Many debates about the moral status of things-for example, debates about the natural rights of human fetuses or nonhuman animals-eventually migrate towards a discussion of the capacities of the things in question-for example, their capacities to feel pain, think, or love. Yet the move towards capacities is often controversial: if a human's capacities are the basis of its moral status, how could a human having lesser capacities than you and I have the same "serious" moral status as you and I? This book answers this question by arguing that if something is human, it has a set of typical human capacities; that if something has a set of typical human capacities, it has serious moral status; and thus all human beings have the same sort of serious moral status as you and I. Beginning from what our common intuitions tell us about situations involving "temporary incapacitation"-where a human organism has, then loses, then regains a certain capacity-this book argues for substantive conclusions regarding human fetuses and embryos, humans in a permanent vegetative state, humans suffering from brain diseases, and humans born with genetic disorders. Since these conclusions must have some impact on our ongoing moral and political debates about the proper treatment of such humans, this book will be useful to professionals and students in philosophy, bioethics, law, medicine, and public policy.

Arthur L. Caplan It is commonly said, especially when the subject is assisted reproduction, that medical technology has out stripped our morality. Yet, as the essays in this volume make clear, that is not an accurate assessment of the situ ation. Medical technology has not overwhelmed our moral ity. It would be more accurate to say that our society has not yet achieved consensus about the complex ethical iss ues that arise when medicine tries to assist those who seek its services in order to reproduce. Nevertheless, there is no shortage of ethical opinion about what we ought to do with respect to the use of surrogate mothers, in vitro fertil ization, embryo transfer, artificial insemination, or fertil ity drugs. Nor is it entirely accurate to describe assisted repro duction as technology. The term "technology" carries with it connotations of machines buzzing and technicians scurrying about trying to control a vast array of equip ment. Yet, most of the methods used to assist reproduc tion that are discussed in this volume do not involve exotic technologies or complicated hardware. It is technique, more than technology, that dominates the field of assisted reproduction. Efforts to help the infertile by means of the manipu lation of human reproductive materials and organs date 1 2 Caplan back at least to Biblical times. Human beings have en gaged in all manner of sexual practices and manipulations in attempts to achieve reproduction when nature has balked at allowing life to begin.

The concept 'health' is ambiguous [18,9, 11]. The concept 'mental health' is even more so. 'Health' compasses senses of well-being, wholeness, and sound ness that mean more than the simple freedom from illness - a fact appreci ated in the World Health Organization's definition of health as more than the absence of disease or infirmity [7]. The wide range of viewpoints of the con tributors to this volume attests to the scope of issues placed under the rubric 'mental health. ' These papers, presented at the Fourth Symposium on Philos ophy and Medicine, were written and discussed within a broad context of interests concerning mental health. Moreover, in their diversity these papers point to the many descriptive, evaluative, and, in fact, performative functions of statements concerning mental health. Before introducing the substance of these papers in any detail, I want to indicate the profound commerce between philosophical and psychological ideas in theories of mental health and disease. This will be done in part by a consideration of some conceptual developments in the history of psychiatry, as well as through an analysis of some of the functions of the notions of mental illness and health. 'Mental health' lays a special stress on the wholeness of human intuition, emotion, thought, and action.

This book challenges the unchallenged methods in medicine, such as "evidence-based medicine," which claim to be, but often are not, scientific. It completes medical care by adding the comprehensive humanistic perspectives and philosophy of medicine. No specific or absolute recommendations are given regarding medical treatment, moral approaches, or legal advice. Given rather is discussion about each issue involved and the strongest arguments indicated. Each argument is subject to further critical analysis. This is the same position as with any philosophical, medical or scientific view. The argument that decision-making in medicine is inadequate unless grounded on a philosophy of medicine is not meant to include all of philosophy and every philosopher. On the contrary, it includes only sound, practical and humanistic philosophy and philosophers who are creative and critical thinkers and who have concerned themselves with the topics relevant to medicine. These would be those philosophers who engage in practical philosophy, such as the pragmatists, humanists, naturalists, and ordinary-language philosophers. A new definition of our own philosophy of life emerges and it is necessary to have one. Good lifestyle no longer means just abstaining from cigarettes, alcohol and getting exercise. It also means living a holistic life, which includes all of one's thinking, personality and actions. This book also includes new ways of thinking. In this regard the "Metaphorical Method" is explained, used, and exemplified in depth, for example in the chapters on care, egoism and altruism, letting die, etc.

