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.

Some conferences produce proceedings, others an inspiration to labor, which finally leads to a published work. Such has been the case with regard to this volume. In 1984, the Center for Ethics, Medicine, and Public Issues held a conference with the title 'When are Competent Patients Incompetent?' with the support of the Texas Committee for the Humanities, a state-based program of the National Endowment for the Humanities. Assistance was provided by both Baylor College of Medicine and the Institute of Religion. This conference evoked a con siderable interest in examining further the moral status of competency determinations in the clinical setting. This interest is realized in this volume, which now affords us an opportunity to thank all those individ uals who made the conference possible, only some of whom are acknowledged in this Preface. In particular, we wish to express our gratitude to Baruch A. Brody, Rebecca Dresser, the Honorable Jerome Jones, H. Steven Moffic, Margery W. Shaw, Eleanor Tinsley, and Albert Van HeIden. The volume took its shape through the labors of Earl Shelp and Mary Ann Gardell Cutter, who inspired the further evolution of the papers presented at the conference and attracted contributions from individuals who had not attended. Earl Shelp and Mary Ann Gardell Cutter have produced a volume following extensive reflection and dialogue; they were ably assisted in the final preparation of the manu script by Thomas J. Bole III and George Khushf, to whom special thanks are due."

The place of drugs in American society is a problem more apt to evoke diatribe than dialog. With the support of the Na tional Science Foundation's program on Ethics and Values in Science and Technology, and the National Endowment for the Humanities' program on Science, Technology, and Human Values, * The Hastings Center was able to sponsor such dialog as part of a major research into the ethics of drug use that spanned two years. We assembled a Research Group from leaders in the scientific, medical, legal, and policy com munities, leavened with experts in applied ethics, and brought them together several times a year to discuss the moral, legal and social issues posed by nontherapeutic drug use. At times we also called on other experts when we needed certain issues clarified. We did not try to reach a consensus, yet several broad areas of agreement emerged: That our society's response to nontherapeutic drug use has been irrational and inconsistent; that our attempts at control have been clumsy and ill-informed; that many complex moral values are entwined in the debate and cannot be reduced to a simple conflict between individual liberty and state paternalism. Of course each paper should be read as the statement of that particular author or authors. The views expressed in this book do not necessarily represent the views of The Hastings Center, the National Science Foundation, or the National En dowment for the Humanities."

In the past few years an increasing number of colleges and universities have added courses in biomedical ethics to their curricula. To some extent, these additions serve to satisfy student demands for "relevance. " But it is also true that such changes reflect a deepening desire on the part of the academic community to deal effectively with a host of problems which must be solved if we are to have a health-care delivery system which is efficient, humane, and just. To a large degree, these problems are the unique result of both rapidly changing moral values and dramatic advances in biomedical technology. The past decade has witnessed sudden and conspicuous controversy over the morality and legality of new practices relating to abortion, therapy for the mentally ill, experimentation using human subjects, forms of genetic interven tion, suicide, and euthanasia. Malpractice suits abound and astronomical fees for malpractice insurance threaten the very possibility of medical and health-care practice. Without the backing of a clear moral consensus, the law is frequently forced into resolving these conflicts only to see the moral issues involved still hotly debated and the validity of existing law further questioned. In the case of abortion, for example, the laws have changed radically, and the widely pub licized recent conviction of Dr. Edelin in Boston has done little to foster a moral consensus or even render the exact status of the law beyond reasonable question."

The expense of critical care and emergency medicine, along with widespread expectations for good care when the need arises, pose hard moral and political problems. How should we spend our tax d'ollars, and who should get help? The purpose of this volume is to reflect upon our choices. The authors whose papers appear herein identify major difficulties and offer various solutions to them. Four topics are discussed throughout the volume: First, encounters between patients and health professionals in critical situations in general, and where scarcity makes rationing necessary; second, allocation and social policy, including how much to spend on preventive, chronic or critical care medicine, or for medicine in general compared to other important social projects; third, conflicts between or ranking of important goals and values; and fourth, conceptual issues affecting the choices we make. Since these topics are raised by the authors in almost every essay, we did not divide the papers into separate sections within the volume. Warren Reich begins the volume with a parable illustrating a key problem for contemporary medicine and two very different approaches to its solution. His story begins with the "delivery" of three indigent, critically ill, foreign patients to the emergency room of a large American private hospital. Although the hospital is legally bound to care for these patients, providing long term, high cost care for them and others soon becomes a major financial strain.

