For a very long time, two strong, cohesive forces have characterized western medicine. The first is a set of governing moral precepts (a "guardian moral syndrome") related to those that govern life in the military, the government, and the church; the second is a network of social relationships ("gift relationships") based on mutual acts of giving and receiving. These precepts and relationships have created the context in which healing takes place and have, in many ways, contributed directly to that healing. They are, however, fundamentally incompatible with the divisive precepts and relationships that govern commerce. It is the thesis of this editorial that as medical care is increasingly bought and sold in the marketplace, we sense that we are forced to compromise more than individual moral precepts and that we are losing more than individual gift relationships. We realize, in effect, that the entire moral, cultural, and social fabric that has always defined medicine-the integrity of its guardian moral syndrome (considered in part 1 of this editorial) and of its network of gift relationships (considered in part 2)-is at risk of being torn to pieces. It is hardly surprising that we smell trouble.

The work of social geographer and critic Jane Jacobs provides us with an analytic framework here [3]. Jacobs posits that two sets of moral precepts, the "guardian" and the "commercial" moral syndromes, make up the nexus of public life and that these syndromes have evolved from the two basic modes of human survival, "taking" (think conquest, hunting, taxes, and tithes) and "trading" (think contracts, investments, capital, and interest), respectively (Table 1). Note that the less public social interactions, including the arts, love, sex, friendship, and scholarship, lie largely outside of the two syndromes. These constructs assume, moreover, that many basic moral qualities (for example, cooperation, courage, moderation, mercy, and common sense) are held in common by the two syndromes.

Guardian precepts are what guide people when they take responsibility for territories and need to maintain public order and safety, combat corruption, and deal with enemies, among other things; commercial precepts guide people when they manage viable businesses. Historically, the guardian syndrome probably developed first, its roots deep in military life. As civilian rule evolved, guardian precepts were carried into government; then into the church; and then, to a degree, into the professions. Guardian precepts have sustained social class distinctions and nurtured the arts; the commercial moral syndrome, in contrast, created the environment in which individual human rights emerged and science flourished.

Jacobs' own analysis barely touches on medicine, but it is not hard to see that medicine has traditionally operated under moral precepts whose origins are overwhelmingly guardian in character (Table 1). Most important, medicine has historically shunned trading (recall, for example, the self-imposed ethical ban on physician advertising). But medicine has also been obedient and disciplined (structured training, professional certification, licensing); been exclusive (resistance to the incursions of other practitioners into our professional "turf"); respected hierarchy (powerful staff and departmental organizations, professional societies); exerted prowess (life and death decisions); adhered to tradition (the Hippocratic oath, "schools" of clinical practice); treasured honor (deep public respect for exemplary physicians); been loyal (reluctance to testify against each other in the courtroom); shown fortitude (unrelenting residency training hours, night call); dispensed largesse (the unrestrained dispensing of medical resources that has pushed the costs of medicine up to 15% of the gross domestic product); made rich use of what little leisure it has (the legendary obsession with golf); been ostentatious (owning of obviously expensive cars and houses); been fatalistic (realistic clinical prognoses); and deceived for the sake of the task (use of Latin and other jargon, withholding of "disturbing" information from patients and families). It seems that the only guardian precept by which we have not lived is the taking of vengeance.

To be sure, medicine's moral range extends well beyond guardian precepts, and medicine has always incorporated some precepts from the commercial side, including competition and honesty. What's more, the intrusion of commercial interests into medicine is not new; it began in earnest, unrecognized, more than 150 years ago, with the entry of science into medicine. Science, after all, requires rigorous intellectual honesty, inventiveness, optimism, and dissent, all of which challenge the hierarchy, tradition, obedience, and fatalism of a traditionally guardian profession. In fact, the current debate over evidence-based medicine still reflects this challenge [4]. Science has also created a kind of medicine that really "works" in an objective, biological sense (antisepsis, potent drugs, effective surgery, powerful imaging), a tangible, valuable commodity that can be traded in the marketplace. In the process, scientific medicine quietly displaced the social and "apostolic" functions of medicine, the comforting, counseling, and placebo effect-in sum, the "drug doctor." These were once the primary things that the profession had to offer, but they were linked too tightly to the persons of individual practitioners to be easily bought and sold [5].

