The invasion of medicine by commercial interests, now on a global scale, has led to a serious clash of values. The resulting tensions are particularly unfortunate since, as I have said elsewhere (1), elements of both the medical and commercial value systems are essential if health care is to flourish. I agree with Dr. Mazza that the reluctance of governments to consider health and health care as important, much less as rights, certainly contributes to the problem. But change has to start somewhere, and a major intent of the Tavistock principles is to catalyze that change.

Dr. Nelson emphasizes the important distinction, not always recognized clearly, between ethics and law. In past years, fortunately, the law (both legislatures and the courts) has generally resisted being drawn into medicine. Unfortunately, the commercialization of medicine has also encouraged the long arm of the law to reach ever deeper into medical affairs. In this context, Dr. Nelson's wise counsel to remember that professional ethics is outside—and above—the law is welcome.

The interesting ethical principles described by Pochard and colleagues appear intended to apply primarily on a "micro" scale, that is, to individual clinical decisions at the bedside. The Tavistock principles are likely to matter more on a "macro" scale, that is, to how health care organizations and systems should behave. Ideally, the "micro" principles for individual care decisions should interact seamlessly with the principles that operate on a "macro" scale. The three principles defined by Pochard and colleagues would appear to fit well within the broader Tavistock framework, but the question deserves further thought.

Many people question whether health and health care should be considered as rights. In that connection, Dr. Goodman's report that a majority of the people of Maryland believe everyone is entitled to health insurance coverage is of special interest. The effort in Maryland to develop universal coverage is exciting and deserves to be watched closely.