Building the Ethical Foundations of Medicine: What Enables Honest Practice

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The article argues that medicine’s crisis involves not only clinician distress but also weakened moral infrastructure that can impede ethical, humane practice.
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Moral infrastructure comprises sufficient time and continuity, meaningful discretion, psychological safety, and relational margin.
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Relational margin is the reserve of time, attention, flexibility, and emotional steadiness needed for ethically responsive care.
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When relational margin contracts, ordinary acts of attention can carry personal costs, even when clinicians remain committed to caring.
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Responsibility for moral infrastructure is shared across individuals, health care organizations, and broader systems, while organizations retain consequential authority over local working conditions.

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