Human existence is marked by pain, limitation, disability, disease, suffering, and death. These facts of life and of death give ample grounds for characterizing much of the human condition as unfortunate. A core philosophical question is whether the circumstances are in addition unfair or unjust in the sense of justifying claims on the resources, time, and abilities of others. The temptation to use the languages of rights and of justice is und- standable. Faced with pain, disability, and death, it seems natural to complain that "someone should do something," "this is unfair," or "it just isn't fight that people should suffer this way." Yet it is one thing to complain about the unfairness of another's actions, and another thing to complain about the unfairness of biological or physical processes. If no one is to blame for one's illness, disability, or death, in what sense are one's unfortunate circumstances unfair or unjust? How can claims against others for aid and support arise if no one has caused the unfortunate state of affairs? To justify the languages of fights to health care or justice in health care requires showing why particular unfortunate circumstances are also unfair, in the sense of demanding the labors of others. It requires understanding as well the limits of property claims. After all, claims regarding justice in health care or about fights to health care limit the property fights of those whose resources will be used to provide care.

The spectacular development of medical knowledge over the last two centuries has brought intrusive advances in the capabilities of medical technology. These advances have been remarkable over the last century, but especially over the last few decades, culminating in such high technology interventions as heart transplants and renal dialysis. These increases in medical powers have attracted societal interest in acquiring more such knowledge. They have also spawned concerns regarding the use of human subjects in research and regarding the byproducts of basic research as in the recent recombinant DNA debate. As a consequence of the development of new biomedical knowledge, physicians and biomedical scientists have been placed in positions of new power and responsibility. The emergence of this group of powerful and knowledgeable experts has occasioned debates regarding the accountability of physicians and biomedical scientists. But beyond that, the very investment of resources in the acquisition of new knowledge has been questioned. Societies must decide whether finite resources would not be better invested at this juncture, or in general, in the alleviation of the problems of hunger or in raising general health standards through interventions which are less dependent on the intensive use of high technology. To put issues in this fashion touches on philosophical notions concerning the claims of distributive justice and the ownership of biomedical knowledge.

in the culture of medicine, and they saw their mission as a generation of profit for stockholders, not necessarily medical care for clients. Cost-effective medicine was the goal in the context of a profit-making enterprise. Although preventive health care programs were promised, very few were realized and they were not nearly comprehensive. The definition of unnecessary testing slowly expanded to mean virtually any high-cost test requiring the service of a medical specialist, and low priced generalist physicians with limited diagnostic and therapeutic skills were made available to patients with the instruction they should limit their access to high-cost specialists. Managed care organizations tended to re ward primary care physicians who avoided specialty referrals, and severed contracts with those who persisted in sending their patients to outside consultants. Most notoriously, managed care organizations maintained veto authority over the provision of complex and expensive care, and that veto was often wielded in defiance of a physician's recommendation by managed care employees without medical training or experience. Managed care did indeed slow the rate in increase of medical costs, but not without limitations on the care provided to patients and the professional integrity of physicians. Managed care organizations were so successful that they could provide extremely high salaries to their executives even in the context of limiting cost and care. It is these developments that the papers of this symposium addressed. The most fundamental ethical issue is posed in the first paper by Dr."

This collection provides a philosophical and historical analysis of the development and current situation of managed care. It discusses the relationship between physician professionalism and patient rights to affordable, high quality care. Its special feature is its depth of analysis as the philosophical, social, and economic issues of managed care are developed. It will be of interest to educated readers in their role as patients and to all levels of medical and health care professionals.

Human existence is marked by pain, limitation, disability, disease, suffering, and death. These facts of life and of death give ample grounds for characterizing much of the human condition as unfortunate. A core philosophical question is whether the circumstances are in addition unfair or unjust in the sense of justifying claims on the resources, time, and abilities of others. The temptation to use the languages of rights and of justice is und- standable. Faced with pain, disability, and death, it seems natural to complain that "someone should do something," "this is unfair," or "it just isn't fight that people should suffer this way." Yet it is one thing to complain about the unfairness of another's actions, and another thing to complain about the unfairness of biological or physical processes. If no one is to blame for one's illness, disability, or death, in what sense are one's unfortunate circumstances unfair or unjust? How can claims against others for aid and support arise if no one has caused the unfortunate state of affairs? To justify the languages of fights to health care or justice in health care requires showing why particular unfortunate circumstances are also unfair, in the sense of demanding the labors of others. It requires understanding as well the limits of property claims. After all, claims regarding justice in health care or about fights to health care limit the property fights of those whose resources will be used to provide care.

The spectacular development of medical knowledge over the last two centuries has brought intrusive advances in the capabilities of medical technology. These advances have been remarkable over the last century, but especially over the last few decades, culminating in such high technology interventions as heart transplants and renal dialysis. These increases in medical powers have attracted societal interest in acquiring more such knowledge. They have also spawned concerns regarding the use of human subjects in research and regarding the byproducts of basic research as in the recent recombinant DNA debate. As a consequence of the development of new biomedical knowledge, physicians and biomedical scientists have been placed in positions of new power and responsibility. The emergence of this group of powerful and knowledgeable experts has occasioned debates regarding the accountability of physicians and biomedical scientists. But beyond that, the very investment of resources in the acquisition of new knowledge has been questioned. Societies must decide whether finite resources would not be better invested at this juncture, or in general, in the alleviation of the problems of hunger or in raising general health standards through interventions which are less dependent on the intensive use of high technology. To put issues in this fashion touches on philosophical notions concerning the claims of distributive justice and the ownership of biomedical knowledge.