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This chapter provides a commentary on, and introduces, the collection of papers in this volume. It begins by outlining how professional forms of health care expertise have become increasingly subject over the last four decades to third-party scrutiny, as well as how we have witnessed greater public involvement in the monitoring and quality assurance of healthcare work, particularly in Western neo-liberal societies. It then discusses how these changes have led the ‘social closure’ model of professional work to become revised, and in doing so how this raises concerns regarding academic engagement with members of the public as part of a broader patient advocacy and policy reform agenda focused on the promotion of the public interest. This discussion helps set the scene for subsequent chapters, which together seek to unpack the complex relationships that exist between health care practitioners, civil society, the state and professional groups in a variety of different international borders and regulatory jurisdictions. In doing so, each author seeks to explore critically how calls for increased efficiency and cost effectiveness in healthcare are balanced with the need to promote the public interest through providing citizens with essential health services.

Bias impacts all aspects of research: from the questions formulated in the study design to the dissemination of results and perceptions by different target groups. The implementation of evidence is not a simple, unidirectional pipeline, nor do target groups operate in a vacuum, eagerly waiting for any information. Recommendations are made to improve the evidence base and message design through (a) public funding of clinical trials, (b) development and reinforcement of information standards, (c) improvements in the delivery of information in continuing medical education, (d) support and development of information sources independent of commercial interests, (e) helping clinicians communicate uncertainty to their patients. Recommendations are also made to correct and/or avoid imbalances in the delivery of health information. Powerful stakeholders can influence the production of evidence (research) as well as its dissemination. In most countries this poses a greater threat to pluralism than the suppression of individual opinions. The interplay between private sources (industry), voluntary and academic organizations, and a broad range of media and government regulation is necessary for a balanced expression and promotion of information. To ensure this, public regulation and intervention may be needed.

This chapter discusses the film Article 99v (1999), which tells the story of veterans at a fictitious government veteran's hospital unable to receive needed medical care because of funding cutbacks and an arcane, bureaucratic regulation known as “Article 99.” This regulation states that, even though a veteran is eligible for “full medical benefits,” treatment for certain medical problems cannot be provided “as the diagnosed condition cannot be specifically related to military service.” The film illustrates the conflict that physicians and other health care providers experience when bureaucratic obstacles prevent them from providing the care that patients need. Physicians and bioethicists view such obstacles as intrinsically unethical: physicians have a responsibility to advocate for their patients and provide the best care that they can in spite of obstacles.