The Bishop Bekkers Foundation, devoted to the welfare of those with mental handicap and to the amelioration and prevention of this and related disabilities, is to be warmly congratulated for sponsoring and organizing the 1986 Inter national Workshop from which the present book is derived. With commendable foresight, the Foundation recognized that genetic aspects of mental handicap were a timely focus for the Workshop and that dramatic biomedical developments and prospects in this sphere have highly significant psychosocial and ethical ramifications. The papers of the 23 contributors in each of these areas, together with an introductory essay and discussion summaries, comprise this volume. Much of the subject matter is inevitably concerned with such sensitive issues as sanctity and quality of life and the - sometimes contrasting and even in conflict - rights and needs of the actually and potentially handicapped, their relatives and society in general. Such considerations, not surprisingly, engender different approaches and viewpoints. The papers in this book reflect this, with the editing attempting to achieve, as far as possible, a coherent and consistent format and not an identical outlook. The perceptions and views expressed in each paper are there fore those of the author concerned and not necessarily those of the editors or of the Bishop Bekkers Foundation."

CATHOLIC PERSPECTIVES AND CONTEMPORARY MEDICAL MORALS A Catholic perspective on medical morals antedates the current world wide interest in medical and biomedical ethics by many centuries 5]. Discussions about the moral status of the fetus, abortion, contraception, and sterilization can be found in the writings of the Fathers and Doctors of the Church. Teachings on various aspects of medical morals were scattered throughout the penitential books of the early medieval church and later in more formal treatises when moral theology became recog nized as a distinct discipline. Still later, medical morality was incorpor ated into the many pastoral works on medicine. Finally, in the contemporary period, works that strictly focus on medical ethics are produced by Catholic moral theologians who have special interests in matters medical. Moreover, this long tradition of teaching has been put into practice in the medical moral directives governing the operation of hospitals under Catholic sponsorship. Catholic hospitals were monitored by Ethics Committees long before such committees were recommended by the New Jersey Court in the Karen Ann Quinlan case or by the President's Commission in 1983 ( 8, 9]). Underlying the Catholic moral tradition was the use of the casuistic method, which since the 17th and 18th centuries was employed by Catholic moralists to study and resolve concrete clinical ethical dilem mas. The history of casuistry is of renewed interest today when the case method has become so widely used in the current revival of interest in medical ethics ll]."

This volume tracks the development in the United States of the field of Bioethics, Ethics applied to the disciplines of medicine, nursing, and health care in general, including medical research and the complex economic and political problems surrounding the provision of medical and nursing care. It explains how the United States developed, case by case, the central rules and principles of ER ethics in the Health Care System. The discussion includes the controversies centering on birth, death, clinical research, experimental procedures (cloning, reproductive technology, organ transplants), and ends with a substantial suggestion on the provision of health care for all.

This is the second volume of Biomedical Ethics Reviews, a series of texts designed to review and update the literature on issues of central importance in bioethics today. Five topics are dis cussed in the present volume. Section I, Public Policy andRe search with Human Subjects, reviews the history of the moral issues involved in the history of research with human subjects, and confronts most of the major legal and moral problems involving research on human subjects. Questions addressed in this section range from those concerning informed and proxy consent to those dealing with the adequacy of monitoring hu man research via institutional review boards (IRBs). Section II deals with a second broad topic in bioethics, The Right to Health Care in a Democratic Society. Here the concern not merely that of determining whether there is a right to is health care, but also, if there is such a right, how it ought best be understood and implemented. To answer questions such as these, we learn that one must distinguish legal from moral rights, assess the merits of various theories of rights, clarify the relationship between rights and duties, and attempt to deter mine a just method for the distribution of health care. Advances in medical technology often pose new legal and moral problems for legislators and health care practitioners."

