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Professional Promises: Hopes and Gaps in Access to Oral Health Care |
Key words: ethics, community, rhetoric, discursive ethics
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Abstract |
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 Top Abstract The received viewEthics as a reflection...Ethical action within...Ethical relationships among...References |
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There are two issues involved here. In the first place, what kind of moral agents are organizations, and how do they differ from individuals? Secondly, how do moral agents attempt to change each other on ethical issues, and how do they regulate the ethics of their members and speak on their behalf? These questions flow from a shift in ethical perspective away from the question of "what is right?" to the challenge of "what moral influence can be had on others?"
In early May 2005, the board of directors of the company NCR announced its support of a state policy on domestic partner benefits being debated in the Ohio legislature. The board also made it clear that this was not company policy, but rather an opinion regarding how business should be conducted in the entire state. Two months earlier the employees of NCR had gone on record in opposition to domestic partner benefits as state policy. On the same day activists in Seattle took ads in newspapers calling for a boycott of Microsoft over its position on the definition of marriage. The Washington State legislature had just failed to pass a law that would have liberalized the definition. Microsoft’s position was that it had no position, and gay rights advocates felt that was morally reprehensible enough to warrant an economic attack.
In 1541 the burghers of Geneva kicked out the papal legate Iacopo Sadoleto over issues of trade deficits and balance of payments owed to Rome. To order their moral affairs they called in Jean Chauvin, a good Catholic boy from France who had flirted with humanism under the name of Johannes Calvinus and was later to become the first puritan. He instituted a system of weekly in-home visits by clergy to ensure adherence to a strict code of behavior and had a few folks burned at the stake (preserving in a casuist way the biblical injunction against shedding blood). But business flourished and that was taken as a sign from God in proof of the election of hard-working moralists. On the whole, this experiment was more successful than Torquemada’s auto-da-fé in Spain that burned something in excess of eight thousand people who couldn’t get it right and raped three races wholesale—the Jews, the Muslims, and the natives of Central and South America—while silencing the voices of art and science and squandering one of the largest windfalls in foreign cash any nation has ever seen.
These examples illustrate the difficulties of taking moral positions for others. It is inescapable that some members of groups must define and defend the ethics of other members of the group, and the nature of community life depends on it being done well. It is probably true as well that human progress depends on the ways groups work out their differences in values. On the whole, the field of ethics has provided very little help in solving these problems. For the most part, ethics has adopted either of two, equally useless perspectives. On the one hand, ethics has been regarded as an individual decision. On the other, we have been engaged in centuries-long quests for a universal view that all could (or should) subscribe to. The fact that there are more ethical theories now than there have been at any time in history is not a comforting thought. No theory of ethics that starts from the individual or the universal view of ethics seems to have given us more than a local or temporary account of the ethical problems introduced above.
The ethical program so far could be summarized as a dogged search for ethical first principles that would be universal in application. Being unethical has meant refusing to bow to what is right. The boundaries of ethics ended at discovering standards and perhaps labeling some practices or some folks as being unethical. Doing anything about unethical behavior has been a political, economic, public relations, or legal problem outside of ethics proper. The Inquisition never killed anyone or confiscated their property; it merely identified those deserving of such fates and refused to intercede to save them when the state did its duty. The intent of this article is to expand the scope of the ethics business to include the obligations that exist on any group of people who claim to take an ethical position. As such, ethics becomes a relationship rather than a first position, and the ethical individual becomes an oxymoron.
I will first sketch the current approach to teaching ethics in dental schools, which is inadequate because it is grounded in universal theory (principles) or dilemmas, which are by definition interpersonal. Next I will discuss four techniques for creating community: coercion, rhetoric, witness, and ex officio responsibility. The latter three are useful. Finally, I will draw some general conclusions about the discursive approach.
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The Received View |
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Most dental schools go beyond principles to include discussion of cases presenting moral dilemmas. This is a useful enhancement because it gives students an opportunity (to some extent) to recognize issues, consider alternatives, and provide public reasons for potential behavior. Cases, however, are simulations; they admit of alternative interpretations. From personal experience with this method I have come to recognize that differences among students are in many cases differences of interpretation of the imagined details of the case. When pushed, students can be brilliant in imagining an interpretation that allows them to do as they wish while claiming to honor the generalizations their instructors espouse. As there are no actual applications in ethics courses, this "individuality within community" that is so important in dentistry can continue. It is an example of what psychologists call parallel play.2 Commonly observed among young children, individuals engage in activity (including talk) that involves shared objects, rhythms, and language, but is essentially guided by personal mental plans. I have never seen an ethics seminar built around cases where the facilitator forced a consensus. Neither have I seen a course where the assignment was to change the ethical practices in a group.
