New beginnings give us the opportunity to do better “the next time.” In the rush to welcome the new millennium, it is fitting to take time to look more thoughtfully at issues not adequately covered in decades past. Robert Frost's musing about less traveled roads gives poetic life to the theme of this CQ Special Section, exploring some of the all too unknown territory between doctors and patients.

“Monsieur Chardin is obliged to keep his subject before his eyes.” That remark, by a long forgotten critic, was meant as a rebuke for the painter who did not work from sketches. Jean Simeon Chardin's counter, “We have to teach our eyes to look.”

Today's Zeitgeist dictates that physicians not only care for their patients, but also care deeply about them. According to a recent article in a prominent journal, “patients who are given good medical treatment are often upset or angry when they feel that their doctors do not care about them personally.” It may well be that the Zeitgeist says more about how we feel as potential patients than what we actually expect of physicians. Nonetheless, this Zeitgeist poses an important problem for the physician who cares for a sentimental patient. “Sentimental” here describes a contrived exaggeration of the emotional availability of physicians. Despite the impossibility of articulating precisely how much emotional engagement clinical encounters demand, sentimental patients expect too much of their caregivers.

Armstrong describes the rise of a new mode of medical practice that he calls “surveillance medicine,” in the following terms: “Despite the obvious triumph of a medical theory and practice grounded in the hospital, a new medicine based on the surveillance of normal populations can be identified as emerging in the twentieth century.” Surveillance medicine gives rise to a novel and underexplored aspect of the long-standing tension between the different goals of clinical medicine and public health.

As every physician knows, “do no harm” is a basic tenet of medical ethics. Ironically, however, the increasingly powerful science used in patient care may undermine adherence to this tenet. In particular, science now enables the physician to identify “partial patients”—as Greaves defines them—by diagnosing disease or risk factors for disease before physical symptoms occur. But simply by identifying such partial patients, the physician may unwittingly inflict emotional harm on them. “Do no harm” requires the physician to anticipate and minimize such harms.

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.

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.

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.

These CQ Sources were compiled by David Buehler.

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.

The physician of fifty years ago is barely recognizable today. Rural, autonomous, and isolated, he did everything from mending broken bones to pronouncing people dead. He was responsible for a well-circumscribed community, who came to him for all their medical needs, regardless of the hour.

No political, economic, or cultural segment of society has escaped the universal impact of recent cataclysmic change. Physicians were no exception. During the 20th century, all members of society, including physicians, have experienced change of enormous speed and magnitude. Futurist Alvin Toffler noted that global societal transformation has created a “future shock” of personal malaise that poses difficulty for both individual and group adaptation. Toffler further described current change as a fundamental shift and conflict in all aspects of civilization (how we live, work, and relate to each other). Toffler also noted major alterations in the basis for distribution of societal power (who controls what, why, and how). One manifestation of recent change directly affecting all members of society, including physicians, has been the social transformation of medicine that has been a power shift from the individual physicians to control by organizations and management.

Many people see high income as the primary motivation of today's American physicians. But in “The Culture of Physician Autonomy, 1900 to Present,” Dr. Pont offers a provocative new idea: that preserving professional autonomy has been a far more powerful motivation through this century.

The point of Judith Jarvis Thomson's violinist example is to establish that one person, A, can acquire a right to use the body of another person, B, if and only if B performs some kind of affirmative act that gives A such a right. On her view, the reason it is permissible for you to unplug yourself from the violinist is that you did nothing to give the violinist a right to use your body: the violinist was plugged into you without your consent. Thus it follows that the mere fact that A needs use of B's body to survive is not enough to give rise to a right in A to use B's body. Accordingly, Thomson concludes, the claim that the fetus has a right to life does not imply abortion is morally impermissible.

In a special issue of this journal, a range of authors addressed the critical problem of difference in bioethics. To what extent do class, culture, ethnicity, and race affect the ethical decisions that patients and professionals must make in a medical context? Those arguing for an understanding of cultural influences in bioethical decisionmaking—for example, Hern, Koenig, Moore, and Marshall—typically argue from the perspective of individual case studies to demonstrate the importance of these social constructs. Others, like Erika Blacksher, however, worry that this approach will obscure the uniqueness of individual decisionmakng patterns, allowing all persons of a single group to be aggregated as if their class, cultural construct, or religious affiliation were the single motive element in their medicolegal decisionmaking. There is, she cautions, a risk of misuse if a professional care provider reflexively assumes individual patient or surrogate reactions on the basis of ethnicity or culture.

A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a Central American country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system.

In this case, when the ethics committee is asked “What is our duty to this patient?” the questions that should be addressed are “What is whose duty to the patient, and whose duty has primacy?”

This is a case that speaks directly to the issue of an organization's mission. As private insurance and government reimbursement decline, the economic pressures facing healthcare systems both public and private continue to increase. For many institutions it is no longer a question of prospering but surviving. As this case accurately describes, survival is dependent on continually reducing costs and maximizing reimbursement. These strategies often include reducing the number of nonpaying or charity cases while attempting to remain faithful to the mission of the organization, whether this be a religious or civic mission. The ethics committee, although it may be an appropriate forum for discussions to begin concerning this patient, is not the appropriate decisionmaking body regarding whether this gentleman receives the treatment he needs. That task should fall to whichever group defines or articulates the mission and values for the organization, normally the hospital's administration in concert with the board of directors or trustees.

Ethics raises questions about what kind of society we ought to be, questions that are at the heart of this case. Increasingly, inequalities in healthcare fueled by lack of access, inadequate insurance coverage, and rising costs are creating dilemmas in the proper distribution of healthcare resources. Questions of distributing scarce and valuable resources are fundamentally questions of justice. The classic definition of justice is the duty to give to each person what they deserve and can legitimately claim so that justice is understood as a moral obligation to help persons exercise their rights. Distributive justice, i.e., what distribution of resources is fair, equitable, and appropriate, thus turns on the concept of rights. One of the key questions in this case is whether and to what extent this patient has a right to treatment for his heart disease. In the classic understanding of justice, he must assert and we as a society must agree that he has a right to treatment for his heart condition before we are morally obligated to provide this care. Are there limits to this patient's right to healthcare? If so, what are they? The differing principles of distributive justice use different criteria to rank or weight decisions regarding the proper and just distribution of healthcare services. In this case, at least two competing but ethically valid principles can be identified: the humanitarian principle and the libertarian principle.

To ask whether and to what extent there is an obligation to treat illegal immigrants implies—just in the asking—that any duty to treat an illegal resident is different from or lesser than the duty to treat a citizen. What could be the reason for thinking that morality affords fewer benefits or rights to illegal residents?