Despite the gradual incursions of the market-place, commercial precepts have until recently remained peripheral to medicine, more a slightly embarrassing necessity than the "name of the game," as they are in the commercial sector. However, with the recent, rapid, and extensive expansion of commerce in medicine, it is obvious that the primacy of the guardian moral syndrome in medicine is now being seriously challenged. It therefore is important to understand what happens more generally when the distinction between the two moral syndromes becomes blurred and one syndrome is blended with, or replaced by, the other.

A key point in this regard is the recognition that although the individual precepts in each syndrome may appear banal, every precept links directly with some and indirectly with all of the others in that syndrome. Each syndrome is thus a tightly knit, coherent whole; each has its own integrity. Any major breach of a syndrome's integrity-by the adoption of an inappropriate function, for example, or by the rejection of a single, crucial precept-can cause "some normal virtues to convert automatically to vices, and still others to bend and break for necessary expedience" [6]. Given the contradictory nature of the two syndromes, it is not surprising that sufficient blurring and blending of their precepts can result in what Jacobs calls "intractable systemic corruption" or, in the extreme, "monstrous hybrids."

Monstrous hybrids are not hard to find: Take, for example, the massive inefficiency that can result when guardian precepts like largesse, deceit, and ostentation hold sway in such areas as the production of goods and services that are usually controlled by the commercial sector. (Congressional pork barrel and Pentagon spending come to mind, although the most striking modern example of this species of monstrous hybrid was almost certainly the Soviet Union). Hybrids of the opposite kind also occur; for example, the amplification of ill-conceived guardian largesse that develops when commercial precepts such as competitiveness, industriousness, and efficiency intrude into guardian affairs [6]. (Foreign debt became seriously aggravated when commercial banks entered into World Bank financing of international loans, for example.)

And indeed, the tell-tale footprints of a monstrous hybrid are increasingly evident all over the U.S. medical care system: Marketing of health care systems is rampant, industrial principles of organization and quality improvement are widely applied [7], and aggressive business practices have become standard operating procedure [8, 9]. Even the language has changed: Health care professionals are "providers," patients are "consumers," and money spent on patient care is a "loss ratio." In fact, the mixing of moral syndromes has made it difficult even to define "fraud" in the new health care system. Payments used to induce referrals (once known as kickbacks and deemed unethical, even illegal, under medicine's guardian precepts) are now accepted as just another market-driven activity aimed at improving efficiency, quality, or market share. Indeed, remuneration of this kind is now considered fraud only if its intent is to achieve a future flow of business [10]. Quentin Young, a Chicago internist and president-elect of the American Public Health Association, characterized one result of such syndrome-mixing as follows [11]:

"There was plenty of self-interest abuse under traditional medicine, but that happened when people strayed outside the realm of their professional oaths. If the goal of medicine becomes to maximize shareholder return, then financial self-interest will become not a violation but the norm-a standard, expected practice [emphasis added]."

But in the real world, of course, things are not so simple. All well-functioning societies need both commercial and guardian work; they can and must try to find a way for the two syndromes to work together, although they must try to do so without creating intractable corruption or monstrous hybrids. Besides, in some respects, medicine may have carried its guardian precepts, such as dispensing largesse, showing fortitude, adhering to tradition, and having loyalty, to extremes. This could account for such comments as the recent reference in the Wall Street Journal to "a bourgeois medical establishment that's been hibernating too long, unperturbed by market forces" [12]. Could medicine use a healthy dose of certain commercial moral precepts, including promotion of comfort and convenience (think of the generally dismal quality of hospital food, the disappearance of house calls), improved efficiency (think of long waiting times, extremes of practice variation), and better investment (think of our deteriorating public hospitals)?

