tients get the pain medication they need is simply a microcosm of the much larger problem of how the system of education, training, and financing health care leaves many in our society without effective access to physicians, who are "gatekeepers" for the vast majority of us who will be in some system of managed care. With effective leadership, however, the matrix of choice for health care is different from, say, the matrix of choice between purchasing a Honda or a Chevrolet. There are vast personal, social, and ethical issues involved in how we live and die.
A political alliance between physicians and present, past, and future patients is easy to build because of the institutional force of medicine. The current popularity of the idea that patients need "rights" to cope with the new form of health care delivery called "managed care" reinforces the centrality of the physician-patient dyad. Legislation that tries, for example, to ensure a mother's "right" to forty-eight hours of hospital stay after delivery of a child masks much deeper problems of public policy. For instance, should physicians be the leaders in proposing some system of providing health care for pregnant women and newborns? What might physicians, working in collaboration with insurance groups and governments, devise that might provide a model in one state? Would such a coalition be able to appeal to our own sense of obligation of self-care to help us see that "free" health care for some pregnant women might in fact be cost-effective in the long run?
In a democratic and pluralistic society, many of these questions will have to involve political processes, with all of their limitations. Eventually, physicians themselves will have to propose some alternatives to our present crisis approach to cost containment and reasonable access to health care. Medicine and law are social systems within a dynamic, fluid community. Neither medicine nor law can provide meaningful lives or graceful deaths, but these social systems can provide choices that affirm for individuals who they are. It is within this matrix of choice that beginnings as well as endings have value for each of us, as well as for our society.