Categories
Feature Articles

The strengths and shortcomings of empathy in medicine

Every day medical students and doctors are faced with challenging, ethical, and moral dilemmas. Caring for patients can be draining and bearing witness to their suffering can often take a toll on the mental and emotional health of practitioners. A key psychological component affecting how we react to these situations is empathy. Here, the effects of empathy on our health and relationships with patients as well as the benefits and challenges of using empathic practice are examined.

Not even one’s own pain weighs so heavy as the pain one feels with someone, for someone, a pain intensified by the imagination and prolonged by a hundred echoes.”

― Milan Kundera, The Unbearable Lightness of Being [1]

 

Several times a day, if not more often, I see prescriptions for metformin on patient charts. Diabetes in hospital patients is almost as common as perfectionism in medical students; over 900,000 hospitalisations – or 9% of all hospitalisations – in Australia in 2013 were for management of diabetes as the principal or additional diagnosis [2]. Having lived with type 1 diabetes now for over 16 years, I have heard innumerable lectures on the pitfalls of chronic hyperglycaemia. With my last HbA1c falling in the “dangerously high” region at 12.9%, I am all too aware of how this can affect my long-term health. Yet, I cannot in good conscience stand at the bedside of patients with diabetes and lecture them on adherence to medication or better sleeping and eating habits when I myself struggle everyday with poor results. I often find myself torn between judging patients – and myself – for poor control, or letting poor control slide in acceptance of the human capacity for error. Rather than simply ruminating on my own shortcomings, the aim of this essay is to use my own as well as other patients’ experiences to highlight the all-too-real dilemma of allowing empathy to guide us while still separating personal feelings from professional agendas in medicine.

Empathy is a complex phenomenon, involving cognitive and affective processes that affect our capacity to understand and respond to other people’s emotional and mental states. Cognitive empathy can be defined as the awareness and understanding of another’s emotion. Affective empathy refers to the vicarious experience of emotions consistent with those of the observed person and often results in empathic concern, which involves feelings of compassion or concern for another. A more problematic form of affective empathy is personal distress: personal feelings of discomfort and anxiety in response to another’s suffering [3].

A recent popular article published in Scientific American explored the idea of empathy as being a double-edged sword [4]. The authors discussed the psychological construct of empathy’s ability to overwhelm their clinical judgment, however they also underlined its importance in relating to patients and being a well-adjusted human being. The article concluded, “[the] key is knowing when empathy is called for and when it is detrimental. It should not be the goal of physicians, then, to be more empathetic. They should aim instead to find the right balance, the golden mean that optimises care.”

Several studies have demonstrated that as clinical reasoning and experience in medicine widens, empathy decreases [5,6]. Reasons for this change are uncertain, however I question whether the inverse relationship between experience and empathy may be linked to the x-axis of time: the longer medical students spend exposed to the realities of medicine, the less able they become to expose their emotions to the harsh realities of patients’ lives. We can’t save everyone and often we can’t even eliminate much of their burden of disease – so losing the ability to empathise so as to limit emotional and psychological burden is likely a factor here as well. The evidence for this decrease in empathy over time is elegantly demonstrated in a study by Newton and colleagues which revealed that medical students’ empathy scores drop significantly between their first and third years [5]. This study used a standardised empathy scale to evaluate the same class of students every year between first and fourth year, and they found overall medical education was a determinant differentially affecting the vicarious empathy of students, with the greatest impact on male surgical specialties. The authors concluded, “the significant decrease in vicarious empathy is of concern, because empathy is crucial for a successful physician–patient relationship.” Another study of American medical students demonstrated the drop in empathy scores to be most significant across the third year (their first clinical year), with no significant drop during basic sciences teaching [6]. They also reported greater feelings of psychological distress in students over this same period, which is consistent with Australian statistics from Beyond Blue that report one in five medical students have had suicidal thoughts in the past year [7].

