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

Modern medicine has put a new twist on one of our most fundamental values . . . self-determination. A patient's right to self-determination becomes a poignant and volatile issue in the context of modern life-sustaining technologies. When the benefit of medical treatment is overshadowed by the resulting burdens, treatment may ethically be withdrawn. Patients have the right to make this decision, assuming they still have the capacity to make it. Through advance directives a competent patient can extend his right to consent to or refuse medical treatment indefinitely into the future. Whether in the form of informal oral instructions or formal written documents, advance directives insure patients that their treatment wishes will be carried out. They also alleviate the uncertainty, guilt, and/or fear of legal consequences facing the family and caregivers. This volume is a collection of fourteen essays investigating the advantages and disadvantages of different kinds of directives, the role of professionals in making and honoring them, policy issues that need to be addressed, and future directions which directives may take. Although such documents may be used to request treatment, this volume limits its focus to their more common function . . . the refusal of treatment. Timely and comprehensive, Advance Directives in Medicine provides a stimulating overview of this relevant topic. The papers in this volume were originally presented at a multidisciplinary conference on advance directives. Revised and edited for this text, they address a variety of questions and issues, for instance: What are the individual and societal benefits of advance directives? Does an advance directive tamper with thesanctity of life? Will normalizing directives have an adverse effect on the practice of medicine? Should a patient specify treatments to be withheld within a directive, such as the use of CPR, nutrition, or hydration? What legal sanctions should apply against those who ignore directives? Should directives be used to reduce health care expenditures by insurance companies, Medicare, and Medicaid? What is a physician's role in helping his patient formulate an appropriate directive and when is a patient ready to confront his own mortality?

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

"Healing by Heart" is a book of stories--stories of people's search for culturally responsive health care from U.S. providers. It offers resources to providers and institutions committed to delivering culturally responsive health care, paying special attention to building successful relationships with traditional Hmong patients and families. It makes available extensive information about the health-related beliefs, practices, and values of the Hmong people, including photographs of traditional healing methods.

Ranging in age from young infants to older adults, the patients in the stories present a wide range of health problems. The clinicians are from family practice, internal medicine, pediatrics, emergency medicine, surgery, obstetrics-gynecology, psychiatry/psychology, and hospice.

Each of the fourteen case stories is accompanied by discussion questions as well as two or three commentaries. The commentaries--written by patients, family members, shaman, Western clinicians (including Hmong physicians, nurses, and social workers), medical anthropologists, health care ethicists, social workers, psychologists, and clergy--are rich in personal reflections on cross-cultural health care experiences. Readers are rewarded with a combination of perspectives, including those of Hmong authors who have not previously published in English and scholars with years of professional experience working with the Hmong in Laos, Thailand, and the United States.

The editors offer a model for delivering culturally responsive health care with special attention to matters of cross-cultural health care ethics. The model identifies questions health care providers can focus on as they seek to understand the health-related moral commitments and practices prevalent in the cultural groups they serve, ethical questions that arise frequently and with great poignancy in cross-cultural health care relationships, and points to consider when a patient's treatment wish challenges the provider's professional integrity.

By sharing stories of suffering, confusion, and success, "Healing by Heart" couples an accessible method of learning about others with concrete recommendations about how to enhance cross-cultural health care relationships.

"Healing by Heart" is a book of stories--stories of people's search for culturally responsive health care from U.S. providers. It offers resources to providers and institutions committed to delivering culturally responsive health care, paying special attention to building successful relationships with traditional Hmong patients and families. It makes available extensive information about the health-related beliefs, practices, and values of the Hmong people, including photographs of traditional healing methods.

Ranging in age from young infants to older adults, the patients in the stories present a wide range of health problems. The clinicians are from family practice, internal medicine, pediatrics, emergency medicine, surgery, obstetrics-gynecology, psychiatry/psychology, and hospice.

Each of the fourteen case stories is accompanied by discussion questions as well as two or three commentaries. The commentaries--written by patients, family members, shaman, Western clinicians (including Hmong physicians, nurses, and social workers), medical anthropologists, health care ethicists, social workers, psychologists, and clergy--are rich in personal reflections on cross-cultural health care experiences. Readers are rewarded with a combination of perspectives, including those of Hmong authors who have not previously published in English and scholars with years of professional experience working with the Hmong in Laos, Thailand, and the United States.

The editors offer a model for delivering culturally responsive health care with special attention to matters of cross-cultural health care ethics. The model identifies questions health care providers can focus on as they seek to understand the health-related moral commitments and practices prevalent in the cultural groups they serve, ethical questions that arise frequently and with great poignancy in cross-cultural health care relationships, and points to consider when a patient's treatment wish challenges the provider's professional integrity.

By sharing stories of suffering, confusion, and success, "Healing by Heart" couples an accessible method of learning about others with concrete recommendations about how to enhance cross-cultural health care relationships.