or not to treat the newborn. The article advocates a more fluid, ongoing process that takes into account the evolving situation. O&G‘s bottom line: “The prenatal consultation process should be viewed as an ongoing, long-term, shared decision-making process that provides desired information, emotional support, and compassion to parents.” As I’ve argued before, the autonomy-trumps-all approach of the physician asking “Do you want us to let your loved one die?” is an abrogation of professional physician responsibility for actions and decisions. This article takes a welcome step away from inappropriately placing the entire burden of decision-making on highly-stressed parents who may not be in a position to make such a decision.

From Marianne Burda, “What is New in Ethical Issues in Obstetrics? Best Articles From the Past Year.” Obstet Gynecol 2016;127:157–8

Speaking about dignity

Several years ago, while on the verge of delivering the baby of a seventeen year old, I was taken aback by the number of friends that she had asked to accompany her at the event…an event formerly considered far more private than one in which fifteen or so friends might attend (it was a large delivery room). And speaking of private, the wording and location of her tattoo demonstrated further that private areas had lost their former distinction.

The only practical option at that time was to ignore the crowd and attend to the imminent delivery, and ensure the newborn’s and mother’s safety. I could only hope that everyone had the sense to stay out of the way if an emergency arose. There was no time for instructions, explanations, or crowd control.

All turned out well. The teenager delivered a healthy baby, and I stayed on duty on labor and delivery. Our paths never crossed again, but I have thought of that brief encounter many times over the ensuing years.

When I think of the struggle to protect human dignity from innumerable external onslaughts, I think of battles such as those over public policy, technology, and cultural trends. But what I have not seen well is how the struggle extends to the hospital bedside, when the most pressing threat is from the patient herself. How much ought we, as physicians, while comforting and testing and treating and advising, take a firm stand and square off with patients, to explain why they themselves are the biggest threat to their own dignity?

Such a stance doesn’t reconcile easily with the current notions of patient autonomy. A sense of patriarchy within the medical profession comes rushing back, and it would be foolish to claim that patriarchy was always done well.

I am hard pressed to think of examples of seeing a physician address such concerns, unless couched in biomedical terms. It is difficult to know which of the numerous behaviors a patient exhibits falls, ethically and practically, within the realm of the practice of medicine. What I can say, with the advantage of some years, is that with the transformation of medicine to an autonomy-centered realm, we have lost sight of the most important defender of each person’s human dignity: the person herself. If we are to claim our dedication to a patient’s dignity, then should we not be more willing to speak the truth about it—even if it shines a light on an area the patient would rather not be seen?

Epistemological Uncertainty & Autonomy

In the September 17, 2014 issue of JAMA Scott Stonington, MD, PhD wrote a remarkable piece entitled “Whose Autonomy?” This short piece should be required reading for everyone in medicine.

Stonington discusses the idea of family roles and puts this in light of his anthropological work in northern Thailand. He uses his fieldwork experience to introduce the idea that, when ill, people may not express their true wishes, but instead play the role that is expected of them by their society. This renders taking a patient at his or her word problematic. One of his examples is of a father dying of cancer who says, “Leave me alone and let me die” but the son says, “No, we are taking you to the hospital and getting you treatment!” Our standard reading of this scenario is: leave the father alone, respect his wishes, and let him die in peace! However, Stonington suggests that in northern Thailand the father does not really want to be left alone to die at home—he says that to fulfill his role of the stoic father. And the son would be remiss if he “took him at his word” because his role is to care for his father despite protests. The point he makes is that this situation is not isolated to northern Thailand, but that elements of family relationships like this exist here in the U.S. as well.

This article is unsettling, because it questions the core of what most physicians these days use as to guide their care of the patient. If we take this story seriously, then we have to dig more deeply and not rely on mere autonomy to sort out the right course of action in a particular situation.