'Reprogen-Ethics and the Future of Gender' brings together three tightly related topics, which have so far been dealt separately in bioethics: assisted reproduction, enhancing and gender. Part one in this book targets present policies and legislature of assisted reproduction. Part two focuses on current views of the ethics of PGD and enhancing. Part three tackles the future of gender. Part four deals with artificial wombs and ectogenesis. The aim of this book is to provide a joint perspective in order to get the big picture. Contributors include Matti Hayry, Tuija Takala, Soren Holm, David Heyd, Daniel Callahan, Harriet Bradley, Ekaterina Balabanova and others. Some chapters in this book will significantly contribute to the current discussion of the topics at stake; other chapters will start a discussion on issues that have not yet been discussed. 'Reprogen-Ethics and the Future of Gender' will certainly appeal to readers who are interested in any of the intersecting topics of assisted reproduction, genetic enhancing and gender; bioethicists, sociologists, genetic counsellors, gynaecologists, legislators, and students of the relevant disciplines.

Can the Hippocratic and Judeo-Christian traditions be synthesized with contemporary thought about practical reason, virtue and community to provide real-life answers to the dilemmas of healthcare today? Bishop Anthony Fisher discusses conscience, relationships and law in relation to the modern-day controversies surrounding stem cell research, abortion, transplants, artificial feeding and euthanasia, using case studies to offer insight and illumination. What emerges is a reason-based bioethics for the twenty-first century; a bioethics that treats faith and reason with equal seriousness, that shows the relevance of ancient wisdom to the complexities of modern healthcare scenarios and that offers new suggestions for social policy and regulation. Philosophical argument is complemented by Catholic theology and analysis of social and biomedical trends, to make this an auspicious example of a new generation of Catholic bioethical writing which has relevance for people of all faiths and none.

We who live in this post-modern late twentieth century culture are still children of dualism. For a variety of rather complex reasons we continue to split apart and treat as radical opposites body and spirit, medicine and religion, sacred and secular, private and public, love and justice, men and women. Though this is still our strong tendency, we are beginning to discover both the futility and the harm of such dualistic splitting. Peoples of many ancient cultures might smile at the belatedness of our discovery concerning the commonalities of medicine and religion. A cur sory glance back at ancient Egypt, Samaria, Babylonia, Persia, Greece, and Rome would disclose a common thread - the close union of religion and medicine. Both were centrally concerned with healing, health, and wholeness. The person was understood as a unity of body, mind, and spirit. The priest and the physician frequently were combined in the same individual. One of the important contributions of this significant volume of essays is the sustained attack upon dualism. From a variety of vantage points, virtually all of the authors unmask the varied manifestations of dualism in religion and medicine, urging a more holistic approach. Since the editor has provided an excellent summary of each article, I shall not attempt to comment on specific contributions. Rather, I wish to highlight three 1 broad themes which I find notable for theological ethics."

This volume offers a collection of writings on ethical issues regarding retarded persons. Because this important subject has been generally omitted from formal discussions of ethics, there is a great deal which needs to be addressed in a theoretical and critical way. Of course, many people have been very concerned with practical matters concerning the care of retarded persons such as what liberties, entitlements or advocacy they should have. Interestingly, because so much practical attention has been given to issues which are not discussed by ethical theorists, they offer a rare opportunity to evaluate ethical theories themselves. That is, certain theories which appear convincing on other subjects seem implausible when they are applied to reasoned and com pelling views we hold concerning retarded individuals. Our subject, then, has both practical and conceptual dimensions. More over, because it is one where pertinent information comes from many sources, contributors to this volume represent many fields, including philosophy, religion, history, law and medicine. We regret that it was not possible to include more points of view, like those of psychologists, sociologists, nurses and families. There is however, a good and longstanding literature on mental retardation from these perspectives."

