Attempts to reform the US health care system in the 1980s and 1990s were inspired by the system's inability to adequately provide access, ensure quality, and restrain costs. In the era of managed care, after the Clinton administration's failed legislative effort at reform, access, quality, and costs are still problems, and medical professionals are increasingly dissatisfied. To aid understanding of why the system is now so dysfunctional, I have drawn upon discussions with thoughtful physicians about their direct experience. They raised important concerns not usually considered by health care reformers. Their central concern was about the abandonment of medicine's core values. They felt that health care has become dominated by large, bureaucratic organizations which may not honor these core values. Patients and physicians are often caught in conflicts between competing interests and demands. Those who work in health care may be subject to perverse incentives that discourage ethical practice. Health care leaders may be ill-informed, incompetent, self-interested, or even dishonest. Examples of attacks on the scientific basis of medicine have become more frequent. These worrying trends are not confined to the US. Physicians elsewhere should be skeptical of approaches to health care reform derived from the American model. European doctors should ensure the new health care initiatives do not undermine their core values or the best interests of their patients.