The reason case-based ethics instruction works on its own terms and fails in general might be traced to the nature of the ethical dilemma. For centuries, this has been an effective pedagogical technique for promoting reflection. The essence of a dilemma is that two truths (dilemma) are shown to be mutually inconsistent in some context. The available solutions include dropping one or the other, prioritizing them, using context to privilege one or the other, or creating a new lemma that harmonizes them. Almost the entire literature in health ethics consists of applying these techniques.
To qualify, however, as a dilemma, both givens must be initially accepted as valid and must be in the "same head." If you and I disagree whether health care is a right, we do not have a dilemma. This is a conflict. It is not (primarily) a teaching opportunity; it is an issue about actions and allocations of resources. All of the examples at the beginning of this article are conflicts (not dilemmas); each of them requires that initially conflicted individuals and groups harmonize their actions.
Some teachers of ethics have argued that principles and dilemmas may not be sufficient, but they are a necessary first step to improving the moral tone of the profession. This has yet to be demonstrated empirically, and it may not even be a plausible claim. There is good agreement with Leon Festinger’s view that inconsistencies among beliefs, or among behaviors, or between beliefs and behaviors cause cognitive dissonance that motivates efforts to achieve resolution.3 So is his observation that it is often easier and more effective to change behavior, with the expectation that supporting values will follow. Professionals and students who have never taken a course in ethics or even read about it can be counted on to have well-developed theories.
The prospect of a universal ethical standard continues to maintain a firm hold on the Western rational mind. Some claim to have discovered such an absolute code (and there are many to choose from), although their neighbors may not agree and the number of details in application are really annoying. Others subscribe to an aspirational view that we have not found a universal code yet, but that doesn’t prove we should abandon the effort.4 Others, typically known as postmoderns, believe that claims of universal codes are all personal codes imagined to be universal. Habermas,5–6 Foucault,7 and even Rawls8–9 tend to be of this stripe. The social economist Kenneth Arrow10 has proven that there is no universally ethical distribution of social health benefits. To appreciate this view, it may help to think of the pot of gold at the end of the rainbow. Although the concept can be talked about in principle and considered from multiple perspectives in case discussion, it makes no sense to set out to go get it. When we take our perspective with us, we move the goal as we move.
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Ethics as a Reflection of Community |
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Examples can be multiplied to demonstrate that ethics is sometimes and perhaps always context- specific. One of the sure ways of knowing whether you belong to a community is that your behavior causes few surprises to others in the community. One of the ways of recognizing that an ethical conflict exists is the realization that others’ behavior can only be explained as reasonable if there must exist some, as yet uncommunicated, expectations about how the world is supposed to function.
Humans can and do function successfully in multiple simultaneous ethical communities and at the boundaries between communities that differ fundamentally on some points but not others. When conflict is recognized, groups and individuals may choose to act independently—thus becoming "outlaws," literally those outside the law. Human nature is equipped to negotiate differences in values. As with many things in life, some of the equipment works better than others.
Discursive Communities
Now we come to the heavy lifting in this discussion: In what ways are communities moral entities? Certainly countries, companies, and families have legal status that prescribes and proscribes specific actions and lays out responsibilities. The same is true in the ethical domain. China, for example, is currently exercised that Japan has not apologized for war atrocities committed in the 1930s and 1940s.
Communities are created through discussion. All communities are dynamic and grow through mutual consideration of proposed alternative meanings for various behaviors that matter in the group. Communities are best thought of as patterns of member behavior and patterns of meaning. It is obvious that the Inquisition and the consistory in Geneva would not accept this interpretation; but it is difficult to see NCR or Microsoft in any other light.
Discursive action to create community means building shared and mutually beneficial interpretations of reality that become the taken-for-granted basis for valued action.12–14 What is valued in a community is easier to realize in action; what is not valued or what is disapproved of is more difficult. This is both a statement about the influence a community exercises over individual behavior and a statement about how the community behaves. In other words, the community creates itself ethically. An example is the U.S. surgeon general’s report on oral health. It is neither true nor false, but it certainly has made some forms of behavior (some public pronouncements and grant applications) easier.