While it is undoubtedly true that empathy is necessary for healthy doctor-patient relationships, I question whether there is an element of self-preservation involved in the gradual loss of empathy over the course of our clinical years. Throughout my childhood, my younger sister was in and out of hospital for neurosurgeries involving a hard-to-access cyst in the pineal recess of her third ventricle. I was able to recite these words as a nine-year-old, and as a ten-year-old, I decided I wanted to be a doctor so that I could fix people like her. The problem was that I also hated hospitals; a normally well-mannered child, I would become hysterical after going to see her. In hindsight, I think that paediatric neurosurgery wards do this to a lot of people and in my case this was certainly caused by a vicarious empathetic response of personal distress. The immense suffering you see on these wards can make a bright day seem sombre, and it takes a special kind of nurse and surgeon to work in that environment day-in-day-out. If these people had not distanced themselves from their patients to a degree, the suffering they witnessed would almost certainly cause significant psychological distress. To preserve the emotional well-being of the medical staff on such wards, coping strategies such as intellectualisation, humour, and team support are essential [8].

There was one moment of kindness in that hospital which remains etched in my mind to this day. My sister was a bright child, and on the day before her surgery, unbeknownst to any of us, she secretly wrote a letter outlining her fears and questions for her surgeon. This man was the extremely busy head of neurosurgery and that morning, as usual, he charged into her room for rounds with his trailing procession of residents hanging on every word. After he had checked her over and turned to leave, my sister in a tiny voice announced she had something for him and thrust a piece of coloured paper at him. It was her list, carefully written out in crayon, of questions she wanted answered, number one being “Am I going to die?” He took it from her hand, glanced quickly at it, frowned, and left the room. My mother was appalled at his perceived indifference, while my father tried to soothe the situation with platitudes about how busy the man was. My sister was quiet and said little. Half an hour later we were surprised by the return of the surgeon, this time alone and with his white coat thrown over his shoulder. He walked in, nodded at my mother, and said to my sister, “Now that we’ve gotten rid of all those yucky doctors, let’s take a look at this list.” For the next ten minutes, he carefully went through each question with her and he told her the truth about everything. She calmly listened, occasionally asking more and when finished he rubbed his hands together and asked, “Are we good to go?” After she nodded, he smiled towards my parents and me and strode out of the room. Whether or not he was motivated by empathy I can only speculate, but it seems likely the surgeon recognised the suffering of my parents and sister and he demonstrated empathic concern: sympathy and compassion for others in response to their suffering. Whatever the case, I am thankful that this man was able to control his emotions without losing his humanity and I can only aspire to one day be able to do so as well.

I will conclude by making a case for using empathy in medicine. Empathy is derived from humanity and according to Hippocrates, “Wherever the art of medicine is loved, there is also a love of humanity” [9]. When a patient feels comfortable with a doctor, they are more likely to come forward with their true feelings and admit to forgetting to take prescription medications or to having sex without a condom, whatever the case may be. It is true that as future doctors we need to protect ourselves from feeling too deeply, but if we forget to open our hearts to the people we aim to help, we will risk losing their confidence altogether. Additionally, quite apart from the physician’s need to take a patient’s history to understand their affliction, the process of telling one’s story can be therapeutic for patients [10] and may help facilitate the healing process. Finally, empathy is beneficial to physicians – other physicians have noted that doctors who are more attuned to the psychosocial needs of their patients are less likely to experience burnout [11].

As for myself, I no longer fear going into the hospital but there are still many days where, as a result of connecting with a patient, I feel the urge to cry on my walk home. I try to balance this by looking forward to the time when, as a doctor, I can improve patients’ lives, just as the neurosurgeon did for my sister. I believe that empathy is a good tool to improve listening and understanding of the patient’s perspective. Ultimately my goal is to have the attributes of an excellent physician and a compassionate human being without letting my awareness of the pain of others pain destroy my soul.

 

Conflicts of interest

None declared.

 

References

[1] Kundera M. The unbearable lightness of being. New York: Harper & Row; 1984. 38 p.

[2] Diabetes (AIHW) [Internet]. Aihw.gov.au. 2016 [cited 2016 5 Jul]. Available from: http://www.aihw.gov.au/diabetes/

[3] Davis, M. H. Measuring individual differences in empathy: Evidence for a multidimensional approach. J Per Soc Psychol. 1983;44: 113–126.

[4] Haque OS, Waytz A. Why doctors should be more empathetic – but not too much more. Sci Am[Internet]. 2011 Apr 25 [cited 2016 7 Jul]. Available from: http://www.scientificamerican.com/article/doctors-and-dehumanization-effect/

[5] Newton BW, Barber L, Clardy J, Cleveland E, O’Sullivan P. Is there hardening of the heart during medical school? Acad Med. 2008;83(3):244–9.

