Mistakes and errors happen in most spheres of human life and activity, including in medicine. A mistake can be as simple and benign as the collection of an extra and unnecessary urine sample. Or a mistake can cause serious but reversible harm, such as an overdose of insulin in a patient with diabetes, resulting in hypoglycemia, seizures, and coma. Or a mistake can result in serious and permanent damage for the patient, such as the failure to consider epiglottitis in an initial differential diagnosis, resulting in a chronic vegetative state for a seven-year-old boy. Or a mistake can be an error in judgment that leads to a patient's death.

The bioethics literature on managed care has devoted significant attention to a broad range of conflicts that managed care is perceived to have introduced into the practice of medicine. In the first part of this paper we discuss three kinds of conflict of interest: conflicts of economic incentives, conflicts with patient and physician autonomy, and conflicts with the fiduciary character of the physician–patient relationship. We argue that the conflicts are either not as serious as they are often alleged to be or not unique to managed care. In part two we argue that managed care represents a new paradigm for medical care that features a new concept of management. We discuss three types or levels of management that managed care highlights, namely, administrative, clinical, and resource, which together offer a more sophisticated vantage point from which to assess patient care. We do not endorse managed care, but attempt to highlight some of the positive changes brought by managed care that were difficult to attain under traditional reimbursement systems.

The word enhancement is value laden and potentially misleading in the context of genetics. Dictionary definitions of enhance include “increase in value,” “improve,” “appreciate,” and “inflate.” The term genetic enhancement would be better replaced with a more neutral term such as “genetic manipulation” to reflect the fact that the consequences of as yet largely untried technology may be beneficial, balanced, or harmful. The aim of this paper is to highlight some of the potential negative consequences of the use of “enhancing technology” and hence to challenge whether “enhancements” are actually always enhancements. Thus it is necessary to question whether what may appear to be a new means of enhancement may not actually result in any significant change or is less effective than existing means of enhancement; may actually make things worse; or may on some measures actually make some things better, but on other measures or in other senses make things worse (either for the person being enhanced or for others).

The term “industrial action” includes any noncooperation with management, such as strict “working to rule,” refusal of certain duties, going slow, and ultimately withdrawal of labor. The latter form of action, striking, has posed particular problems for professional ethics, especially in those professions that provide healthcare, because of the potential impact on patients' well-being. Examination of the issues, however, displays a difference in response between the healthcare professions, in particular between doctors and nurses. In considering the ethics of industrial (especially strike) action there are various aspects of professional ethics to consider: (1) whether there is a tension between industrial action and the very notion of professional ethics; (2) what specific issues arise in the case of healthcare professions; (3) what, if anything, can explain and/or justify different responses from the medical and nursing professions?

Among the most significant findings of SUPPORT was that 50% of ICU patients suffered from moderate to severe pain during the last days of life. At the time of its publication late in 1995, SUPPORT was merely the latest in a long series of articles in the medical literature documenting the widespread and significant undertreatment of pain, beginning with a 1973 study of hospital inpatients. Much has been written about the phenomenon of undertreated pain and inadequate care of patients at the end of life, and many positive suggestions for reform of clinical education and clinical practice have been iterated and reiterated in the two decades separating the studies. Proposals for modifying clinician behaviors in this aspect of patient care have tended to focus on particular barriers to effective pain management and palliative care.

“Collective action” usually brings to mind images of picket signs held by laborers striking for better wages and benefits. Collective action, however, need not be limited to the withholding of labor. Nor need it involve only the working or middle classes, as airline pilots have recently demonstrated. Finally, collective action need not have as its only purpose the self-interest of the group. Collective action does, however, always involve a joining together of individuals united by common goals or interests in order to consolidate power for the purpose of negotiating with another group or entity. Examples of collective action obviously include striking, other withholding labor actions, and slowdowns, but can also include many other activities. “Paper strikes,” for example, have been threatened or used by house officer organizations in the past. In a paper strike, patient care continues but without documentation, and thus, the institution suffers from absent or delayed financial remuneration.

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures—liposuction, breast augmentation, eyelid surgery, and facelift—443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

Medicine needs our trust. We need to be able to rely on individual clinicians and researchers, and we need to be able to have confidence in hospitals and clinics. Yet the organization of our healthcare institutions is not designed to promote that trust. In fact, the structure of our medical institutions seems to undermine our faith.