It is my concern that the strong focus on respect for autonomy exacerbates the problem of physicians who think of themselves as “service providers” where the goal is to maximize choices for “healthcare consumers.” This market analogy has been dominant for generations now and is what provides the background for Edmund Pellegrino’s sage writings about the real foundation of the profession of medicine: the fact of illness and the call we feel to respond to those suffering. Once we enter this profession we sign up for an ethics of supererogation—above and beyond what is required of the citizen, or neighbor, or businessman. This article by Stonington reminds us of this by pointing out that “doing the right thing” may be much more complicated than just doing what the patient says.

Limning the Limits

Shortly after I submitted my last post “Limning Autonomy in Surgery” I was contacted by the blog editor letting me know that I had made a typo in my title and that he would go ahead and correct it for me. The problem is that I really do mean to use the word “limn.” When I was at Wheaton College a couple of my professors edited a book entitled Limning the Psyche, so I figured the verb “to limn,” which means to draw, delineate, or describe, was in common parlance. These entries are not an attempt to “limit” autonomy, but rather to draw out what it looks like in the surgical encounter. Indeed, it is as we reach the limits of autonomy in certain situations that we understand its outlines and contours.

The practice of surgery is inherently parentalistic. (Historically paternalistic is the term used, but my wife is also a surgeon. . .  ) For many reasons (which I plan to unpack in subsequent posts) the surgeon’s decision-making takes precedence to the patient’s. I am not arguing that it ought to take precedence; I am merely reporting that it does (c.f. Hume’s fork.) The prime example is the decision that someone is “not a surgical candidate.” This could be due to a tumor being “unresectable” or to the physiologically deconditioned state of the patient, or the narrow margin of improvement a patient could make with an operation. The point is that this is a function of the praxis of the surgeon, which hopefully has been developed in the crucible of residency and through years of experience. Charles Bosk, in his classic text Forgive & Remember: Managing Medical Failure, notes that it is this development of sound surgical judgment that is the most important part of a surgical residency. Surgeons are intimately linked with the outcomes of their patients, and every day is the Catch-22 of cutting someone (for their own good) and the Hippocratic dictum primum non nocere. So we are cautious and, in making a decision who will benefit from an intervention, parentalistic.

But society has rejected paternalism and the abuses that went along with it. Parentalistic actions must be expunged from practice, so all decisions made by the surgeon are open to question. Barron Lerner explored and contrasted the paternalistic / non-paternalistic approach in his recent book The Good Doctor.  One of the results of this is the necessity to define certain interventions as “futile.” Then the hospital can have a futility policy that states that physicians do not have to perform futile procedures. For example, let’s say a family demands that an aortic root replacement be performed on their grandmother who has been deemed “not a surgical candidate” by the cardiac surgeon. The contemporary “way out” of a situation like this is to state the procedure itself is futile, and then invoke the futility policy. The problem that I have with this is that it reifies the idea of a “futile treatment” and pretends to be more objective than it is. There is a tremendous amount of subjectivity involved in decisions like these. The uncertainties surrounding the many variables in play belie precise objective quantification.

A particular surgeon operates on a specific patient on any given day and that event is a performance. We predict outcomes by conglomerating large numbers of these performances and statistically analyzing these data, but I contend that the decision of whether or not a patient “is a surgical candidate” is one that relies on the kind of tacit knowledge that Polanyi described. I am not trying to disparage endeavors to minimize variations in performance nor attempts to capture these statistics in a way to hopefully better understand what exactly our surgical interventions do, I am merely saying that there is much more to it than that.  No matter how well-informed  about an operation a patient is, there is something incommunicable that the surgeon knows that requires him or her to make definitive judgments on behalf of the patient. This is where autonomy hits the wall.

Drawing the line between coercion and persuasion

Is it ever right for a doctor to try to persuade a patient to choose one course of action over another? Some would argue that this is an example of blatant paternalism, even coercion, unethical because it violates a patient’s autonomy. To such people, the doctor’s job is to present unvarnished, unbiased facts: just present the options and let the patients choose. (I would argue that such a position is a repudiation of the whole idea of medicine as a profession, that autonomy viewed in such a fashion makes the doctor not a professional but a shopkeeper, just presenting his wares to whoever will buy. The ethical imperative that is an essential component of a profession is obliterated by such a view of autonomy. But that’s a subject for another post.)