Ethical Problems and Genetics Practice provides a rich, case-based account of the ethical issues arising in the genetics clinic and laboratory. By analysing a wide range of evocative and often arresting cases from practice, Michael Parker provides a compelling insight into the complex moral world of the contemporary genetics professional and the challenges they face in the care of patients and their families. This book is essential reading for anyone interested in the ethical issues arising in everyday genetics practice. Ethical Problems and Genetics Practice is also a sustained engagement with the relationships between bioethics and social science. In proposing and exemplifying a new approach to bioethics, it makes a significant contribution to debates on methods and interdisciplinarity and will therefore also appeal to all those concerned with theoretical and methodological approaches to bioethics and social science.

Not long ago, a colleague chided me for using the term "the biological revolution. " Like many others, I have employed it as an umbrella term to refer to the seemingly vast, rapidly-moving, and fre quently bewildering developments of contemporary biomedicine: psy chosurgery, genetic counseling and engineering, artificial heart-lung machines, organ transplants-and on and on. The real "biological revo lution," he pointed out, began back in the nineteenth century in Europe. For it was then that death rates and infant mortality began to decline, the germ theory of disease was firmly established, Darwin took his famous trip on the Beagle, and Gregor Mendel stumbled on to some fundamental principles of heredity. My friend, I think, was both right and wrong. The biological revolution did have its roots in the nineteenth century; that is when it first began to unfold. Yet, like many intellectual and scientific upheav als, its force was not felt for decades. Indeed, it seems fair to say that it was not until after the Second World War that the full force of the earlier discoveries in biology and medicine began to have a major impact, an impact that was all the more heightened by the rapid bi omedical developments after the war."

This book arises from a two-fold conviction. The first is that autonomy, despite recent critiques about its importance in bioethics and philosophy of medicine, and the traditional resistance of medicine to its "intrusion" into the doctor-patient relation, is a fundamental building block of an individual's identity and mechanisms for dealing with illness, disease, and incapacity. As such it is an essential component in the health care professional's armamentarium employed to bring about healing. Furthennore, it functions in a similar way to assist the health professional in his or her relations to the sick and injured. The second conviction follows from the fITst. Autonomy is far more complex than appears from the philosophical use of the concept. In this conviction we join those who have criticized the over-reliance on autonomy in modem, secular bioethics originating in the United States, but gaining ascendancy in other cultures. This critique relies on appeals to the richer contexts of persons' lives. Elsewhere the contemporary critique of autonomy appears in a variety of alternative ethical models like narrative ethics, casuist ethics, and contextualism. Indeed, postmodern criticism of all bioethics argues that there is no defensible foundation for claims that one ought to respect autonomy or any other principle as a way of ensuring that one is ethical.

The best things in my Ufe have come to me by accident and this book results from one such accident: my having the opportunity, out of the blue, to go to work as H. Tristram Engelhardt, Jr. 's, research assistant at the Institute for the Medical Humanities in the University of Texas Medi cal Branch at Galveston, Texas, in 1974, on the recommendation of our teacher at the University of Texas at Austin, Irwin C. Lieb. During that summer Tris "lent" me to Chester Bums, who has done important schol arly work over the years on the history of medical ethics. I was just finding out what bioethics was and Chester sent me to the rare book room of the Medical Branch Library to do some work on something called "medical deontology. " I discovered that this new field of bioethics had a history. This string of accidents continued, in 1975, when Warren Reich (who in 1979 made the excellent decisions to hire me to the faculty in bioethics at the Georgetown University School of Medicine and to persuade Andre Hellegers to appoint me to the Kennedy Institute of Ethics) took Tris Engelhardt's word for it that I could write on the history of modem medical ethics for Warren's major new project, the Encyclopedia of Bioethics. Warren then asked me to write on eighteenth-century British medical ethics."

The Dutch experience has influenced the debate on euthanasia and death with dignity around the globe, especially with regard to whether physician-assisted suicide and euthanasia should be legitimized or legalized. A review of the literature reveals complex and often contradictory views about the Dutch experience. Some claim that the Netherlands offers a model for the world to follow; others believe that the Netherlands represents danger, rather than promise, and that the Dutch experience is the definitive answer regarding why we should not make active euthanasia and physician-assisted suicide part of our lives. Given these contradictory views, it has become clear that fieldwork is essential to developing a more informed opinion. Having investigated the Dutch experience for a number of years, and after thoroughly reading the vast literature published in English, I went to the Netherlands for one month in the summer of 1999 to get a feel for the local situation. I felt that this would provide the basis on which I could better interpret the findings of the available literature. I visited the major centers of medical ethics, as well as some research hospitals, and spoke with leading figures in the euthanasia policy and practice. The time spent was extremely beneficial and enriching. I followed in the footsteps of Carlos Gomez, who 1 published a book following one month of extensive research in the Netherlands.

