Clinical loyalties and the social purposes of medicine

Physicians increasingly face conflicts between the ethic of undivided loyal ty to patients and pressure to use clinical methods and judgment for social purposes and on behalf of third parties. The principal legal and ethical p aradigms by which these conflicts are managed are inadequate, because they either deny or unsuccessfully finesse the reality of contradiction between fidelity to patients and society's other expectations of medicine. This rea lity needs to be more squarely acknowledged. The challenge for ethics and l aw is not to resolve this tension-an impossible task-but to mediate it in m yriad clinical circumstances in a way that preserves the primacy of keeping faith with patients while conceding the legitimacy of society's other expe ctations of medicine.