In the fifteen years since the Karen Ann Quinlan decision, the trends that first emerged in the 1966-76 decade have become all the more prominent and powerful. Outsiders to medicine, more conspicuously and successfully than physicians, now define the social and ethical questions facing the profession and set forth the norms that should govern it. The appointment of Morris Abram to the commission chairmanship is inexplicable without an appreciation of the events of 1966-76. In no other way can one fathom the selection of a former civil rights lawyer to head a study of medical ethics. Judicial decisions, directly and indirectly, will encourage patient prerogatives and reinforce proceduralism. The process of change may be accelerated because if patients today are more sovereign than ever before, medicine itself is more bureaucratic, enmeshed in forms, committees, and procedures. This bureaucratization can adversely affect patients as well as practitioners.