[6] Hojat M, Vergare M, Maxwell K, Brainard G, Herrine S, Isenberg G et al. The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School. Acad Med. 2009;84(9):1182-1191.

[7] Urgent action needed to improve the mental health and save the lives of Australian doctors and medical students [Internet]. Beyondblue.org.au. 2016 [cited 5 Jul 2016]. Available from: https://www.beyondblue.org.au/docs/default-source/media-release-pdf/urgent-action-needed-to-improve-the-mental-health-and-save-the-lives-of-australian-doctors-and-medical-students-october-2013.pdf?sfvrsn=0

[8] Meadors P, Lamson A. Compassion fatigue and secondary traumatization: Provider self care on intensive care units for children. J Pediatr Health Care. 2008;22(1) 24–34.

[9] Khan Z. Airway management. 1st ed. New York: Springer International Publishing; 2014. 5 p.

[10] Adler HM. The history of the present illness as treatment: who’s listening, and why does it matter? J Am Board Fam Pract. 1997;10(1):28-35.

[11] Anfossi M, Numico G. Empathy in the doctor-patient relationship. J Clin Oncol. 2004;22(11):2258-2259.

Categories
Review Articles

Complementary medicine and hypertension: garlic and its implications for patient centred care and clinical practice

This review aims to explore the impact that patient attitudes, values and beliefs have on healing and the relevant implications these have for clinical practice and patient centred care. Using a Cochrane review as a platform, garlic as a complementary medicine was evaluated based on current societal trends and pertinent clinical practice points. The study found that when engaging with a patient using complementary medicine it is important to consider not only the efficacy of the proposed treatment, but also variation in preparations, any possible interactions and side effects, and the effect of patient beliefs and the placebo effect on clinical outcomes. The use of garlic in the treatment of hypertension could serve to enhance the therapeutic alliance between clinician and patient and potentially improve clinical outcomes.

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Introduction

Hypertension is the most common cardiovascular disease in Australia. Approximately eleven percent of the population (2.1 million people) are affected by the condition. [1] The prevalence is twice as high in the indigenous population, affecting 22 percent of those aged 35 or older.[1] Hypertension is a significant risk factor for transient ischaemic attack, stroke, coronary heart disease and congestive heart failure, increasing the risk of these by two to three fold. [2] Cardiovascular disease accounts for 47,637 or 36 percent of deaths in Australia each year and costs the economy a total of $14.2 billion AUD per annum – 1.7 percent of GDP. [3,4] Hypertension also accounts for six percent of all general practice consultations, making it the most commonly managed condition. [5] Given the significant effect hypertension has on society, it is imperative to evaluate potential therapies to combat hypertension.

Hippocrates is quoted as saying “let food be thy medicine and medicine be thy food”. [6] A considerable number of complementary therapies are thought to be effective in the treatment of hypertension by the general public. Such medicines include cocoa, acupuncture, coenzyme Q10 and garlic. [7] Medical texts from the ancient civilisations of India, China, Egypt, Rome and Greece all reference the consumption of garlic as having numerous healing properties. [8] Garlic (Allium sativum) was selected as the medicine of choice for this review as it is one of the most widely used and better studied complementary therapies in the management of hypertension. [9]

In addition to the effect of garlic on blood pressure, it is interesting to consider the implications of using this complementary medicine in light of patient centred care and clinical practice. It is highly recommended to medical students and clinicians that a patient’s cultural attitudes, values and beliefs are recognised and incorporated into clinical decision-making. The incorporation of patient perspectives into clinical practice may be done by negotiating the use of garlic as a complementary medicine alongside the use of a recognised antihypertensive drug. This study therefore aims to explore the findings and implications of controlled studies on the use of garlic to prevent cardiovascular morbidity and mortality in hypertensive patients in relation to good clinical practice and patient centred care. The aim of this investigation is to use a Cochrane review as a platform to explore garlic as an antihypertensive, and to discuss this treatment in the context of patient centred care and clinical practice.

 

Methods

The review focused on recent literature surrounding the use of garlic as an antihypertensive. A Cochrane review was used as an exemplar to discuss the broader implications of using garlic as a therapy for hypertension.  Use  of  garlic  was  explored  through  the  framework of current societal trends, clinical practice and patient centred care. Selected publications present both qualitative and quantitative data.

