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pandora essence Presumably these will include the signing of consent form (though as observed earlier, a signed consent form is no guarantee of an effective or valid consent) (p 6).6 But if consent is an expression of fidelity in the medical covenant, it must be seen as part of an open ended relationship in which clinical decisions are made in the course of honest, open, and free dialogue between patient and professional (Messer, p 13).32 Such a relationship, according to May, should be “transformational, and not merely transactional”: responsive “not simply to the patient’s self perceived wants but to his or her deeper needs”(p 37).29The covenant model has been criticised for failing to deliver on its promise of a richer account than the contractual model, and for having too narrow a religious base to be of use in pluralist societies.17 However, Campbell et al hold that it can articulate a sense of medical vocation understood in religious or humanistic terms.18 A further danger is that the covenant model advances an over idealised picture of the health professional, which makes unrealistic and perhaps harmful demands on the professional and risks reopening the door to paternalism.18,29,33 According to May (p 145 68), an understanding of health professionals as “teachers” of their patients offers some safeguard against these dangers20,29; this will be discussed further in a later section.(4) The ethic of careAnother critique of mainstream modern ethical theory is to be found in the “ethic of care”. This approach, as a formal theory, originates in the work of the psychologist Carol Gilligan,34 who claimed that men and boys tend to approach moral problems in terms of principles, rules, and rights (the “voice of justice”), whereas women and girls typically place more emphasis on relationships, empathy, and responsibility (the “voice of care”), though neither “voice” is restricted to one or other gender (Beauchamp and Childress, p 371).14 Gilligan’s theory has been supported and complemented by others such as Nel Noddings.35An ethic of care is obviously relevant to professional patient relationships.PRACTICE OF INFORMED CONSENTThis section will briefly discuss some practical aspects of informed consent. Medical treatment and research are the subjects most extensively covered in the literature on consent, but other increasingly problematic areas are organ and tissue procurement (both from living and from cadaveric “donors”),39 the use of patient information, for example in communicable disease surveillance,40 and public health measures such as vaccination programmes.41Various important distinctions can be made between varieties of consent pandora essence.