We are thus faced with a dilemma. On the one hand, medicine, like society at large, needs the influence of both syndromes. On the other hand, as Jacobs puts it [13],

"To seek harmony [between the two syndromes] in the sense of oneness is a profoundly false lead ... Trying to do it can't produce harmony-quite the opposite. The contradictions are innate."

Indeed, the violent reaction to the American Medical Association's recent "harmonization" of guardian and commercial precepts in its agreement with the Sunbeam corporation testifies to the strength of these contradictions. Jacobs suggests that the way out of the dilemma is, first and foremost, to maintain the identity and integrity of each syndrome, then-and only then-bring the two syndromes together. Only in this way is it possible to create a true symbiosis of guardian and commercial work, in the original sense of symbiosis: the living together of two dissimilar organisms, especially when the association is mutually beneficial.

Historically, two primary approaches have been used to maintain the integrity of the syndromes while allowing a degree of symbiosis to develop between them: a "caste" system and the application of "knowledgeable flexibility." In a caste system, the guardian and commercial syndromes remain "pure" because they essentially function separately, as they have in many cultures over the years. Unfortunately, caste systems are maintained only at the price of enormous social class rigidity; they are also inefficient because the interaction of two syndromes is largely adversarial and takes place at a distance. In the long run, moreover, caste systems eventually break down in an uncontrolled fashion-witness what has happened to the rigid historical separation between the medical and commercial "castes" in the United States, with physicians and nurses scrambling for MBAs while insurance executives, administrators, and politicians decide who gets what kind of care.

In medicine as elsewhere, then, knowledgeable flexibility may be the last, best hope for effective syndrome symbiosis. Under this approach, the integrity of the two syndromes is recognized and respected, but the persons working within the syndromes need to be morally flexible enough to adapt to either one as required and knowledgeable enough to know the difference between them [14]. Jacobs points to many "syndrome-friendly" examples of knowledgeable flexibility that have been used to create and maintain symbiosis, as, for example, when guardians (the government) say, "Here's what you commercial people have to do and we'll enforce it, but how you comply is your responsibility. Find your own commercial ways and means" [15]. The government mandate to make cars that get increased mileage per gallon is one such case; the ways in which industry complied-more efficient engines, lighter cars, equipment for alternate fuels-was left to them.

Knowledgeable flexibility, of course, is not without its own problems and limitations. For one thing, it is hard to get people to buy into it in the first place; for another, it is hard to maintain, being itself subject to corruption. Although it is certainly possible to overcome these problems and limitations, it will never be easy, particularly because we can't rely on an "intelligentsia" to make critical and discriminating moral judgments for us. Jacobs suggests that ultimately there is no way around the need for managers at all levels in organizations to habitually discuss these matters with each other and "think about the enterprise's legitimate values and the morality of what it's doing or planning to do" [16]. Everyone, each by each, needs to be habitually aware of the moral implications of what he or she is asked to do.

Guardian (government) regulation of managed care has begun [17]. Moreover, new codes of ethics that deal with the dilemmas created by managed care are under consideration [18-20]. To the extent that new regulations, new codes of ethics, or other such measures can support widespread moral under standing and respect for the two moral syndromes, such measures could become "syndrome-friendly tinkering"-important and reliable buttresses of knowledgeable flexibility. As such, they might help replace the rigidities of caste and ultimately create the kind of optimal syndrome symbiosis that we hope is possible in medicine. To the extent that they abandon the clear moral distinctions between the two syndromes, however, in ill-advised attempts to create moral "oneness," such measures are likely to only speed up the process by which medical care in the United States, now well on its way to becoming a monstrous hybrid, is fully transformed into one of those ugly and destructive creatures.