Tris' request for a leave that interrupted his clinical c1erkships, so that he could undertake his graduate studies in Austin. The field, not just Tris, owes Jim Knight a hearty "thank you" for his decision to approve Tris' request, which was unusual, to say the least, in the conservative world ofmedical education at the time. Whenhereturned toTulane to complete his medical degree, Tris undertook withRichardZanerthe translationofAlfred Schutz'sandThomas Luckmann's 6 The Structures of the Life-World. Tris did this work while on his clinical rotations, including obstetrics and gynecology. In between delivering babies, most of whom were delivered by medical students at New Orleans' Charity Hospital, he worked on this translation. Tris once told me that, as a medical student, he had delivered scores ofbabies alone. Ican see him sitting with a patient in the labor area or maybe in the hall, attending to her, monitoring her progress in labor and the fetus' status, and translating from German, which is his first language, as well as thatofhis children. As this translation indicates, Tris believes in texts and scholarship about texts in a way that is decidedly not post-modem. This is also plain to anyone who has read his work. Forexample, the two editions of The Foundations of Bioethies, whateverelse one might thinkofthem, are monuments ofscholar- ship in the historiesofphilosophy, medicine, theology, and ideas generally, not to mention excellent primers on Texana. These books are packed with re- ferences and footnotes.

Many of the demands being voiced for a "humanizing" of health care center on the public's concern that they have some say In determining what happens to the individual in health care institutions. The essays in this volume address fundamental questions of conflicts of rights and autonomy as they affect four selected, controversial areas in health care ethics: the Limits of Professional Autonomy, Refusing! Withdrawing from Treatment, Electing "Heroic" Measures, and Advancing Reproductive Technology. Each of the topics is addressed in such a way that it includes an examination of the locus of responsibility for ethical decision making. The topics are not intended to exhaustively review those areas of health care provision where conflicts of rights might be said to be an issue. Rather they constitute an examination of the difficulties so often encountered in these specific contexts that we hope will illuminate similar conflicts in other problem areas by raising the level of the reader's moral awareness. Many books in bioethics appeal only to a limited audience in spite of the fact that their subject matter is of deep personal concern to everyone. In part, this is true because they are frequently written from the perspective of a single discipline or a single profession. As a result, one is often left with the impression that such a book views the philosophical, historical, and! or theological problems as essentially indifferent to clinical, legal, and! or policy-making problems.

* How important is national health insurance? * What should a national health insurance plan entail? * What about the welfare of laboratory animals? These important issues form the core of this eighth volume in Humana's acclaimed Biomedical Ethics Reviews series. Interdisciplinary in approach, Biomedical Ethics Reviews * 1990 presents keen insights into these and related problems in chapters by leading experts in ethics and medicine. Each topic is briefly summarized in an introductory chapter, followed by a focused, thought-provoking analysis of specific issues within the topic. The use of technical jargon has been minimized in order to render the articles readily accessible and useful to interested laypersons. Biomedical Ethics Reviews * 1990 constitutes an extremely valuable-as well as timely-resource for everyone concerned with national health insurance or laboratory animal welfare today-topics that have had an undisputed, and sometimes tumultuous, impact not only on healthcare professionals, but also on the public agenda.

This book summarizes the efforts and results of the first international Ifgene conference on presuppositions in science and expectations in society with respect to genetic engineering which was held at the Goetheanum, Dornach, Switzerland, October 2-5, 1996. The Goetheanum provided a unique opportunity to gather people from diverse disciplines who have opposing attitudes on modern science and technology. It is due to this venue, among other things, that the participants were able to develop an open, power-free dialogue and could focus more on judgement-forming than a polarizing debate. This Ifgene conference could not have happened without the financial support from many private individuals and the following organisations listed in no particular order: Fetzer Foundation; Stichting Triodos; Evidenzgesellschaft; Mahle Stiftung GmbH; Gemeinnlitzige Treuhandstelle e. Y. Bochum; Initiative gegen 'Bioethik'; Verband fur anthroposophische Heilpadagogik - CHi Verband flir anthroposophische Heilpadagogik, Sozialtherapie und Sozialarbeit e. Y. - D; Stichting ter bevordering van de Heilpaeda- gogie; Iona Stichting; Antroposofische Vereniging in Nederland; Stichting Klaverblad; Swissair & Crossair; The Rudolf Steiner Association; The Welcome Association; Anthro- posophische Gesellschaft in Deutschland; Helixor Heilmittel GmbH & Co; Goethea- num Dornach; Verein flir anthroposophisches Heilwesen e. Y. - D; The Oakdale Trust; Unilever Nederland BV; NV Verenigde Bedrijven Nutricia; Migros-Genossenschafts- Bund; Ministerie van Landbouw, Natuur en Visserij; CIBA; Stichting Elise Mathilde Fonds; Anthroposophic Society Australia; Therexsys; COOP Schweiz and selected speakers (G. Stotzky - USA, H. A. de Boer - NL, J. Girard-Bascou - F, P. G.

