Dear Marion,

Thank you for your letter.  Nothing is further from my mind
than wanting to stop you before you write again.  On the contrary,
it's not mere rhetoric, when I write "Thank you for your letter." 
I'm not sure that I can do justice to your efforts, but I'll try.
My propensity to mysticism persuades me that our correspondence
is reciprocal reparation of sorts for the inane disagreements
and misrepresentations that split our family for so many decades.
Reparation, not in the sense that tort law contemplates the 
payment and recovery of damages as penalty and compensation,
but reparation in the deeper sense of repair, of "Wiedergutmachung",
of making whole again what should never have been broken,
of recovering what should never have been lost.

The issue of the physician as an official who implements regulations
and guidelines deserves more scrutiny. I am aware that the theses
which I proposed entail a contradiction to be resolved.  I distinguished
the physician's purveying of medical services to the patient as his or
her "official" function, from a non-official function of mediating
between the patient and the disease. I argued that only the official
function entails the adherence to rules or guidelines. Then I contradicted 
myself with the argument that such rules and guidelines should not be
binding.

Many of the textbooks of medicine and surgery and their numerous
subspecialties, are very well written, very learned and very
sophisticated.  I have admired them as examples both of science and
literature, and have spent many hours studying them. It's a mistake
to approach these treatises as if they constituted regulations and
guidelines; they do not.  To the extent that textbooks are valid,
they provide not dogmatic statements of answers, but dialectical
representations of uncertainties, of problems, and they instruct
the reader not what he should do, but how he should think in a given
situation: the optimal course of action flowing not from the
instruction by the text but from the reflection and understanding
of the reader.

Laws, Rules, Regulations and Guidelines on the other hand, by their
very nature prescribe a given course of action: they tell the physician
what he must or must not do, and they provide rewards for compliance
and penalties for non-compliance. It would be an interesting and
non-trivial exercise to reconstruct from historical data regulations
and guidelines such as might have been issued in 1990, 1970, 1950,
and to contemplate hypothetical requirements that would then have
been in force. Mastectomy for fibrocystic disease, radical mastectomy
for cancer, prefrontal lobotomy, sympathectomy for hypertension,
tonsillectomy for nothing, hysterectomy for everything, hemipelvectomy
for incurable malignancies, enucleation for choroidal melanoma,
exenteration for melanoma of the eyelid. Most of these hypothetically
mandated procedures would have been terribly destructive and
unnecessary. To contemplate what the conventional wisdom would
have required of him in years past is a nightmare for any responsible
physician.  Many medical decisions are excruciatingly difficult under
the best of circumstances. To be required to make them to comply with
regulation or guideline would take them out of the realm of existential
responsibility. It would be an intellectual and moral catastrophe.