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The ethical problems in every-day practice are rarely discussed in the literature. In part this is because they are considered trivial, in part because they lack the “prurient” appeal of more flamboyant problems and in part because their solutions are at best still unsatisfactory. Many are system related problems in which the fact that physicians should do all they can to change the system is uniquely unhelpful in dealing with the immediate problem. And yet changing the system, keeping involved in bringing about changes, refusing to accept today’s shameful lack of care for millions and refusing to allow medicine to be practiced by non-medical people (as insurers do when they “permit” or “disallow” certain tests or treatments for certain patients) is ultimately the only long term and never finished answer for many of these problems. Physicians and other health care workers need to remain involved in fashioning and maintaining a system in which sufficient elbowroom to practice ethical medicine is given. Remaining involved may range from being advisers for the community to acts of civil disobedience when no other course remains open. There is one thing physicians and health care workers cannot, in today’s society, countenance: not doing the best possible for a patient in order to increase the profit of managed care organizations.

The most that one can say about any of these is (1) that health-care workers need to think about and then have the courage to apply their priorities to concrete situations, (2) that being the patient’s advocate may, at times, entail unpleasantness and (3) that—trite as it may sound—only pushing to create a system which makes proper ethical practice possible can ultimately achieve what all health-care professionals seek: sufficient time and space to deal appropriately with the many daily ethical problems they must face.

The ethical problems in every-day practice are rarely discussed in the literature. In part this is because they are considered trivial, in part because they lack the “prurient” appeal of more flamboyant problems and in part because their solutions are at best still unsatisfactory. Many are system related problems in which the fact that physicians should do all they can to change the system is uniquely unhelpful in dealing with the immediate problem. And yet changing the system, keeping involved in bringing about changes, refusing to accept today’s shameful lack of care for millions and refusing to allow medicine to be practiced by non-medical people (as insurers do when they “permit” or “disallow” certain tests or treatments for certain patients) is ultimately the only long term and never finished answer for many of these problems. Physicians and other health care workers need to remain involved in fashioning and maintaining a system in which sufficient elbowroom to practice ethical medicine is given. Remaining involved may range from being advisers for the community to acts of civil disobedience when no other course remains open. There is one thing physicians and health care workers cannot, in today’s society, countenance: not doing the best possible for a patient in order to increase the profit of managed care organizations.

The most that one can say about any of these is (1) that health-care workers need to think about and then have the courage to apply their priorities to concrete situations, (2) that being the patient’s advocate may, at times, entail unpleasantness and (3) that—trite as it may sound—only pushing to create a system which makes proper ethical practice possible can ultimately achieve what all health-care professionals seek: sufficient time and space to deal appropriately with the many daily ethical problems they must face.

The ethical problems in every-day practice are rarely discussed in the literature. In part this is because they are considered trivial, in part because they lack the “prurient” appeal of more flamboyant problems and in part because their solutions are at best still unsatisfactory. Many are system related problems in which the fact that physicians should do all they can to change the system is uniquely unhelpful in dealing with the immediate problem. And yet changing the system, keeping involved in bringing about changes, refusing to accept today’s shameful lack of care for millions and refusing to allow medicine to be practiced by non-medical people (as insurers do when they “permit” or “disallow” certain tests or treatments for certain patients) is ultimately the only long term and never finished answer for many of these problems. Physicians and other health care workers need to remain involved in fashioning and maintaining a system in which sufficient elbowroom to practice ethical medicine is given. Remaining involved may range from being advisers for the community to acts of civil disobedience when no other course remains open. There is one thing physicians and health care workers cannot, in today’s society, countenance: not doing the best possible for a patient in order to increase the profit of managed care organizations.

The most that one can say about any of these is (1) that health-care workers need to think about and then have the courage to apply their priorities to concrete situations, (2) that being the patient’s advocate may, at times, entail unpleasantness and (3) that—trite as it may sound—only pushing to create a system which makes proper ethical practice possible can ultimately achieve what all health-care professionals seek: sufficient time and space to deal appropriately with the many daily ethical problems they must face.