Results

While the literature search retrieved a number of randomised controlled studies suggesting a beneficial effect of garlic on blood pressure, [5,10] the most recent Cochrane review by Stabler et al. retrieved only two controlled studies that assessed the benefit of garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients. [5,11,12] Of the two studies, Kandziora did not report the number of people randomised to each treatment group, meaning their data could not be meta-analysed. [5] They did report however, that 200mg of garlic powder in addition to hydrochlorothiazide-triamterene baseline therapy produced a mean reduction of 10-11 mmHg and 6-8mmHg in systolic and diastolic pressure respectively, compared to placebo therapy. [5] Auer’s 1990 study randomised 47 patients to receive either 200 mg garlic powder three times daily or placebo determining that garlic reduces mean arterial systolic blood pressure by 12mmHg and diastolic blood pressure by approximately 6-9mmHg in comparison to a placebo. [5] Ried’s meta-analysis revealed a mean systolic decrease of 8.4mmHg ± 2.6mmHg (P≤0.001) and a mean diastolic reduction of 7.3mmHg ± 1.5mmHg (P≤0.001) in hypertensive patients. [10]

Given these findings fall within the normal parameters for blood pressure measurement variability, the efficacy of garlic as an antihypertensive is inconclusive. It is also difficult to ascertain the implications of the Cochrane review for morbidity and mortality as neither of the trials reported on clinical outcomes for patients using garlic as a hypertension treatment and insufficient data was provided on adverse events. As such, garlic cannot be recommended as a monotherapy for the reduction of hypertension. [13] Despite this, there are other potential uses for garlic in the treatment of hypertension which encompass both patient centred care (PCC) and evidence based practice.

Different garlic preparations

Several   garlic   preparations   are   available   for   the   treatment of hypertension including: garlic powder (as per the Cochrane studies), garlic oil, raw garlic, cooked garlic and aged garlic extract. [5,14] Ried and colleagues suggests that aged garlic extract is the best preparation for treatment of hypertension, and may reduce mean systolic blood pressure by 11.8mmHg ± 5.4mmHg over 12 weeks compared to placebo (P=0.006). Ried also noted that aged garlic extract did not interact with any other medications, particularly warfarin. [14]

Drug interactions

A number of drug interactions may occur when using garlic. Edwards et al. noted an increased risk of bleeding in patients who take garlic and blood thinning agents such as aspirin and warfarin. The same study also noted that the efficacy of HIV medications such as saquinavir may be reduced by garlic interactions, and some patients suffer allergies to garlic. [15]

Patient beliefs and the placebo effect

Patient beliefs must be incorporated into clinical practice not only for adherence to PCC but also as a therapy itself. Numerous studies have suggested that placebo treated control groups frequently experience a relevant decrease of blood pressure in pharmacological investigations into hypertension. [16]

Discussion

The findings of the Cochrane review are useful in making evidence based decisions regarding patient care, yet it is important to reflect on the issue of hypertension holistically and to consider what the review may have overlooked. Given that the Cochrane review provided insufficient data on the potential adverse effects, including drug interactions, of garlic consumption, prescribing garlic as a therapy for hypertension at this stage would be a failure to uphold best evidence based practice and would breach ethical principles such as non-maleficence.

Different types of garlic preparation are available. If a patient wishes to use this complementary therapy they should be guided to the most appropriate type. On a biochemical level, aged garlic extract has two main benefits for clinical practice. It contains the active and stable component (S)-allyl-cysteine which is measurable, and may allow for standardisation of dosage. [14] Aged garlic extract is also reportedly safer than other preparations and does not cause the bleeding issues associated with blood thinning medications such as warfarin. [15]

Patient centred care is particularly important as patient centred approaches   have   numerous   influences   over   clinical   outcomes. Bauman et al. proposes that PCC reduces patient anxiety and morbidity, improves quality of life, patient engagement and both patient and doctor satisfaction. [17]   Evidence also suggests PCC increases treatment adherence and results in fewer diagnostic tests and unnecessary referrals, which is important to consider given the burden of hypertension on the health care system. [17,18] Particularly significant for all stakeholders (patients, clinicians and financiers) is the use of PCC as a dimension of preventative care. For the primary prevention  of  disease,  clinicians  should  discuss  risk  and  lifestyle factors with patients and the detrimental effects they can have on a patient’s health. [2,5] Given the effect of PCC on treatment adherence it  is  important  to  consider  open  communication  and  discussion with patients not only as a part of treatment, but also as a part of preventative medicine. Further, if a patient is willing to take garlic for hypertension it may be a tool for further discussion between clinician and patient, especially if the treatment sees some success. This success may open windows for a clinician to discuss further the effects of lifestyle modification on health. [7]