Communities make promises.15 "It is the policy of ADEA not to discriminate based on race, religion, or gender," for example. That is a promise that creates pro-social, rationally discussable expectations in both the dealings within the organization and between the organization and others.
There is, however, a fundamental difference between the promises made by individuals and those made by communities. The individual offers to guarantee (through apology for nonconformance, indemnity, acceptance of penalties, etc.) reasonable mutual understandings of their promises. Communities do the same. In addition, communities make simultaneous internal promises. Members of communities promise to generally uphold the promises made by the community (sometimes formally as in swearing of allegiance), and the community collectively promises to distribute common goods—including goodwill, mutual support, and sometimes economic benefits—and to enforce sanctions to ensure group survival. Thus, the twin ethical principles of distributive and retributive justice flow from the nature of communities as ethical entities that make promises.
Communities as Ethical Agents
Individuals and communities must meet standards in addition to making promises in order to be considered ethical "agents." Agency requires the capacity to make promises that will be generally understood as meaningful in the agent’s context and the ability to make good on promises. The first part of this standard—capacity to make meaningful promises—is part of Habermas’s "competency" requirement: all those who are affected by a decision and are competent are allowed to participate.6 The second part of the standard speaks to resources. An individual or community must own the use of those resources necessary to sustain a promise. This is the test used to determine whether an individual can "speak on behalf of an organization." They can, or the organization can, take a public position if they are in a position to make good on the promise. The employees at NCR are not moral agents for the company with respect to policy on domestic partner benefits; the board of the company probably is, but only so far as NCR goes. The Inquisition was clearly a moral agent that was prepared to back up its promises, even though this example demonstrates that history—itself a moral agent—can change its mind.
This leads to two rather heretical results. First, the primacy of the individual is essential to the modern view of the world that began with the humanistic movement (meaning literally that man was the measure of all things) and reached its fulfillment in the 1789 Declaration of the Rights of Man and of the Citizen ("Liberty consists in the freedom to do everything which injures no one else; hence the exercise of the natural rights of each man has no limits except those which assure to the other members of society the enjoyment of the same rights"). Such primacy may be misplaced. Individuals are the elements of communities only in some physical sense. Their existence as significant, rational, and independent entities is not a precondition to participation in community. In fact, it is a result. Think, for example, of the infant who has no sense of self or other and is nothing but personal will until repeated encounters with a contrary community (the family) develops such a sense of relationship. In a similar fashion, we can turn Kant on his ear and state that communities accept as ethical the individual behavior they would accept as meaningful to all members of the community. The egocentrism of Kant’s categorical imperative16 can be seen immediately if consideration is given to pedophiles and "members of the other political party" using it.
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Ethical Action Within Communities |
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In what follows I make the single assumption that human nature is wired to pursue what it feels is in its long-term best interests: that is, human nature is teleological—it seeks to maximize what it takes to be its characteristic qualities. Although there are intrinsic limits, such as bounded rationality, this self-interest extends over time, circumstances, and individuals.
Democracy
In democracies, members promise to abide by the (representative) majority decisions of the group in exchange for an uncoerced opportunity to speak to any group decision. If members wish to challenge the will of the group, they must either witness or resign from the group.17 (In most cases, democracies are so loosely structured that dissenters can function undetected.)
Democracy is an ideal form. Decision scientists have worked the theoretical limitations of this approach in gory detail. Its saving grace was articulated by Winston Churchill in his quip, "Democracy is the worst imaginable form of government, except for all the other forms." The theoretical limitations inherent in democracy are only a serious objection to philosophers who have not yet given up on searching for universals.18 For those with a discursive leaning, the limitations of democracy furnish the very conditions that drive the endless give and take of building better communities.
Office
Organizations are forced by problems of size and complexity of modern life to adopt representative forms of self-management. They pick individuals authorized to "speak in their names." The board of directors at NCR is elected by the shareholders to function in this capacity. Members of large organizations exercise their moral initiative indirectly through attempted influence on those in positions of authority or by removing them from their positions. Otherwise, they function as individuals or as members of other groups. For example, an employee of NCR might write a letter to the board, vote in the employee initiative, and lobby directly as a member of an interest group on the issue of domestic partner benefits, but they would have no vote in the Ohio legislature. Members of the legislature are expected to represent their constituencies rather than their personal views—to the extent they recognize the moral suasion of their constituencies.
