Respect for patient autonomy is one of the major ethical goals of modern medicine. Therefore, it is important to analyse whether the organisational structure of the German health care system impedes the realisation of patient self-determination. It will be shown by means of historical and ethical analysis that the nature of the doctor-patient relationship as well as other factors in the organisation of modern medicine systematically undermine patient autonomy. If individual responsibility in the health care setting is to be strengthened, patients' influence on public health decision-making processes, too, has to be advanced. The paper shows from a patient perspective where this could be the case.