Being a multifaceted dimension of health, PCC recognises each patient is a unique individual, with different life experience, cultural attitudes, values and beliefs. Capraz et al. found that a percentage of patients use  garlic  in  preference  to  antihypertensive  drugs  whilst  others use it as a complementary medicine in combination with another antihypertensive drug. [19] This affirms the potential for disparity in patient ideals. A patient may prefer garlic because of concern over the

addictive potential of drugs (including antihypertensive). [19] Such concerns should be explored with the patient to ensure patients can make informed decisions about their healthcare. Other viewpoints may be complex, for example mistrust in pharmaceutical companies, or simply having a preference for natural therapies. [19] Again, these somewhat concerning perceptions are worthy of discussion with a willing patient.

Amongst all the information provided it is worth taking the time to appreciate the role of demographic and religious factors. The social context of a patient’s health may influence how a patient considers the findings of the review. [20] It may also provide an indicator for the likelihood of complementary medicine use. [20] Xue et al. suggests that  females  aged  18-34  who  have  higher-than-average  income, are well educated and had private health cover were more likely to use a complementary or alternative medicine, such as garlic for hypertension. [20] Religion is also a significant determinant in patient centred care. Adherents to Jainism are unlikely to be concerned with the findings of the review, as they do not consume garlic, believing it to be an unnecessary sexual stimulant. [21] Similarly, some Hindus have also been noted to avoid garlic during holy times for the same reason. [21] A clinical decision regarding garlic as a complementary medicine would have to consider these factors in consultation with the patient.

When making decisions about the course of clinical practice in consultation with a patient, it is important to remember patients have a right to making a well informed decision. [22] It would be appropriate to disclose the findings of this review to patients considering the use of garlic so that a patient can make an informed decision regarding treatment options. It is essential that patients seeking treatment for hypertension understand the true extent of the efficacy of garlic: that it only has minimal (if any) blood pressure lowering effects. Patients should also be advised against garlic as a monotherapy for the reduction of hypertension until there is sufficient evidence to support its use. It is also important to inform patients of their right to use garlic as a complementary medicine if the patient so wishes to do so. [13,19] Given the potential detrimental effects of some garlic preparations, the implications of these effects should also be discussed with patients. If there is discrepancy between the views of the patient and the clinician, then the clinician must remain professional, upholding the codes of ethics which necessitates clinicians respecting the needs, values and culture of their patients. [23] The clinician must also provide the best clinical advice, and negotiate an outcome that is agreeable to both parties’ agendas. [23]

Conclusion

Hypertension is the most commonly managed condition in general practice. A Cochrane review assessing the benefit of garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients found a negligible effect on morbidity and mortality. [5] The study did not reflect on clinical outcomes for patients and neglected to discuss different garlic preparations used in the studies, potential differences this may have had on patient outcomes or any pertinent side effects. It is recommended that more studies be performed on the clinical effectiveness and side effects of different types of garlic preparations, particularly aged garlic extract. Patient centred care is important for the best clinical outcomes and for disease prevention. [17,18] Regardless of the efficacy of garlic, it is highly recommended to clinicians that a patient’s cultural attitudes, values and beliefs are recognised and incorporated into clinical practice. This may be done by negotiating the use of garlic as a complementary medicine, along with the use of a prescribed recognised antihypertensive drug if the patient desires a complementary medicine. The significant effect that patient values have on healing should be realised and utilised by clinicians and students alike. Ultimately, the use of garlic in the treatment of hypertension could serve to enhance the therapeutic alliance between clinician and patient and potentially improve clinical outcomes.

Acknowledgements

Jacob Bonanno for his assistance in proof-reading this article.

Conflict of interest None declared.

Correspondence

A S Lane: angus.lane@my.jcu.edu.au

References

[1] Australian Bureau of Statistics. Cardiovascular Disease in Australia: A Snapshot, 2004-5. In: Australian Bureau of Statistics. Canberra. 2006. p. 1-3.