K. Danner Clouser is one of the most important figures in establishing and shaping the fields of medical ethics, bioethics, and the philosophy of education in the second half of the twentieth century. Clouser challenged many established approaches to moral theory and offered innovative strategies for integrating the humanities into professional education, especially that of physicians and nurses. The contributions published in Building Bioethics: Conversations with Clouser and Friends on Medical Ethics are unique both in their devotion to a critical review of his contributions, and in bringing together internationally known figures in bioethics, medical ethics, and philosophy of medicine to comment upon Clouser's work. These leaders of the field include Tom Beauchamp, Daniel Callahan, James Childress, Nancy Dubler, H. Tristram Engelhardt, Al Jonsen, Loretta Kopelman, Larry McCullough, John Moskop, and Robert Veatch. This book merits special attention from those interested in bioethics, philosophy of medicine, medical ethics, philosophy, medical education, religious studies, and nursing education.

This book contributes to an overall understanding of the nature and the impact of sexual boundary violations. By exploring an extreme human experience, childhood sexual abuse, the present study allows an insight into a hidden, silenced, and destructive aspect of human relations. It is the first of its kind to make comprehensible both the general path from violation to sickness, and the particular logic of assault embodiment. Due to its theoretical and methodological framework, the present study provides evidence that the embodiment of sexual violation experience is informed by situated logic and rationality. These, however, do not correspond to scientific logic and rationality. The universe of socio-culturally constituted meaning and that of scientifically constructed knowledge are shown to be incompatible. Subjectively informed violation embodiment is likely to be misinterpreted and consequently maltreated within the objectively grounded framework of current biomedical praxis. Consequently, victims of silenced sexual violence are revictimized by medicine.

The editors have incurred many debts in preparing this book, and both etiquette and ethics would be contravened if they were not discharged here. Above all, we wish to thank the contributors for so cheerfully complying with our suggestions for preparing their papers for publication and efficiently meeting our schedules. It is thanks to their cooperation that this volume has appeared speedily and painlessly; their revisions have helped to give it internal coherence. This volume has emerged from papers delivered at a conference on the History of Medical Ethics, held at the Wellcome Institute for the History of Medicine, London, 1 December, 1989. We are most grateful to the Wellcome Trust for having underwritten the costs of the conference, and to Frieda Houser and Stephen Emberton whose organizational skills contributed so much to making it a smoothly-run and enjoyable day. In addition to the papers delivered at the conference, we are delighted to have secured further contributions from David Harley and Johanna Geyer-Kordesch. Our thanks to them for their eager help. From start to finish, we have received splendid encouragement from all those connected with the Philosophy and Medicine series, especially Professor Stuart Spicker, and Martin Scrivener at Kluwer Academic Publishers. Their enthusiasm has lightened our load, and expedited the editorial process.

Positive conceptions of healthy aging are rightly displacing negative ageist perceptions of older members of our society. Nevertheless, at some stage, most elderly citizens will require some form of assistance from other members of society. When the body or mind begins to fail, a legitimate need for intervention and care will arise. This second volume on Aging discusses this theme.

The term bioethics' was coined in 1971, just as interest in the medical humanities claimed a prominent place in medical education. Out of this interest, a substantial area of research and scholarship took shape: the philosophy of medicine. This field has been directed to the epistemological, ontological, and value-theoretical issues occasioned by medicine and the biomedical sciences. Bioethics is nested in this field and can only be fully understood in terms of the foundational issues it addresses. This collection of essays in honor of Stuart F. Spicker, one of the individuals who gave shape to the philosophy of medicine, lays out the broad scope of concerns from the philosophy of embodiment, to issues of the role of ethics consultants, to concepts of disease, equity and the meaning of history.

