these care teams and hospital committees, their moral virtues or religious faith no longer confer moral authority. Any decisions must be articulate, defensible for both content and procedure and often, even in religious medical centers, by secular considerations Among specific institutional and procedural questions are: On what grounds(and by whom)are patients to be judged"decisionally incompetent"? How are surrogates for the incompetent patient to be chosen and their" substituted judgments"to be assessed? Should candidates for organ transplants be selected by committee, and, if so, who should sit on these committees? Should carce or costly hospital resources be allocated by medical benefit alone? Or should quality of life, social desert or worth, or age be taken into account? When should allocation be decided by a policy of first come, first served or other chance mechanisms? Is the goal of profit-maximization by which corporations define their fiduciary responsibility to shareholders reconcilable with the goals of insuring or providing adequate care to a range of patients with a variety of ailments? Physicians and society These clinical or micro-matters lead to sues of medicine as a publ publicly supported and allocated. The increasing and costs of hospital medicin of drug al st out-patient services. In response, philosophers have proposed contractarian and natural law rationales for age-relative distributions, as well as utilitarian analyses of cost-efficient allocations These macro-issues raise questions about physicians social and political responsibilities. Most physicians recognize narrow public health and safety obligations to report a patient's communicable diseases, gunshot wounds, signs of child abuse, or serious violent intentions -socially motivated exceptions to traditional pledges of confidentiality. But what of obligations to work toward a more just system of healthcare? Such a system might well limit both physician income and professional choices even more than current corporate organization of medical care in the United States. Physicians might, for example be less free to refuse poor or poorly insured patients. Physician autonomy would become subject to a redefined, or renewed "social contract between the profession and the society which educates, licenses, and grants its various privileges General professional ethics addresses such contracts and privileges. As these social issues emerge, medical ethics becomes less focused on the doctor at the bedside Relationships between doctor and patient are increasingly linked with those between doctor and hospital, hospital and insurer or corporate owners and stockholders, and the ill and the healthy members of society, the rich and the poor. In short, the field has become less iatrocentric expanding into the larger domain of health care ethics and clinical ethics Metaethical and pedagogic issues3 these care teams and hospital committees, their moral virtues or religious faith no longer confer moral authority. Any decisions must be articulate, defensible for both content and procedure and often, even in religious medical centers, by secular considerations. Among specific institutional and procedural questions are: On what grounds (and by whom) are patients to be judged "decisionally incompetent"? How are surrogates for the incompetent patient to be chosen and their "substituted judgments" to be assessed? Should candidates for organ transplants be selected by committee, and, if so, who should sit on these committees? Should scarce or costly hospital resources be allocated by medical benefit alone? Or should quality of life, social desert or worth, or age be taken into account? When should allocation be decided by a policy of first come, first served or other chance mechanisms? Is the goal of profit-maximization by which corporations define their fiduciary responsibility to shareholders reconcilable with the goals of insuring or providing adequate care to a range of patients with a variety of ailments? Physicians and Society These clinical or micro-matters lead to larger issues of medicine as a public good, publicly supported and allocated. The increasing scope and costs of hospital medicine have prompted restraint and rationing in matters of drug prescriptions, elective surgery, in-patient hospital stays, out-patient services. In response, philosophers have proposed contractarian and natural law rationales for age-relative distributions, as well as utilitarian analyses of cost-efficient allocations of treatment and research funds. These macro-issues raise questions about physician's social and political responsibilities. Most physicians recognize narrow public health and safety obligations to report a patient's communicable diseases, gunshot wounds, signs of child abuse, or serious violent intentions —socially motivated exceptions to traditional pledges of confidentiality. But what of obligations to work toward a more just system of healthcare? Such a system might well limit both physician income and professional choices even more than current corporate organization of medical care in the United States. Physicians might, for example, be less free to refuse poor or poorly insured patients. Physician autonomy would become subject to a redefined, or renewed "social contract" between the profession and the society which educates, licenses, and grants its various privileges. (General professional ethics addresses such contracts and privileges.) As these social issues emerge, medical ethics becomes less focused on the doctor at the bedside. Relationships between doctor and patient are increasingly linked with those between doctor and hospital, hospital and insurer or corporate owners and stockholders, and the ill and the healthy members of society, the rich and the poor. In short, the field has become less iatrocentric, expanding into the larger domain of health care ethics and clinical ethics. Metaethical and Pedagogic Issues