[2] Kannel WB. Blood pressure as a cardiovascular risk factor: prevention and treatment. JAMA. 1996;275:1571-6.

[3] Australian Bureau of Statistics. Causes of Death, Australia, 2011 In: Australian Bureau of Statistics. Canberra. Australian Bureau of Statistics 2013. p. 100-9.

[4] Abernethy A, et al. The Shifting Burden of Cardiovascular Disease in Australia. The Heart Foundation. 2005.

[5] Stabler SN, Tejani AM, Huynh F, Fowkes C. Garlic for the prevention of cardiovascular morbidity and mortality in hypertensive patients. Cochrane Database of Systematic Reviews [Internet]. 2012; (8). Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD007653.pub2/abstract

[6] Smith R. “Let food be thy medicine…”. BMJ. 2004;328(7433):211.

7]  Nahas  R.  Complementary  and  alternative  medicine  approaches  to  blood  pressure reduction. Can Fam Physician. 2008;54:1529-33.

[8] Rivlin RS. Historical perspective on the use of garlic. Journal Nutr 2001;131:951s-4s.

[9] NPS annual consumer surveys: Findings about complementary medicines use 2008. [cited  2014  Nov  2]  Available  from:  http://www.nps.org.au/about-us/what-we-do/our research/complementary-medicines/nps-consumer-survey-cms-use-findings

[10] Ried K, Frank OR, Stocks NP, Fakler P, Sullivan T. Effect of garlic on blood pressure: a systematic review and meta-analysis. BMC Cardiovascular Disorders. 2008;8:1-12. [DOI: 10.1186/1471-2261-8-13]

[11] Auer W, Eiber A, Hertkorn E, Koehrle U, Lorenz A, Mader F, Merx W, Otto G, Schmidt-Otto B, Taubenheim H. Hypertension and hyperlipidaemia: garlic helps in mild cases. Br J Clin Pract 1990;Supplement 69:3-6.

[12]  Kandaziora  J.  Blood  pressure  and  lipid  lowering  effect  of  garlic preparations  in combination  with  a  diuretic  [Blutdruk-  und lipidsenkende  Wirkung  eines  Knoblauch-Praparates in Kombination mit einem Diuretikum]. Artzliche Forschung 1988;35:1-8.

[13]  Qian  X.  Garlic  for  the  prevention  of  cardiovascular  morbidity and  mortality  in hypertensive patients. Int J Evid Based Healthc. 2013;11:83.

[14] Ried K, Frank OR, Stocks NP. Aged garlic extract reduces blood pressure in hypertensives: a dose-response trial. Eur J Clin Nutr 2013;67:64-70.

[15] Edwards QT, Colquist S, Maradiegue A. What’s cooking with garlic: is this complementary and alternative medicine for hypertension? J Am Acad Nurs Pract. 2005;17:381-5.

[16] Deter HC. Placebo Effects on Blood Pressure Berlin Charite University; 2007 [cited 2013 19/04]. Available from: http://clinicaltrials.gov/show/NCT00570271.

[17] Bauman AE, Fardy HJ, Harris PG. Getting it right: why bother with patient-centred care? Med J Aust. 2003;179:253-6.

[18] Roumie CL, Greevy R, Wallston KA, Elasy TA, Kaltenbach L, Kotter K, et al. Patient centered primary care is associated with patient hypertension medication adherence. J Behav Med. 2011;34:244-53.

[19] Capraz M, Dilek M, Akpolat T. Garlic, hypertension and patient education. Int J Cardiol. 2007;121:130-1.

[20]  Xue  CC,  Zhang  AL,  Lin  V,  Da  Costa  C,  Story  DF. Complementary  and  alternative medicine use in Australia: a national population-based survey. J Altern Complement Med 2007;13:643-50.

[21] Mehta N. Faith and Food: Jainism. 2009. [cited 2013 19/04]. Available from: http://www.faithandfood.com/Jainism.php.

[22] Faden RR, Becker C, Lewis C, Freeman J, Faden AI. Disclosure of information to patients in medical care. Medical Care. 1981;19:718-33.

[23] Australian Medical Students’ Association. Australian Medical Students’ Association: Code of Ethics. Australian Medical Students’ Association 2003. Available from: http://media.amsa.org.au/internal/official_documents/internal_policies/code_of_ethics_2003.pdf .