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."

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."

Naturalized Bioethics represents a revolutionary change in how health care ethics is practiced. It calls for bioethicists to give up their dependence on utilitarianism and other ideal moral theories and instead to move toward a self-reflexive, socially inquisitive, politically critical, and inclusive ethics. Wary of idealizations that bypass social realities, the naturalism in ethics that is developed in this volume is empirically nourished and acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments. The essays in this collection examine the variety of embodied experiences of individual people. They situate the bioethicist within the clinical or research context, take seriously the web of relationships in which all human beings are nested, and explore a number of the many different kinds of power relations that inform health care encounters. Naturalized Bioethics aims to help bioethicists, doctors, nurses, allied health professionals, disability studies scholars, medical researchers, and other health professionals address the ethical issues surrounding health care.

Naturalized Bioethics represents a revolutionary change in how health care ethics is practiced. It calls for bioethicists to give up their dependence on utilitarianism and other ideal moral theories and instead to move toward a self-reflexive, socially inquisitive, politically critical, and inclusive ethics. Wary of idealizations that bypass social realities, the naturalism in ethics that is developed in this volume is empirically nourished and acutely aware that ethical theory is the practice of particular people in particular times, places, cultures, and professional environments. The essays in this collection examine the variety of embodied experiences of individual people. They situate the bioethicist within the clinical or research context, take seriously the web of relationships in which all human beings are nested, and explore a number of the many different kinds of power relations that inform health care encounters. Naturalized Bioethics aims to help bioethicists, doctors, nurses, allied health professionals, disability studies scholars, medical researchers, and other health professionals address the ethical issues surrounding health care.

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.

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.

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 law serves a function that is not often taken seriously enough by ethicists, namely practicability. A consequence of practicability is that law requires elaborated and explicit methodologies that determine how to do things with norms. This consequence forms the core idea behind this book, which employs methods from legal theory to inform and examine debates on methodology in applied ethics, particularly bioethics. It is argued that almost all legal methods have counterparts in applied ethics, which indicates that much can be gained from comparative study of the two. The author first outlines methods as used in legal theory, focusing on deductive reasoning with statutes as well as analogical reasoning with precedent cases. He then examines three representative kinds of contemporary ethical theories, Beauchamp and Childress's principlism, Jonsen and Toulmin's casuistry, and two versions of consequentialism-Singer's preference utilitarianism and Hooker's rule-consequentialism-with regards to their methods. These examinations lead to the Morisprudence Model for methods in applied ethics.

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.

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."

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.