In When Medicine Went Mad, one of the nation's leading bioethicists-and an extraordinary panel of experts and concentration camp survivors-examine problems first raised by Nazi medical experimentation that remain difficult and relevant even today. The importance of these issues to contemporary bioethical disputes-particularly in the thorny areas of medical genetics, human experimentation, and euthanasia-are explored in detail and with sensitivity.

The National Institute on Aging (NIA) has historically been concerned with the protection of human subjects. In July 1977, the NIA sponsored a meeting to update and supplement guide lines for protecting those participating in Federal research pro jects. Although the basic guidelines had been in effect since 1966, it had been neglected to include the elderly as a vulnerable population. In November 1981, the NIA organized a conference on the ethical and legal issues related to informed consent in senile dementia cases. The present volume offers the latest and best thinking on Alzheimer's Dementia to have emerged from the dialog that was first embarked upon at the NIA meeting. Indeed, the issues and concerns it treats now seem even more relevant than they appeared historically because of the vastly greater awareness in the community of the entire spectrum of problems Alzheimer's disease confronts us all with. Our interest and concern is both humanitarian and self serving. Clearly older people must be protected from in appropriate research and careful attention must be paid to the circumstances under which research is conducted on those older persons who have given anything less than full consent. It is equally necessary, however, for the research enterprise to be protected so that today's elderly and those of the future can benefit from the fruits of research."

This volume inaugurates a series concerning philosophy and medicine. There are few, if any, areas of social concern so pervasive as medicine and yet as underexamined by philosophy. But the claim to precedence of the Proceedings of the First Trans-Disciplinary Symposium on Philos ophy and Medicine must be qualified. Claims to be "first" are notorious in the history of scientific as well as humanistic investigation and the claim that the First Trans-Disciplinary Symposium on Philosophy and Medicine has no precedent is not meant to be put in bald form. The editors clearly do not maintain that philosophers and physicians have not heretofore discussed matters of mutual concern, nor that individual philosophers and physicians have never taken up problems and concepts in medicine which are themselves at the boundary or interface of these two disciplines - concepts like "matter," "disease," "psyche. " Surely there have been books published on the logic and philosophy of medi 1 cine. But the formalization of issues and concepts in medicine has not received, at least in this century, sustained interest by professional phi losophers. Groups of philosophers have not engaged medicine in order to explicate its philosophical presuppositions and to sort out the various concepts which appear in medicine. The scope of such an effort takes the philosopher beyond problems and issues which today are subsumed under the rubric "medical ethics."

The roles of both the consumer and the health advocate professional have become increasingly significant in to day's climate of "rationed" health care. It seems clear that the timely exchange of ideas among seasoned health care advocates is necessary if we are to deal with the complex problems of a technologically advanced so ciety seeking to ration its heath care in a truly humane way. Toward such a timely exchange, the first Confer ence on Advocacy in Health Care was organized by the Health Advocacy Program of Sarah Lawrence College and recently held. Advocacy in Health Care: The Power of a Silent Constituency is the proceedings of the conference and will, we believe, greatly extend our efforts to share both the problems and solutions that effective patient advocacy entails. Never before has the issue of advocating for special population groups by combining the resources of consumers and professionals been the exclusive focus of one volume. This book discusses the power of such an alignment and describes specific organizational techniques that have been effective in bringing about changes in the delivery system. The final section of the book, "Questions, Com ments and Answers," presents a selection of topics of special interest that surfaced during the open disc- vii viii Preface sion at the last conference session. The comments were forthright in their criticism of public policy, and the vigor of the argument underscored the vitality of the co alition between professionals and consumers."