Ex officio means as a function of one’s office. Many behave as though it meant nonvoting. When individuals accept the obligation to function on behalf of the members of an organization, they are not permitted to pick those duties they find convenient. In other words, organizations expect that its officers will perform both the attractive and the unattractive aspects of the job. This is particularly the case in dental schools. By law, administrators must take appropriate action when they are aware of harassment. Not all do. Some faculty members overlook patient abuses and students "cutting corners." In almost ten years of using a competency-based clinical evaluation system at Pacific that requires faculty members to identify students who would benefit from supplemental instruction, there are a handful of instructors who have had the good fortune of never having encountered a single such student. Others have seen cheating on tests but are not convinced that it is part of their jobs to take action based on what they have seen because "one can never rule out the possibility of mitigating circumstances." These are examples of abrogation of the responsibility of office. They are cases where one wants the benefits of membership in an ethical organization without the responsibility.
Brotherhood
We are our brothers’ keepers. At least we are if we wish to belong to a group for the benefits it provides. If our reputation depends on the behavior of others who bear the same name (dentist, graduate of Pacific, etc.), we are obliged to pay attention to both the negative and positive behavior of our colleagues. Whistle-blowing is a positive ethical obligation. So are peer review and intervention in the case of impaired colleagues. Recently in an ethics seminar, a guest private practitioner told students he could think of no reason (short of the death of a patient) that would be grounds for a dentist to bring even gross or continuous neglect of a patient to the attention of state licensing officials. Students frequently say the same thing about known cases of their classmates’ cheating. Communities, then, must also address concerns of retributive justice. Without a willingness to back the obligations of distributive justice, communities offer hollow advantages to their members while eroding the trust upon which community is based.
Agency
Agents are individuals or groups that work for the best interests of their principles.19 The relationship is long term and general (as opposed to changing from transaction to transaction), and the agent offers to provide services the principle cannot normally perform because of their specialized nature. Dentists are agents for their patients, as are almost all professionals. In addition to their consideration (fees, percentages, options, etc.), agents tend to take a little something extra—known as the "agency cost." This includes shirking (doing less than compensated for—e.g., upgrading insurance coding), shrinkage (using the principle’s resources as the agent’s own—e.g., treating a case for ego or CE presentation), and extortion (e.g., telling the principle that unnecessary services are needed).
Principles have an ethical (and in some cases, as with Sarbanes-Oxley, a legal) responsibility for their own behavior in managing the agency relationship. Monitoring agents is largely ineffective, and most principles rely on aligning the interests of agents with their own as a preferred approach. This creates communities based on value—ethical communities—even in complex organizations where a wide range of specialized behaviors is typical. As almost any organization is based on differentiation of function, agency is a fundamental means of determining how organizations behave. The Inquisition used the state as agents to carry out beheadings and burnings because of their specialized expertise in these areas. The City Council in Geneva chose Calvin as its moral agent, and actually fired him once from that position.
In recent years, America has seen the rise of the "proxy" organization. These are groups that represent the collective conscience of individuals on issues that have no natural community other than a position. There are "green" organizations, accordion music foundations, and anti-this and pro-that groups of people who have nothing else in common and have never met each other or seen the salamanders they are passionate about. For the most part, these organizations have three activities: cash the checks of contributors, lobby, and solicit donations. According to Robert Putnam,20 in 2000, there were 6.5 million nonprofit organizations in the United States that had only honorary members. The American Association of Retired Persons is frank about its double function as a lobbying organization that is a collective buying group for its members. It is a moral voice for rent.
Witness
Martyrs in the Inquisition were witnessing. This means of building ethical community is like applying judo to coercion. Rather than pushing back when pressures are applied to limit choice and force behavior, one witnesses by accepting the undesirable but honest alternative. Protesting is similar in that it calls attention to others’ attention to practices thought to be unacceptable. But protest can easily spill over into coercion, as in pigeon-holing third parties and making life inconvenient for them. Protesters often aim to force unconcerned individuals to take a position.
