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The best way to understand a linear mixed model, or mixed linear model in some earlier literature, is to first recall a linear regression model. The latter can be expressed as = + , where is a vector of observations, is a matrix of known covariates, is a vector of unknown regression coefficients, and is a vector of (unobservable random) errors. In this model, the regression coefficients are considered fixed. However, there are cases in which it makes sense to assume that some of these coefficients are random. These cases typically occur when the observations are correlated. For example, in medical studies observations are often collected from the same individuals over time. It may be reasonable to assume that correlations exist among the observations from the same individual, especially if the times at which the observations are collected are relatively close. In animal breeding, lactation yields of dairy cows associated with the same sire may be correlated. In educational research, test scores of the same student may be related.

The best way to understand a linear mixed model, or mixed linear model in some earlier literature, is to first recall a linear regression model. The latter can be expressed as = + , where is a vector of observations, is a matrix of known covariates, is a vector of unknown regression coefficients, and is a vector of (unobservable random) errors. In this model, the regression coefficients are considered fixed. However, there are cases in which it makes sense to assume that some of these coefficients are random. These cases typically occur when the observations are correlated. For example, in medical studies observations are often collected from the same individuals over time. It may be reasonable to assume that correlations exist among the observations from the same individual, especially if the times at which the observations are collected are relatively close. In animal breeding, lactation yields of dairy cows associated with the same sire may be correlated. In educational research, test scores of the same student may be related.

The practice of medicine is a social task in which patient and healer must respect each other’s personal morality and moral agency. The vastly greater power (real or perceived) of the health-care provider and specifically of the physician puts the burden of this fiduciary relationship largely (but not solely) on the shoulders of the health-care provider. While health-care providers cannot—and act ethically—impose their own personal morality on the patient neither can the patient ask physicians to violate their own personal morality. Physicians and other health-care providers cannot simply follow the dictates of their particular HMO, MCO or the rules promulgated by the government (and may, in fact, be faced with quite unpleasant choices) and blame “the system”. They carry a heavy responsibility in trying to resist dictates deemed harmful to their patient. Above all they carry not simply the responsibility of accommodating themselves or resisting a system someone else builds for them but of playing their proper part in building a system which is equitable to all members of the community and flexible enough to change as do circumstances.

The ethical problems in every-day practice are rarely discussed in the literature. In part this is because they are considered trivial, in part because they lack the “prurient” appeal of more flamboyant problems and in part because their solutions are at best still unsatisfactory. Many are system related problems in which the fact that physicians should do all they can to change the system is uniquely unhelpful in dealing with the immediate problem. And yet changing the system, keeping involved in bringing about changes, refusing to accept today’s shameful lack of care for millions and refusing to allow medicine to be practiced by non-medical people (as insurers do when they “permit” or “disallow” certain tests or treatments for certain patients) is ultimately the only long term and never finished answer for many of these problems. Physicians and other health care workers need to remain involved in fashioning and maintaining a system in which sufficient elbowroom to practice ethical medicine is given. Remaining involved may range from being advisers for the community to acts of civil disobedience when no other course remains open. There is one thing physicians and health care workers cannot, in today’s society, countenance: not doing the best possible for a patient in order to increase the profit of managed care organizations.

The most that one can say about any of these is (1) that health-care workers need to think about and then have the courage to apply their priorities to concrete situations, (2) that being the patient’s advocate may, at times, entail unpleasantness and (3) that—trite as it may sound—only pushing to create a system which makes proper ethical practice possible can ultimately achieve what all health-care professionals seek: sufficient time and space to deal appropriately with the many daily ethical problems they must face.

The practice of medicine is a social task in which patient and healer must respect each other’s personal morality and moral agency. The vastly greater power (real or perceived) of the health-care provider and specifically of the physician puts the burden of this fiduciary relationship largely (but not solely) on the shoulders of the health-care provider. While health-care providers cannot—and act ethically—impose their own personal morality on the patient neither can the patient ask physicians to violate their own personal morality. Physicians and other health-care providers cannot simply follow the dictates of their particular HMO, MCO or the rules promulgated by the government (and may, in fact, be faced with quite unpleasant choices) and blame “the system”. They carry a heavy responsibility in trying to resist dictates deemed harmful to their patient. Above all they carry not simply the responsibility of accommodating themselves or resisting a system someone else builds for them but of playing their proper part in building a system which is equitable to all members of the community and flexible enough to change as do circumstances.