This book is a part of the ongoing enterprise to understand the nature of human health and illness. This enterprise has expanded dramatically during the last decades. A great number of articles, as weIl as a fair number of monographs, on this topic have been published by renowned international publishers. In this discussion most participants share the idea that health is a partially normative concept, Le. that health is not a phe nomenon which can be wholly characterised in biological (or otherwise descriptive) terms. To ascribe health to a person is eo ipso, according to this line of thought, to as cribe a positively evaluated property to this person. Moreover, most debators share the idea that health is a holistic property, belonging to the person as a whole, whereas dis eases, injuries and defects are entities (or properties of entities) which can be very lim ited and and normally affect only a part of the individual. My own monograph belongs to this tradition. A feature of my position, which is not universally acknowledged in riyal theories, however, is my emphasis on the notion of ability as a fundament in the theory of health. In my formal characterisation of health I view it as astate of a person which is such that the person has the ability to fulfi1 his or her vital goals."

This book addresses well-known issues - the ethical, legal, and social implications of human genetics - but does so from an unusual perspective: the perspective of the scientific community itself. In distinction to what is common in the ELSI literature, the book also discusses bioethical method. A new kind of casuistry is developed on the basis of the empirical findings of cognitive semantics. It will be of interest to philosophers, bioethicists, geneticists, and policymakers.

Charles Bonnet began his career as a naturalist, from an early age establishing a reputation as a careful observer. It is for those youthful observations, as well as for some suggestive speculations proposed relative to this field, that he is best remembered in English-speaking countries: regarding the taxonomic de mands of natural history he refurbished the idea of a chain of beings; regarding the question of generation he marshaled evidence in support of preforma tion theory; and regarding the analysis of the physiology of the nervous system he advanced a theory that individual nerve fibers receive and retain specific sensations. Following his loss of eyesight in his mid-twenties Bonnet entered a more reflective period, turning to philosophy and pondering the nature of human understanding - considerations he had formerly disdained, but that now seemed a natural outgrowth of his reflections on nature. This essay focuses on the philosophical and psychological works of the later period, the period in which he wrote all his major books. By giving these writings a broader exposure it has been one of my hopes that Bonnet's audience would also be broadened, releasing him, so to speak, from the charge of historians of science so that he might fmd his way, in general books on the "Enlightenment," from scattered footnotes into the texts themselves."

Over a period of a year, the symposium on clinical judgment has taken shape as a volume devoted to the analysis of how knowledge claims are framed in medicine and how choices of treatment are made. We hope it will afford the reader, whether layman, physician or philosopher, a useful perspective on the process of knowing what occurs in medicine; and that the results of the dis cussions at the Fifth Symposium on Philosophy and Medicine will lead to a better understanding of how philosophy and medicine can usefully challenge each other. As the interchange between physicians, philosophers, nurses and psychologists recorded in the major papers, the commentaries and the round table discussion shows, these issues are truly interdisciplinary. In particular, they have shown that members of the health care professions have much to learn about themselves from philosophers as well as much of interest to engage philosophers. By making the structure of medical reasoning more apparent to its users, philosophers can show health care practitioners how better to master clinical judgment and how better to focus it towards the goods and values medicine wishes to pursue. Becoming clearer about the process of knowing can in short teach us how to know better and how to learn more efficiently. The result can be more than (though it surely would be enough ) a powerful intellectual insight into a major cultural endeavor, medicine."

The growth of knowledge and its effects on the practice of medicine have been issues of philosophical and ethical interest for several decades and will remain so for many years to come. The outline of the present volume was conceived nearly three years ago. In 1987, a conference on this theme was held in Maastricht, the Netherlands, on the occasion of the founding of the European Society for Philosophy of Medicine and Health Care (ESPMH). Most of the chapters of this book are derived from papers presented at that meeting, and for the purpose of editing the book Stuart Spicker, Ph. D. , joined two founding members of ESPMH, Henk ten Have and Gerrit Kimsma. The three of them successfully brought together a number of interesting contribu tions to the theme, and ESPMH is grateful and proud to have initiated the production of this volume. The Society intends that annual meetings be held in different European countries on a rotating basis and to publish volumes related to these meetings whenever feasible. In 1988, the second conference was held in Aarhus, Denmark on "Values in Medical Decision Making and Resource Allocation in Health Care". In 1989, a meeting was held in Czestochowa, Poland, on "European Traditions in Philosophy of Medicine. From Brentano to Bieganski". It is hoped that these conferences and the books to be derived from them, will initiate a new European tradition, lasting well into the 21 st century! P. J.