The bioethics literature on collective labor protest actions by health professionals is modest and recent, focusing almost exclusively on strike actions—although that is beginning to change. The essays in this special section of the Cambridge Quarterly seek to further explore many of the key ethical issues in some detail. The authors analyze existing ethical tensions and propose responses (none presume to call them solutions) to the increasingly hostile conflicts between licensed health professionals and the new corporate management of healthcare organizations.

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.

The role of the healer is expanding. Attempts by physicians to enhance human capacity are but one among many new medical projects. The twentieth century ushered in significant changes in therapeutic modalities, and the past two decades have seen the role of the physician reshaped by economic, political, and dramatic new social mores. People ask new and different things of their clinicians. Under managed care, the primary care clinician is expected to have much more skill than was traditionally expected of a general internist, and new incentives force physicians to much more explicitly ration the care they provide to patients and to patient populations. But perhaps no change in the contemporary world of health portends more long-term effects than the introduction of enhancement technologies.

Bioethics, clinical ethics, and professional ethics are mature, well-developed fields of applied ethics that focus on medical research, patient autonomy and patient care, patient–healthcare professional relationships, and issues that arise in clinical and other medical settings. However, despite these developments, little attention has been paid to the organizational aspects of healthcare in these fields. This is surprising, because in the last 30 years healthcare has become more and more institutionalized in provider, management, and insurer organizations. Despite JCAHO's preoccupation with organizational ethics during the last decade, the philosophical underpinnings of their requirements have been less explored in the literature. Clinical ethics remains preoccupied with clinical patient care and professional ethics with individual professional guidelines; even the American College of Healthcare Executives focuses primarily on healthcare managers, not on healthcare organizations.

“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.”

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure (or otherwise ameliorate) conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

Public opinion polls consistently reveal that U.S. society wants three basic characteristics in its healthcare system: (1) convenient access to skilled professionals and quality services for everyone, including primary care and specialty personnel and services especially for the very seriously ill; (2) personal affordability at both levels of service; and (3) happy health professionals. Meeting these three goals simultaneously has proved to be quite challenging. The goal of universal access to basic and specialty services pulls against the goal of affordability. Health professionals caught in the middle of this struggle find that their satisfaction with work conditions suffers as a result. If truth is the first casualty of war, worker and consumer happiness appears to be the first casualty of substantive healthcare reform in the United States.

Suppose a “blue sky” meeting had been called among chief medical officers, chief administrative officers, and other leaders from a range of health-related institutions in this country. The question posed for this meeting was simple but unusual: Are the structures of our organizations, systems, and institutions ethical? Though it was a question reminiscent for a few of the focus some time before on whether the conduct of individuals in their organization was ethical, this question seemed more demanding. Is it reasonable to consider structures or arrangements as ethical or not; or in other words, is ethics an applicable attribute of organizations? And if it is reasonable to speak of an ethics of organizations, by what method might one discern any kind of an answer? And what of the informal connections that link different organizations … how can they be evaluated?

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.

Male cats mate happily with any female in heat in the neighborhood. Something similar occurs in colleges as nearness and availability overwhelm all other considerations. So we see young men and women marry people who happen to be at hand when the time is ripe.

Until recently (before managed care), business issues in healthcare organizations (HCOs) were relatively insulated from clinical issues, for several reasons. The hospital at earlier stages of its development operated on a combination of charitable and equitable premises, allowing for providing care to be separated from financial support. Physicians, who were primarily responsible for clinical care, constituted an independent power nexus within the hospital and were governed by their own professional codes of ethics. In exchange for a great deal of control over their conditions of practice, they took almost complete responsibility for patient care. Thus clinical and professional ethics could to some extent be compartmentalized from the business issues—a much easier feat when, as in much of the last few decades, virtually all care was reimbursed from some source or other. In addition, many HCOs were not categorized or treated as businesses, although of course they were presumed to be governed by the same expectation for good management as any other organization.

Can strikes by resident doctors training to become consultants in Indian public-sector teaching hospitals be ethical? These hospitals were established for the medical care of the very poor in a country where health insurance and a national health service are nonexistent. In such a situation, the paralysis of tertiary healthcare centers by striking doctors runs contrary to the raison d'être of the profession. It also violates the first dictum of medicine: Primum, non nocere. And although there is some discussion in the Western literature on strikes by doctors, authorities in India are silent on the subject.

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 a philosopher interested in biomedical ethics, I find recent advances in genetic technologies both fascinating and frightening. Future technologies for genetic therapies and elimination of clearly deleterious genes offer us the ability to get rid of the cause of much human suffering, seemingly at its physiological root. But memories of past eugenics programs gone horribly awry (whether we speak of Hitler's program, California sterilization laws and practices of the 1920s, or even contemporary practices, such as attempts to work out deals that exchange sterilization for early prison release) must make cautious our initial optimism for these generally well-intentioned programs. Most often the scientist proceeds in research with the best of intentions, but that does not make all scientific investigation worth pursuing.

The Clinton administration's revised rules regulating but not prohibiting the common practice in managed care of linking physician compensation with cost cutting and control of services demonstrates the complexity of ethical issues in managed care. As originally proposed, the federal guidelines on payment for Medicare and Medicaid services would have precluded any interrelationship between payment to physicians and delivery of services. Such a restriction would have gutted the primary mechanism in managed care plans to curb the unacceptably high cost of healthcare delivery: making physicians directly responsible for cost control by placing them at direct financial risk. At first blush such a linkage seems to involve an obvious and irreconcilable conflict of interest. How can a physician be responsible for the well-being of a patient while at the same time aware that a proportion of his or her income is linked to the provision of cost-conscious care?

This paper aims to identify some of the values held by physicians in the United States that are relevant to physician strikes and other collective actions, and to articulate a position about collective actions that is consistent with medical professionalism. The concept of medical professionalism includes several elements to which physicians should aspire, but the fundamental definition of professionalism is based on just one of these elements, the virtue of altruism. As stated by a committee project paper of the American Board of Internal Medicine, “professionalism in medicine requires the physician to serve the interests of the patient above his or her self-interest.”

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.