In college I was a fellow traveler with Quakers. When they protested, small numbers of them took vacation from work, dressed well, and provided information. They actually risked losing their jobs. By contrast, the student protests I participated in were more like parties or the running of the bulls in Pamplona and we expected to be taken seriously—only if we weren’t caught. Witnessing is rare because it is so personally expensive. It works because it is a rejection of the "offer that cannot be refused." It is also an enormously powerful way to build community among those who are willing to engage in it.
Promise
The fundamental mechanism for creating community is the promise. This is action language; it is the bridge between ethical judgment and ethical behavior we have been looking for. Habermas5 borrows the concepts of action language from the British linguistic philosophers such as Austin,21 Ayer,22 and Wittgenstein.23 They noted that some language performed only descriptive functions. Examples might include "My phone number is 707-994-4109," "Non-maleficence is an ethical principle," and "I believe access to dental care is a right." As descriptions, these statements might be true or false. It is no accident that the titles of Habermas’s works on ethics contain the word "action."
Promises, on the other hand, do work; they change the value of future behavior because those to whom the promise is made can expect the maker to redeem his or her promise in future action. The condition of being able to use performance language, including making promises on behalf of others, includes the right person, the right circumstances, the right words, and the right effect. Promises are not true or false; they lead to desirable futures or they do not. (This epistemology is prefigured in the American pragmatic philosophical tradition;24 it differs appreciably from the ethical principle of veracity.) Further, the maker of the statement promises to generally behave in the future in ways that are consistent with the position, or to announce that a change has been made. These are essential conditions for civilized society. Even if I disagree with you, I am entitled to meaningfully order my behavior based on what I can expect from you and that you will say only what you believe to be true. (This is a different and deeper principle than veracity.)
Statements about access to oral health behave in strange ways when we try to treat them as promises. "I promise that access is a right" is bad form and uninteresting. "I promise that if you proceed on the understanding that access should be increased, you won’t be sorry" is more interesting, but it will only hold our attention as long as there is something to back up the promise. Two more powerful promises would include, "As an officer, I am authorized to place some of our community’s resources at your disposal for use in addressing access" and "Our community has accepted a position that its members will have the benefit of common resources for the sake of promoting access." (As we will see eventually, these last two statements mean almost the same thing.)
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Ethical Relationships Among Communities |
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The Theoretically Superior Position
This view—the received view—has already been discussed and found wanting. It is supposed to work something like this. Your organization and mine will select champions who will present facts, arguments, and references to authority. In the end, one view will be recognized as "right," and the other side will change its behavior to come into concordance. The likelihood of change coming about in this manner is so small that we avoid direct confrontations and preserve the superiority of our positions by allowing only indirect, asynchronous conversations through editorials and meetings with our friends and carefully worded suggestions that the other guy "doesn’t get it yet." Nothing more needs to be said about this approach except to stand in awe of its long history of frequent use.
Coercion and Misrepresentation
Coercion is attempts to change others’ behavior in ways that are inconsistent with their values. It involves removal or limiting of others’ choices and hence of their dignity as individuals with full potential. In the examples that introduced this article, the Inquisition and the boycott are examples of coercion. They have the common character of seeking to substitute one party’s interests for the others while denying autonomy. The coercive party has decided for the other what is right or wrong. All "soft target" persuasion is coercion. This occurs when innocents are placed in harm’s way to put pressure on a third party. The Microsoft boycott would be an example, so is the violence in Iraq and Africa. Paternalism, as in offering incomplete informed consent, is also coercion.
Misrepresentation is false persuasion that relies on the appearance of engagement with others but creates an unrealistic sense of trust. Lying, the con, and false promises are examples. Calvin certainly accused the Catholics of misrepresentation in the selling of indulgences. Ironically, misrepresentation depends on the prior existence of ethical communities. The con won’t work without trust in the system (and greed). During the period between the two World Wars, the Mafia tried to go international. It was driven out of Italy, first by the Fascists and then the Communists.
Both coercion and misrepresentation violate Habermas’s6 famous rule of ethics that all those who are competent and affected by the outcomes of an action should have an opportunity to speak to the decision. One of the most common forms of coercion is the attempt by various means of declaring individuals or groups to be incompetent. Spain certainly did that with the Indians; modern America, including our professions, is certainly not innocent of the practice in seeking legislation that excludes public scrutiny.