Interest in theories of virtue and the place of virtues in the moral life con- tinues to grow. Nicolai Hartmann [7], George F. Thomas [20], G. E. M. Anscombe [1], and G. H. von Wright [21], for example, called to our atten- tion decades ago that virtue had become a neglected topic in modem ethics. The challenge implicit in these sorts of reminders to rediscover the contribu- tion that the notion of virtue can make to moral reasoning, moral character, and moral judgment has not gone unattended. Arthur Dyck [3] , P. T. Geach [5], Josef Pieper (16], David Hamed [6], and, most notably, Stanley Hauerwas [8-11], in the theological community, have analyzed or utilized in their work virtue-based theories of morality. Philosophical probings have come from Lawrance Becker [2], Philippa Foot [4], Edmund Pincoffs [17], James Wallace [22], and most notably, Alasdair MacIntyre [12-14]. Draw- ing upon and revising mainly ancient and medieval sources, these and other commentators have ignited what appears to be the beginning of a sustained examination of virtue.

This book attempts to answer the question how health care can be incorporated into a comprehensive theory of justice, while realising an acceptable balance between efficiency, justice and care. It seems to be that we can have any two but not all three. Essentially, the central question addressed by this book is the following: how best to square the proverbial welfare circle.

Theologians and theologically educated participants in discussions of bioethics have been placed on the defensive during recent years. The dominance of religious perspectives and theological voices that marked the emergence and establishment of "bioethics" in the late 1960s and 1970s has eroded steadily as philosophers, lawyers, and others have relativized their role and influ ence, at best, or dismissed it entirely, at worst. The secularization of bioethics, which has occurred for a variety of reasons, has prompted some prominent writers to reflect on what has been lost. Daniel Callahan, for example writes, " . . . whatever the ultimate truth status of religious perspectives, they have provided a way of looking at the world and understanding one's own life that has a fecundity and uniqueness not matched by philosophy, law, or political theory. Those of us who have lost our reli gious faith may be glad that we have discovered what we take to be the reality of things, but we can still recognize that we have also lost something of great value as well: the faith, vision, insights, and experience of whole peoples and traditions who, no less than we unbelievers, struggled to make sense of things. That those goods are part of a garment we no longer want to wear does not make their loss anything other than still a loss; and it is not a neglible one" ([2], p. 2).

Psychiatry and religion/spirituality (R/S) share an interest in human flourishing, a concern with beliefs and values, and an appreciation for community. Yet historical tensions between science and religion continue to impede dialogue, leaving clinicians uncertain about how to approach ethical questions arising between them. When are religious practices such as scrupulosity disordered? What distinguishes healthy from unhealthy religion? How should a therapist approach a patient's existential, moral or spiritual distress? What should clinicians do with patients' R/S convictions about faith healing, same-sex relationships, or obligations to others? Discussions of psychiatric ethics have traditionally emphasized widely accepted principles, generally admired virtues, and cultural competence. Relatively little attention has been devoted to the ways that R/S inform the values of patients and their clinicians, shape preferred virtues, and interact with culture. Ethical Considerations at the Intersection of Psychiatry and Religion aims to give mental health professionals a conceptual framework for understanding the role of R/S in ethical decision-making and serve as practical guidance for approaching challenging cases. Part I addresses general considerations, including the basis of therapeutic values in a pluralistic context, the nature of theological and psychiatric ethics, spiritual issues arising in diagnosis and treatment, unhealthy and harmful uses of religion, and practical implications of personal spirituality. Part II examines how these considerations apply in specific contexts: inpatient and outpatient, consultation-liaison, child and adolescent, geriatric, disability, forensic, community, international, addiction and disaster and emergency psychiatry, as well as in the work of religious professionals, ethics committees, psychiatric education, and research. Thick descriptions of case examples analyzed using the framework of Jonson and Winslow show the clinical relevance of understanding the contributions of religion and spirituality to patient preferences, quality of life, decision making, and effective treatment.