Over the past several years, healthcare has been profoundly altered by the growth of managed care. Because managed care integrates the financing and delivery of healthcare services, it dramatically alters the roles and relationships among providers, payers, and patients. While analysis of this change has focused on whether and how managed care can control costs, an increasingly important concern among healthcare providers and recipients is the impact of managed care on the physician–patient relationship. The literature includes a number of theoretical articles and anecdotal accounts of managed care's impact on the doctor–patient relationship, but little data have been collected and analyzed. We designed a survey for distribution to Wisconsin physicians to analyze the prevalence and types of managed care arrangements in the state, and the impact of these arrangements on physicians and their relationships with patients.

Physician strikes in the United States have been relatively rare, although this has not been the case in other countries nor with other members of the healthcare community, such as nurses. This situation, however, could change. More physicians are either joining unions or seriously discussing doing so. The National Guild for Medical Providers, for example, is actively trying to expand its membership of 11,000 doctors in Michigan, Pennsylvania, and New Hampshire into Illinois, California, New Jersey, Colorado, Texas, and South Carolina. The Federation of Physicians and Dentists, with 2,500 members in Florida and Connecticut, is trying to establish itself in Seattle, Las Vegas, Tucson, and Philadelphia. Although unions are neither necessary nor sufficient conditions for strikes, if physician unions do become more prevalent, the potential for collective work actions, including strikes, increases.

Max Weber, the grandfather of organizational theory, recognized the close association between health care organizations and law. When he introduced the concept of a legal–rational bureaucracy, he used hospitals and clinics to illustrate it. Today, there is little doubt that healthcare organizations are “law-saturated,” if not always fully compliant with the law. Like Weber's legal–rational bureaucracies, healthcare organizations have highly formalized rules and procedures. They pay a great deal of attention to legal criteria in decisionmaking, and some have entire departments devoted to legal risk management.

The therapy-enhancement distinction occupies a central place in contemporary discussions of human genetics and has been the subject of much debate. At a recent conference on gene therapy policy, scientists predicted that within a few years researchers will develop techniques that can be used to enhance human traits. In thinking about the morality of genetic interventions, many writers have defended somatic gene therapy, and some have defended germline gene therapy, but only a handful of writers defend genetic enhancement, or even give it a fair hearing. The mere mention of genetic enhancement makes many people cringe and brings to mind the Nazi eugenics programs, Aldous Huxley's Brave New World, “The X-Files,” or the recent movie “Gattaca.” Although many people believe that gene therapy has morally legitimate medical uses, others regard genetic enhancement as morally problematic or decidedly evil.

Hospital ethics committees have evolved as a response to complicated legal, ethical, and social dilemmas that accompany modern medicine. In the United States, their growth has been augmented by Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) standards and the Patient Self-Determination Act. There appears to be an implicit presumption that all clinical ethics consultation practices are relatively similar. Finally, there is heightened awareness of the needs for quality standards and assessment of the outcomes of ethics consultations.

The question of whether physicians or other “essential” healthcare workers are ethically entitled to strike is troubling in that it entails a conflict in obligations. This question of a conflict of obligations (and the answer to it) has wider implications for many other workers.

These CQ Sources were compiled by Bette Anton.

These CQ Sources were compiled by David Buehler.

In the Netherlands, in 1995 approximately 9700 people explicitly requested euthanasia or assisted suicide (EAS), and EAS was performed approximately 3600 times (2.7% of all deaths). The most important reasons for not performing EAS when requested by a patient were that the patient died before EAS was performed, or that the physician refused the request.

These CQ Sources were compiled by Bette Anton, Edward M. Spencer, Ann E. Mills, and Carlton Hegwood Jr.

Regina R. is a 12-year-old girl with recently diagnosed insulin-dependent diabetes. Before discharging her from the hospital, her family physician and consulting diabetes specialist try to instruct the girl and her parents in the appropriate program of treatment, including diet, insulin, and regular self-monitoring. However, the parents become upset when they learn what is involved in insulin treatment and inform the family physician they plan to employ the services of an alternative healing clinic that promises to cure their daughter with a combination of herbal potions, macrobiotics, aroma therapy, therapeutic touch, Ayurveda, homeopathy, and guided imagery.

These CQ Sources were compiled by Bette Anton.