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).

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."

Bioscience ethics facilitates free and accurate information transfer from applied science to applied bioethics. Its major elements are: increased understanding of biological systems, responsible use of technology, and attuning ethnocentric debates to new scientific insights. Pioneered by Irina Pollard in 1994, bioscience ethics has become an internationally recognized discipline, interfacing science and bioethics within professional perspectives such as medical, legal, bio-engineering, and economics. Written for students and professionals alike, the fundamental feature of this book is its breadth, important because bioscience ethics interweaves many diverse subjects in the process of gathering specialist scientific knowledge for bioethical review. It contains chapters which embrace topics affecting human reproduction, end-of-life care and euthanasia, challenge human-dominated ecosystems, and review population growth, economic activity and warfare. A background section describes the evolution of ethical consciousness, explores the future, and proposes that the reworking of ethical boundaries can enhance mature decision-making in harmony with changing technology.

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.

Biomedical Ethics Reviews is an annual publication designed to review and update the literature on issues of central importance in bioethics today. Ordinarily, more than one topic is discussed in each volume of Biomedical Ethics Reviews. This year, however, we have decided to devote the entire volume of Biomedical Ethics Reviews: 1988 to disussion of one topic, namely, AIDS. The ra tionale for this decision should be clear: AIDS is arguably the most serious public health threat facing our nation today, and the char acter of the disease is such that it creates special problems for ethicists, philosophers, theologians, educators, jurists, health care professionals, and politicians. Indeed, the questions that AIDS gives rise to are so numerous and complex that no one text could hope to treat them exhaustively. Still, if it is impossible, in anyone text, to deal with all of the perplexing difficulties that AIDS generates, it nevertheless remains true that each addition to the AIDS literature contributes to our collective knowledge, and in so doing, brings us one step closer to resolving at least some of the problems associated with the disease. We believe that the articles included in the present volume of Biomedical Ethics Reviews serve this purpose admirably, and we hope the reader will agree. James M. Humber Robert F. Almeder vii Contributors Ronald Carson * Medical Humanities Institute, University of Texas Medical Branch, Galveston, Texas David J.

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.

The fate of seriously ill newborns has captured the atten tion of the public, of national and state legislators, and of powerful interest groups. For the most part, the debate has been cast in the narrowest possible terms: "discrimination against the handicapped"; "physician authority"; "family autonomy." We believe that something much more profound is happening: the debate over the care of sick and dying babies appears to be both a manifestation of great changes in our feelings about infants, children, and families, and a reflection of deep and abiding attitudes toward the newborn, the handi capped, and perhaps other humans who are "less than" nor mal, rational adults. How could we cast some light on those feelings and attitudes that seemed to determine silently the course of the public debate? We chose to enlist the humanities-the dis players and critics of our cultural forms. Rather than closing down the public discussion, we wanted to open it up, to illuminate it with the light of history, religion, philosophy, literature, jurisprudence, and humanistically oriented sociol ogy. This book is a first effort to place the hotly contested Baby Doe debate into a broader cultural context."

In the 1960's marked changes occurred throughout the world in philosophies and policies related to man's role in life. These changes, prompted predominantly by extensive increases in knowledge and popula tion density, have produced increased pleasures as well as problems. The rising number of people and improved methods of communication and transportation have caused more relationships among people, with their pleasures, competitions, jealousies, conflicts of interest, oppressions, and crimes. Large assortments of drugs have been developed and are easily obtained. There are drugs to speed us up, slow us down, make us sleep, change our perspectives on life, promote propagation of life or prevent it, prolong life or terminate it, and modify the course of life in many ways. Also, numerous mechanical devices have been developed that influence the propagation of life, the termination of life, and the manner in which we live. Many people have changed their overall goals in life, and in par ticular have experienced major changes in attitudes and policies applying to sexual activity, marriage, birth control, abortion, welfare, children, old people, criminals, economics, social status, careers, education, euthanasia, and suicide. There also has been marked enlightenment concerning the effect of the chemical and physical status of the brain upon normal and abnormal thinking and behavior."

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."

Is it permissible to use a human embryo in stem cell research, or in general as a means for benefit of others? Acknowledging each embryo as an object of moral concern, Louis M. Guenin argues that it is morally permissible to decline intrauterine transfer of an embryo formed outside the body, and that from this permission and the duty of beneficence, there follows a consensus justification for using donated embryos in service of humanitarian ends. He then proceeds to show how this justification commands assent even within moral and religious views commonly thought to oppose embryo use. Beneath his moral reasoning lies a carefully constructed metaphysical foundation incorporating accounts of the ontology of development, embryos, and species. He also incisively discusses nonreprocloning, reprocloning, ectogenesis, and related scientific frontiers. This compelling philosophical study will interest all concerned to understand virtue and obligation in the relief of suffering.