From the tone of the report by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Re search, one might conclude that the whole-brain-oriented definition of death is now firmly established as an enduring element of public policy. In that report, Defining Death: Medical, Legal and Ethical Issues in the Determination of Death, the President's Commission forwarded a uni form determination of death act, which laid heavy accent on the signifi cance of the brain stem in determining whether an individual is alive or dead: An individual who has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem, is dead. A determination of death must be made in accordance with accepted medical standards ( 1], p. 2). The plausibility of these criteria is undermined as soon as one confronts the question of the level of treatment that ought to be provided to human bodies that have permanently lost consciousness but whose brain stems are still functioning."

This Festschrift is presented to Professor Hans Jonas on the occasion of his seventy-fifth birthday, as affirmation of the contributors' respect and admiration. As a volume in the series 'Philosophy and Medicine' the contributions not only reflect certain interests and pursuits of the scholar to whom it is dedi cated, but also serve to bring to convergence the interests of the contributors in the history of humanity and medicine, the theory of organism, medicine in the service of the patient's autonomy, and the metaphysical, i.e., phenome nological foundations of medicine. Notwithstanding the nature of such personal gifts as the authors' contributions (which, with the exception of the late Hannah Arendt's, appear here for the first time), the essays also transcend the personal and serve to elaborate specific themes and theses disclosed in the numerous writings of Hans Jonas. The editor owes a personal debt of gratitude to many, including Hannah Arendt, who offered their assistance during the preparation of the volume."

Recent rapid advances in the biosciences have led to considerable debate about the social, ethical, and legal implications of research and its applications. The mapping of the human genome, advances in cloning techniques, the harvesting of embryonic stem cells for research, increasing use of genetic testing in healthcare, and the development of large-scale genetic databases have not only generated high expectations about new diagnostics and treatments but also considerable widespread fear about their consequences. This book offers a critical appraisal of bioethics and its implications as it pertains to the fields of health and medicine and public health, with a particular emphasis on recent technological innovations as they provide a noteworthy exemplar of the power of bioethics in shaping policies, practices and notions of societal benefits. Whereas other books have tended to examine ethical dilemmas and challenges of applying ethical principles, often in relation to a limited array of issues, this book investigates the socio-political implications of bioethics discourse and practices in relation to a range of controversial (or potentially controversial) developments. Providing a benchmark for future debate and scholarly work, this volume will be of interest to policymakers, clinicians, scholars, and others who are looking for new ways of making sense and evaluating recent developments in the field of bioethics.

The meaning and application of the principle of beneficence to issues in health care is rarely clear or certain. Although the principle is frequently employed to justify a variety of actions and inactions, very little has been done from a conceptual point of view to test its relevance to these behaviors or to explore its relationship to other moral principles that also might be called upon to guide or justify conduct. Perhaps more than any other, the principle of benef icence seems particularly appropriate to contexts of health care in which two or more parties interact from positions of relative strength and weakness, advantage and need, to pursue some perceived goal. It is among those moral principles that Tom L. Beauchamp and James F. Childress selected in their textbook on bioethics as applicable to biomedicine in general and relevant to a range of specific issues ( 1], pp. 135-167). More narrowly, The National Commission for the Protection of Human Subjects of Biomedical and Behav ioral Research identified beneficence as among those moral principles that have particular relevance to the conduct of research involving humans (2). Thus, the principle of beneficence is seen as pertinent to the routine delivery of health care, the discovery of new therapies, and the rationale of public policies related to health care."

My 'discovery' of the Polish School of philosophy of medicine stemmed from my studies in the genesis of Ludwik Fleck's epistemology. These studies, and my interest in the scientific roots of Fleck's epistemology were a nearly 'natural' result of my own biography: like Fleck I had been trained, an had worked as an immunologist, and had later switched to studies in the social history of medicine and biology. Moreover, it so happened that Fleck's book, Genesis and Development of a Scientific Fact -the description of a science as it is, not as it should be -was the first epistemological study in which I found echos of my experience in the laboratory. My interest in Fleck was also highlightened by the fact that in his works, and, as I discovered later, in the works of his predecessors of the Polish School of philosophy of medicine, was formulated the problem that had stimulated my interest in the history of medicine and biology, and is still central to my present investigations: the relationships between biological knowledge and clinical practice. The writing of the book was made possible through to the help of many colleagues and friends. The unfailing support for my research, whatever its subject might be, from my colleagues from Unit 158 of INSERM and in particular from its head Patrice Pinell, has made my study of the Polish School possible.