The practice of medicine is a social task in which patient and healer must respect each other’s personal morality and moral agency. The vastly greater power (real or perceived) of the health-care provider and specifically of the physician puts the burden of this fiduciary relationship largely (but not solely) on the shoulders of the health-care provider. While health-care providers cannot—and act ethically—impose their own personal morality on the patient neither can the patient ask physicians to violate their own personal morality. Physicians and other health-care providers cannot simply follow the dictates of their particular HMO, MCO or the rules promulgated by the government (and may, in fact, be faced with quite unpleasant choices) and blame “the system”. They carry a heavy responsibility in trying to resist dictates deemed harmful to their patient. Above all they carry not simply the responsibility of accommodating themselves or resisting a system someone else builds for them but of playing their proper part in building a system which is equitable to all members of the community and flexible enough to change as do circumstances.

In summary, there are certain critical considerations this chapter has tried to sketch. Among these are cultural and historical differences in thinking about death and the stages of dying; the difference between life as a biological and life as a cognitive, selfrealizing, and self-actualizing state and the ethical implications such considerations may have; various forms of acognitive states; problems of limiting therapy and of artificial feeding; suicide and euthanasia; and problems of futility. Central to all of these issues is the issue of orchestrating death and in so doing communicating with patients and with their families. Healthcare professionals—no matter what their role or area of practice—should seek to have an ongoing dialogue with their patients and with their patients’ families. If they do this, if they share their fallibility, their humanity, and their agony with the patient and with their patient’s families (instead of acting like remote gods), many of these issues will be much easier to deal with than they often are today.

The practice of medicine is a social task in which patient and healer must respect each other’s personal morality and moral agency. The vastly greater power (real or perceived) of the health-care provider and specifically of the physician puts the burden of this fiduciary relationship largely (but not solely) on the shoulders of the health-care provider. While health-care providers cannot—and act ethically—impose their own personal morality on the patient neither can the patient ask physicians to violate their own personal morality. Physicians and other health-care providers cannot simply follow the dictates of their particular HMO, MCO or the rules promulgated by the government (and may, in fact, be faced with quite unpleasant choices) and blame “the system”. They carry a heavy responsibility in trying to resist dictates deemed harmful to their patient. Above all they carry not simply the responsibility of accommodating themselves or resisting a system someone else builds for them but of playing their proper part in building a system which is equitable to all members of the community and flexible enough to change as do circumstances.

The ethical problems in every-day practice are rarely discussed in the literature. In part this is because they are considered trivial, in part because they lack the “prurient” appeal of more flamboyant problems and in part because their solutions are at best still unsatisfactory. Many are system related problems in which the fact that physicians should do all they can to change the system is uniquely unhelpful in dealing with the immediate problem. And yet changing the system, keeping involved in bringing about changes, refusing to accept today’s shameful lack of care for millions and refusing to allow medicine to be practiced by non-medical people (as insurers do when they “permit” or “disallow” certain tests or treatments for certain patients) is ultimately the only long term and never finished answer for many of these problems. Physicians and other health care workers need to remain involved in fashioning and maintaining a system in which sufficient elbowroom to practice ethical medicine is given. Remaining involved may range from being advisers for the community to acts of civil disobedience when no other course remains open. There is one thing physicians and health care workers cannot, in today’s society, countenance: not doing the best possible for a patient in order to increase the profit of managed care organizations.

The most that one can say about any of these is (1) that health-care workers need to think about and then have the courage to apply their priorities to concrete situations, (2) that being the patient’s advocate may, at times, entail unpleasantness and (3) that—trite as it may sound—only pushing to create a system which makes proper ethical practice possible can ultimately achieve what all health-care professionals seek: sufficient time and space to deal appropriately with the many daily ethical problems they must face.

The practice of medicine is a social task in which patient and healer must respect each other’s personal morality and moral agency. The vastly greater power (real or perceived) of the health-care provider and specifically of the physician puts the burden of this fiduciary relationship largely (but not solely) on the shoulders of the health-care provider. While health-care providers cannot—and act ethically—impose their own personal morality on the patient neither can the patient ask physicians to violate their own personal morality. Physicians and other health-care providers cannot simply follow the dictates of their particular HMO, MCO or the rules promulgated by the government (and may, in fact, be faced with quite unpleasant choices) and blame “the system”. They carry a heavy responsibility in trying to resist dictates deemed harmful to their patient. Above all they carry not simply the responsibility of accommodating themselves or resisting a system someone else builds for them but of playing their proper part in building a system which is equitable to all members of the community and flexible enough to change as do circumstances.