Managed care in the USA is best understood in the context of the history of health care. It is an effort to manage the soaring costs of health care while retaining quality. Many ethical concerns arise because managed care organizations (MCOs) have dual purposes: to realize profits and to provide quality care. Dilemmas are created when persons in institutions are expected to play conflicting roles or when professionals, patients, or others in MCOs lose their voices as participating persons. These and other ethical concerns can be addressed by on-going processes of involvement of persons who have a stake in these organizational arrangements.