The April 24th JAMA carries a potentially provocative Viewpoint entitled “Evidence-Based Persuasion: An Ethical Imperative” (you can view the abstract and a little over half the article here). The authors classify persuasion under three headings. The first is removal of bias, the correcting of mistaken beliefs or cognitive biases, such as the mistaken belief that the MMR vaccination causes autism; the authors see this as mandatory. The second is recommending options, that is, assessing patients’ values and counseling them regarding which treatment option is most in line with their values; the authors see this as “usually permissible but sometimes inappropriate.” The third is creating new biases, the creating of new mistaken beliefs or cognitive biases in order to persuade a patient to follow a recommended course of action; the authors see this as “normally impermissible but sometimes acceptable in rare cases.” The authors conclude with a discussion of the importance of context, and the statement that “persuasion is an essential component of modern medical practice, and it may be impossible to respect patients’ autonomy without engaging in persuasion.” (!!)

The removal of bias is perhaps the most problematic, because sometimes (often) we find out in medicine that what we thought we knew, was wrong (The short history of medicine: “Ignorance replaced with fallacy”). But I think the authors strike a good balance between ethical and unethical persuasion. The physician-patient relationship is inherently asymmetrical; the patient is exposed (metaphorically and/or literally) and vulnerable, and the physician has great power over the patient by virtue of the trust the patient places in her, power that potentially could be misused for coercion. Absolute dictums regarding where to place the boundary between autonomy-respecting persuasion and outright coercion are impossible; every person, every relationship is too different and complex to make blanket statements that apply to every situation. But the currently accepted absolute dictum that sees the doctor as shopkeeper and the patient as consumer is as destructive to the patient-physician relationship as the coercion it attempts to eschew; and while it may be easier to take a universal, “just-let-the-patient-decide” approach than to make nuanced, thoughtful, difficult, shared, context-driven decisions, it is also contrary to the fundamental nature of medicine as a helping profession.

A Pope Steps Away

The surprise resignation of Pope Benedict last week was not only significant for the world’s 1.2 billion Catholics. Evangelical Christians, who often find themselves at odds with some aspects of Catholic theology, find they have a strong kinship with them over issues of human dignity and rights-of-conscience, and certainly find allies in the Catholic Church in the debate over embryonic stem cell research. Much of the excellent bioethics scholarship on “our side” comes from within Catholicism. As the head of the Catholic Church, the pope’s words mean a lot to the foundational teachings about these important issues, and we should take note of some of the more recent things Benedict has put forward. Within the context of his impending retirement, they are doubly intriguing, especially as they relate ethically to technology and autonomy.

In his Christmas message, Benedict asked, “Do we have time and space for him? Do we not actually turn away God himself? We begin to do so when we have no time for him. The faster we can move, the more efficient our time-saving appliances become, the less time we have. And God? The question of God never seems urgent. Our time is already completely full.” Columnist Peggy Noonan recently noted that, about Benedict, “there was a lot of speculation that attempting to run the Vatican in the new age of technology, of leaks and indiscretions and instant responses, would be hard on” a nearly 86-year old man in declining health. He is in a season of his life where technology is a double-edged sword. He knows the old ways, knows that magnificent churches and cathedrals stand nearly vacant in the lands where technology occupies the fascination of their people, and time saved is poured back into the pursuit of further technological marvels. We have created amazing tools to serve us and now spend our biggest commodities (money and time) in bowing down to them. But he surely can see, as his health deteriorates, that technology has made him more comfortable, likely able to live longer and serve better. He may not be enthralled by gossipy e-mails emanating from the Vatican, or internet addictions, but certainly he can appreciate the wonderful gift of medical technology, right?

