ined in something which is widely known as 'the doctor-patient relationship'" (Miller, 77-8).
Whether associated with one of several financial structures for health-care delivery--e.g., HMOs, managed care, Medicare--the principal institutional mechanism of treatment of important health problems in the modern American health system is the general hospital. Originating in the seventeenth century with poorhouses and madhouses, institutions "branched out in different directions, as some . . . became devoted to the treatment of a particular affliction (tuberculosis, blindness), a religious or ethnic group (Catholics, Protestants, Jews), a segregated racial group (African Americans), or an age group (children)" (Koop 32). No less significant a fact about premodern health-care delivery was that before the twentieth century hospitals were less places to get well than to receive acute surgery or die (or both, owing to haphazard sanitary practices. "As late as 1950," says Gaylin (38), "a distinguished physiologist could tell an incoming class of medical students that, until then, medical intervention had taken more lives than it had saved."
In 1876, as Koop notes, medical visionaries at Harvard anticipated "that state of perfection where hospitals can be dispensed with" (Koop 32). Technology and research transformed this scenario dramatically, proceeding from the work of French and German researchers who established "a basic understanding of human physiology . . . foundations of pathology . . . and the first true understanding of the nature of disease--the germ theory" (Gaylin 38). Tremendous advances in the number of diseases that can be treated or cured owe much to stringent practitioner protocols and technology or drugs that can control infection and reduce pain. Such advances, however, have brought with them new problems, including "considerations of the nature or quality of survival [which] adds a whole new dimension to the definitions...