Medical centers are a primary context for medical ethics, as well as medical care. Whether physicians, philosophers, or theologians, most medical ethicists are primarily based in medical schools and teaching hospitals, and their principal audiences are (apart from one another)medical tudents and residents. This setting partially explains the primary role of actual case analysis in ethics, by contrast with much ethical writing. Physicians and nurses have little patience heoretical dialectic or fanciful test-cases that constitute much current secular ethics Nor do they readily accept the main theoretical alternatives. The Kantian ideal of persons as ational ends-in-themselves is hard to reconcile with the reality of patients whose mature judgment, sense of self and self-interests, and dignity are subverted by illness. Likewise, the scope of the Hippocratic maxim, "Strive to help but above all, do no harm"is far narrower than the Utilitarian principle, "Everyone counts for one and no more than one. " Some physicians will give some weight to the welfare of a patient's family, hospital staff, or future patients(e.g in drug trials unlikely to benefit current patients), but they will almost certainly ignore the friends, heirs or employers who may be seriously affected by treatment decisions In the light of practitioners resistance, some medical ethicists have forsaken ethical theories that have a single, dominant principle in favor of the jurists tactic of"balancing"several unranked principles. Decisions are to be reached by"weighing"for each case the now canonical principles of autonomy, beneficence, and non-maleficence, and, when appropriate, veracity, sanctity of life and distributive justice Critics find this procedure too dependent on individual intuition, and have proposed various remedies. On one proposal, conflicting general principles are specified"to yield compatible norms for a specific case. On another, the general principles are supplemented or replaced by a larger number of prohibitions drawn from"common sense"morality. On a"bottom up"alternative drawn from Medieval casuistry, it is richly described paradigm cases, not principles, that have the central role in moral reasoning. Other proposals would dispense with principles al together in favor of professional virtues(integrity, fiduciary responsibility, compassion); the central concerns of care ethics"(response to need, dependency, trust); and/or "narratives"sensitively constructed from conversations with patients, families, and other attendants All of these approaches have theoretical aspects and arguments, but the less the explicit appeal to carefully formulated and supported moral principles, the less that special philosophical training may seem necessary for case analysis. Philosophers, of course, pride themselves on their clarity, sense of relevance, and stock of apt questions and distinctions, but so too do lawyers. Moreover medical ethicists liberally borrow notions and cases from the law (due care, act/omission competence; Quinlan, Cruzan, Baby Does, Joyce Brown). There are, however, differences due as much to training as to institutional positions: philosophers give less weight than do"legal risk managers"to institutional interests in deciding contentious cases or formulating policy. On the other hand, medical ethicists may give more weight to institutional interests and physician practices than those bioethicists whose concerns are general issues of the creating, saving, and taking of life, with or without physicians assistance4 Medical centers are a primary context for medical ethics, as well as medical care. Whether physicians, philosophers, or theologians, most medical ethicists are primarily based in medical schools and teaching hospitals, and their principal audiences are (apart from one another) medical students and residents. This setting partially explains the primary role of actual case analysis in medical ethics, by contrast with much ethical writing. Physicians and nurses have little patience with the theoretical dialectic or fanciful test-cases that constitute much current secular ethics. Nor do they readily accept the main theoretical alternatives. The Kantian ideal of persons as rational ends-in-themselves is hard to reconcile with the reality of patients whose mature judgment, sense of self and self-interests, and dignity are subverted by illness. Likewise, the scope of the Hippocratic maxim, "Strive to help but above all, do no harm" is far narrower than the Utilitarian principle, "Everyone counts for one and no more than one." Some physicians will give some weight to the welfare of a patient's family, hospital staff, or future patients (e.g. in drug trials unlikely to benefit current patients), but they will almost certainly ignore the friends, heirs or employers who may be seriously affected by treatment decisions. In the light of practitioners' resistance, some medical ethicists have forsaken ethical theories that have a single, dominant principle in favor of the jurist’s tactic of "balancing" several unranked principles. Decisions are to be reached by "weighing" for each case the now canonical principles of autonomy, beneficence, and non-maleficence, and, when appropriate, veracity, sanctity of life, and distributive justice. Critics find this procedure too dependent on individual intuition, and have proposed various remedies. On one proposal, conflicting general principles are "specified" to yield compatible norms for a specific case. On another, the general principles are supplemented or replaced by a larger number of prohibitions drawn from "common sense" morality. On a "bottom up" alternative drawn from Medieval casuistry, it is richly described paradigm cases, not principles, that have the central role in moral reasoning. Other proposals would dispense with principles altogether in favor of professional virtues (integrity, fiduciary responsibility, compassion); the central concerns of "care ethics" (response to need, dependency, trust); and/or "narratives" sensitively constructed from conversations with patients, families, and other attendants. All of these approaches have theoretical aspects and arguments, but the less the explicit appeal to carefully formulated and supported moral principles, the less that special philosophical training may seem necessary for case analysis. Philosophers, of course, pride themselves on their clarity, sense of relevance, and stock of apt questions and distinctions, but so too do lawyers. Moreover, medical ethicists liberally borrow notions and cases from the law (due care, act/omission, competence; Quinlan, Cruzan, Baby Does, Joyce Brown). There are, however, differences due as much to training as to institutional positions: philosophers give less weight than do "legal risk managers" to institutional interests in deciding contentious cases or formulating policy. On the other hand, medical ethicists may give more weight to institutional interests and physician practices than those bioethicists whose concerns are general issues of the creating, saving, and taking of life, with or without physicians’ assistance