I don’t want to read something that’s not there, but I wonder if his caution about worship at the temple of technology, and his historic resignation, is distinctly BECAUSE he faces the technology that can allow him to continue going and has said, “Enough.” His predecessor, John Paul II, wanted to die well, and publicly, by continuing his work to the end after a long, long season of poor health. Maybe Benedict is mightily aware of what technology can do to keep popes and presidents and even regular people alive beyond the point that they may have ever wanted it, and that it might eventually be incumbent on him to do so. As many human beings seek immortality, perhaps this very important man has decided that he is not SO important that he cannot step away from this role, release the ties to this world, and prepare himself for the next. There will be no new speaking engagements for the soon-to-be former pope, just the life of a monk within quieter quarters in the Vatican. This is Benedict’s advance directive, in a way. He, too, is dying well, but not publicly. When John Paul II lay on his deathbed, the cardinals surrounding him announced, “All hope is lost.” No, it really wasn’t. Perhaps Benedict will now be free to embrace the hope ahead.

On the second point, Benedict spoke in Spain this past weekend, likely for the last time in public. “The church, which is mother and teacher, calls on all its members to renew their spirit, turn back firmly toward God and ignore pride and egoism to live in love,” he said. This dovetailed with another part of his Christmas message on how “busy-ness” and technology have crowded out God: “There is no room for him. Not even in our feelings and desires is there any room for him. We want ourselves. We want what we can seize hold of, we want happiness that is within our reach, we want our plans and purposes to succeed. We are so ‘full’ of ourselves that there is no room left for God.” In this age where personal autonomy reigns supreme, often to radical levels, we can always use a reminder of its dangers when we use it as a justification to make ourselves gods, when we use technology to embrace the paralyzing pride of the trans-humanists, and when we seek to hide from a death that will bring us face-to-face with our Creator. Technology used as a means to give us the desires of our hearts or to chase immortality, apart from a love for God and others that tames it, is a risky thing. I am not a Catholic, but I will pray that this German priest that steps away from power and prestige to find more room for God indeed receives the desire of his heart.

ICDs: Autonomy vs. Beneficence

Implantable cardioverter-defibrillators (ICDs) are like the automatic external defibrillators (AEDs) that you see everywhere these days. They deliver a shock to a heart in a lethal rhythm in order to try to restore the heart to a normal rhythm. Unlike AEDs, however, ICDs are implanted directly on a patient’s heart, are constantly monitoring it, and automatically deliver life-saving shocks whenever needed. The statistics are quite clear for patients with symptomatic heart failure in certain conditions: ICDs prevent mortality from sudden cardiac death (SCD), and are the sole effective therapy for prevention and treatment of lethal heart rhythms. And in a recent study in the Archives of Internal Medicine, more than half of doctors were so convinced by the statistical mortality benefit of ICDs that they valued the statistics more than patient preferences in making decisions about ICD placement.

On the one hand, this could be a good thing: here are a bunch of doctors who want to do what is best for their patients (the principle of beneficence). And if there were no downsides to ICDs, maybe it would be less problematic. But for many patients, the tradeoff for decreased mortality from SCD is dying instead from progressively increasing symptoms of heart failure. There are perfectly reasonable patients who, given the choice between the increased chance of a sudden death and the increased chance of a protracted death from heart failure, would choose the former (exercising the principle of autonomy); but if physicians are so enchanted by their gizmos and their ability to postpone mortality that they don’t elicit patients’ preferences — or don’t inform them of the options — then a lot of patients may be getting procedures that they would not want if they knew the full risks and benefits.

Medical technique and technology have come in the last century to wield great power. That power must be exercised with the utmost care, and with the utmost respect for persons and their inherent dignity. Our love for gizmos and all things high-tech blinds us to the fact that all techniques and technologies have unintended and unforeseen side effects. And our love for empirical, statistical data blinds us to the fact that statistics tell us exactly nothing about the person in front of us. Careful exercise of medical power requires that medical practitioners treat their patients not as part of a statistical herd but as individuals, eliciting their individual values and preferences. In many instances in modern American medicine, autonomy has been elevated too highly and led to questionable practices or to medical practitioners abdicating their duties as moral decision-makers; but the remedy for runaway autonomy does not lie in a return to a paternalism in which a doctor makes all of the decisions for a passive patient.