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It has been widely accepted and recommended that the needed improvements in the quality of health care require fundamental reforms in medical education. However, it is essential to recognize that there are significant problems not only with the quality but also with the quantity of health care in the United States. The medical profession has to confront the fundamental moral problem of unrealized rights and unattained justice in health care that has resulted in explicit harm to the health of a large portion of the population. Does this state of affairs have anything to do with the ways physicians have been educated about civic responsibilities, leadership, and professional integrity? What kind of education is to be provided for what kind of physicians and for what kind of medicine? Emphasis should be placed on the leadership role and on the underlying attitudes and values of physicians that reflect the morality of medicine. The doctor-patient and doctor-society relationships are part and parcel of the moral and professional responsibilities of physicians. Different moralities are involved when medicine is practiced as a job or business or vocation, because these entail different dispositions toward patients and society. The envisioned educational changes should challenge and prepare physicians not only with regard to their knowledge and skills but also with regard to their moral and professional integrity and leadership, so they may serve individuals and society in a health care system that ensures equal access to high-quality services for all.

Financial conflicts of interest arise when physician's judgment and decision making become compromised by financial gains or interests, and thus create risk of undo harm to research participants, to the integrity of research projects, and, ultimately to society at large. Such conflicts also violate the moral maxims of medicine, and thus damage the integrity of physicians and the medical profession. I submit that key remedies for this problem are the integrity (self-respect) of physicians and the respectful engagement of research participants (whether patients or nonpatient volunteers) as partners in research projects. Accordingly, I consider physicians the primary moral agents, research participants the secondary moral agents, and society the tertiary moral agent with responsibilities for protection against whatever undue harm in clinical research. The latter needs to address the powerful, cultural, commercial, political, and social factors that contribute to physicians' financial conflicts of interest.

With maternal serum alpha-fetoprotein testing, large numbers of previously "low-risk" patients are now considered high risk and are offered genetic testing. Anecdotally, these patients have been perceived as more highly anxious than other second-trimester patients referred for genetic testing because of advanced maternal age. Thus we have studied patient demographics, true genetic risks, the perceptions of risk, and state (situational) and trait (constitutional) anxiety for these patients and their partners. Significantly increased state anxiety was noted for mothers as compared with fathers both in the group of women referred for testing because of maternal serum alpha-fetoprotein levels and in those referred due to advanced maternal age. State anxiety was increased in the women referred for maternal serum alpha-fetoprotein levels as compared with women referred for advanced maternal age. True genetic risks were comparable between the groups. Some critics have argued that maternal serum alpha-fetoprotein screening engenders unnecessary anxiety. Our data show that patients undergoing genetic testing due to maternal serum alpha-fetoprotein levels have higher state anxiety than women undergoing testing because of advanced maternal age, but that indication is much less a factor than are partner differences. Therefore, increased anxiety after abnormal maternal serum alpha-fetoprotein testing results cannot be reasonably used as an argument against such testing.