Coercion and misrepresentation create faux communities because they are based on the suppression rather than the harmonization of values. They encourage subtle forms of resistance and retaliation, and reversion is predictable once the means of coercion are relaxed or the misrepresentation is discovered. Interestingly, Festinger3 has demonstrated that extreme coercive measures ensure prompt superficial behavioral compliance with almost no change in values, while less severe coercion, which is ineffective in changing behavior, generates strong value resistance.
Third-Party Appeal
Sometimes it is easier to manipulate a third party than to change the community with whom you disagree. When that third party has influence over those you disagree with, it might be attractive to exert indirect moral influence. Remember when your younger sister threatened, "If you don’t stop doing that, I’ll tell Mom"? That is exactly the strategy employed by the gay marriage activists against Microsoft. It is a frequently heard argument in the access discussion: if organized dentistry doesn’t do something to fix the problem, legislatures will. Third-party appeals need not employ threats. Most public relations efforts are of this stripe. If anyone doubts that the ADA is not lobbying that dentists are already, individually taking care of the access problem, they are not reading their ADA News and they can’t say for certain what GKAS means.25
Third-party appeal can be as ethically unattractive as direct coercion, and even smarmier because of its indirection. It can, under certain circumstances, be a forthright and useful approach. This will be discussed after the notion of rhetoric is considered.
Rhetoric
Rhetoric is the art of persuasion.26 It differs from coercion in aiming to change values rather than behavior and in honoring others’ opportunity to make free choice based on accurate information. Here again is another of Habermas’s6 rules for the ethical community: individuals are only allowed to say things they believe. Presumably, management on one hand and labor on the other at NCR were attempting to persuade the Ohio legislature by stating what they believed. The city council in Geneva would be rhetorically on solid ground if it invited Calvin to create a religious community where commerce could thrive; if they used purely religious language to justify partially commercial ends, they were not acting ethically.
There are three parts to using rhetoric to create ethical communities: 1) cause others to change or substantially modify what they are prepared to do, 2) because they choose to make the change, 3) based on reasons presented to them. Note that control of the choice remains with the person being persuaded. Making an offer that cannot be refused is not persuasion (it is coercion). Classically, rhetoric includes the elements of logic (the sound argument), pathos or empathy (appeal to the entire person being persuaded), and ethos (the ethical stance of the speaker). This latter characteristic is not emphasized as much as argument and emotional appeal today, but the character, integrity, and honor of the speaker have tremendous impact. Certainly, in any attempt to build an ethical community, this cannot be left out.
Persuasion is useful for building meaningful participation of members within communities, for letting other communities know what you stand for, and for resolving ethical conflicts between groups. Results are not guaranteed, but progress tends to be more stable than what can be achieved through coercion. A practical test of the rhetorical stance is to ask oneself, "Do I know what is right for the person I am attempting to persuade before I go into the conversation?" If the answer is yes, rhetoric is out of reach, and argument or coercion will be practiced—whatever name is given to it.
Promise, Again
We have already seen that promise is a powerful mechanism for managing membership within community. We join communities where we have a justifiable belief that our future would be enhanced because of the commonalities with the rest of the community and the faith that the community will use its common resources to ensure such futures. We and the organizations promise each other to work toward a common and mutually preferable future.
Communities can use the same mechanism to adjust their ethical interests. Organizations often promise each other that they will make some resources available to pursue common goals. Communities use discursive methods to compare feasible futures and to identify ones where it is mutually advantageous to act as if other communities had promised to behave in ways that will redeem that faith.
The concept is that communities can work together to create larger communities. They can be thought of as "members" of these metacommunities, and the same expectations about identity and fulfillment through community are expected.
This article is a discursive exercise. It is an attempt to offer alternative, harmonizing meanings to some issues that have divided communities generally, and particularly in oral health. My views are neither right nor wrong; they may be, however, useful in building community or otherwise.
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Footnotes |
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REFERENCES |
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This article has been cited by other articles:
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  D. E. Patthoff The Need for Dental Ethicists and the Promise of Universal Patient Acceptance: Response to Richard Masella's "Renewing Professionalism in Dental Education" J Dent Educ., February 1, 2007; 71(2): 222 - 226. [Abstract] [Full Text] [PDF]
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S. Dharamsi Building Moral Communities? First, Do No Harm. J Dent Educ., November 1, 2006; 70(11): 1235 - 1240. [Abstract] [Full Text] [PDF]
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