In his book, Illness and Culture in the Postmodern Age (University of California Press, 1998), David B. Morris offers a biocultural model in which illness, with its biological and cultural components, always stands at the crossroads of both biology and culture. Given Morris's point that illness is a biocultural construct, it follows that individual and institutional decisionmaking in healthcare also involve a biocultural construct that experience suggests is too often overlooked, to the detriment of all decisionmakers. In the following Special Section, “Culture, Health, and Bioethics,” the authors explore the importance of understanding the cultural processes and concomitant challenges that necessarily play a crucial role as patients, providers, and policymakers grapple with healthcare decisions.

As early as 1981 Gorlin and Zucker produced a film, A Complicating Factor: Doctors' Feelings as a Factor in Medical Care and in a 1983 paper on the subject they described one of the important epiphenomena of the encounter between doctor and patient—namely, the reaction of the physician to the patient and how this affects both the physician and the quality of the relationship. At that time they were concerned with the physicians' ability to reckon with their own reactions to patients who presented with problems or personality traits that complicated the doctor-patient relationship. Some patients were hateful or unlikable, some denied their disease state, some became unusually dependent on the physician, some were intimidating to the doctor. Their behavior evoked responses that tended to complicate the doctor-patient relationship with distancing, unusual identification, or hostility. That publication recognized and explained the problem and went on to suggest a process of achieving emotional awareness and mastery to help physicians maintain their appropriate role.

In the rapidly evolving healthcare environment, perhaps no role is in greater flux and redefinition than that of the clinical bioethicist. The discussion of ethics consultation in the bioethics literature has moved from an ambiguous concern regarding its proper place in the clinical milieu to the more provocative question of which methods and theories should best characterize the intellectual and practical work it claims to do. The American Society for Bioethics and Humanities addressed these concerns in its 1998 report, Core Competencies for Health Care Ethics Consultation. The report tries to answer the question as to what disciplinary training, background experience, and levels of knowledge in ethics the clinical ethics consultant should have, and what specific skills and character traits the clinical ethics consultant should cultivate. In addition to acquiring knowledge of common bioethical issues, theoretical concepts in ethical theory and moral reasoning, and health-related law and policy, the report also recommends that ethics consultants demonstrate knowledge of the health beliefs and perspectives of patients and healthcare providers. In our opinion, this recommendation underscores a crucial aspect of the practice of ethics consultation in the increasingly multicultural settings of healthcare institutions. Clearly, the dynamic of American life and culture is permeated with diversity and variety as new groups suffuse their own beliefs and faith perspectives into the health sector. New immigrant groups force society to question traditional healthcare practices and to accommodate changing medical needs.

Bioethicists have become very interested in the importance of social groups. This interest has spawned a growing literature on the role of the family and the place of culture in medical decisionmaking. These ethicists often argue that much of medical ethics suffers from the individualistic bias of the dominant culture and political tradition of the United States. As a result, the doctrine of informed consent has come under some scrutiny. It is believed that therein lies the source of the problem because the doctrine incorporates the assumptions of the larger society. Thus, informed consent has been reexamined, reinterpreted, and even abandoned as unworkable.

The influx of new groups into society, such as recently established religious groups whose practices differ from societal norms, may disturb relatively stable communities. This instability is exacerbated if these practices contravene long-held fundamental societal tenets, such as the protection of children. This situation now exists in Mexico, where the country's traditional Catholic and secular values clash with those of a religion introduced from the United States, Jehovah's Witnesses. The focal point for these clashes, as it has been elsewhere, is in the bioethics arena.

Bioethics as it stands today is a typically American product, but whether it can be spread across the globe as easily as Coca-Cola remains to be seen. Historically, we can observe that the internationalization of bioethics has taken place in a form of concentric waves beginning in the United States and encompassing increasingly new territories having older roots. Born in the 1960s, bioethics as the study of ethical issues in life sciences began to permeate the Anglo-Saxon world. Ten years later it penetrated countries with developed liberal democratic traditions and remnants of the different Protestant attitudes to life where issues such as patients' rights, abortion, euthanasia, eugenics quickly started to appear frequently in newspapers, magazines, and on television. Then in the '80s the bioethics wave swept into the European community, and by the end of the '80s and early '90s bioethics advanced timidly into Eastern Europe. Because the difficult birth of bioethics in Eastern Europe is not widely known, the purpose here is to provide a perspective of that development, including its struggle with a totalitarian legacy, as well as to offer some comments as to how current cultural gaps between East and West, and especially between the Western and Orthodox worlds, might be bridged.

Ethical questions about end-of-life treatment present themselves at two levels. In clinical situations, patients, families, and healthcare workers sift through ambivalent feelings and conflicting values as they try to resolve questions in particular circumstances. In a very different way, at the societal level, policy makers, lawyers, and bioethicists attempt to determine the best policies and laws to regulate practices about which there are a variety of deeply held beliefs. In the United States we have tried a number of ways to resolve the societal-level issues. We have ignored them, argued to try to convince others of our beliefs, voted to let the majority determine what is right or wrong, and turned to the courts to decide, as in the cases of Karen Ann Quinlan, Nancy Cruzan, and Jack Kervorkian. Yet none of these approaches has yet left us with comfortable, unambiguous cultural norms about issues such as euthanasia and physician-assisted suicide, which are readily assumed by “ordinary people” as they face individual and interpersonal dilemmas.

Within the latter half of the 30-year history of bioethics there has been an increasing pressure to address bioethical issues globally. Bioethics is not traditionally a theory-based enterprise, rather the focus has been problem related. With the introduction of the global perspective, theory has, however, become more important. One of the best known, probably the best known, theory of bioethics is the one presented by Tom L. Beauchamp and James F. Childress in their Principles of Biomedical Ethics in 1979. This theory is known as the “four principles” or the “Georgetown mantra” approach or “mid-level principlism.” It is the attempt to create a global framework for bioethics on the four principles—autonomy, justice, beneficence, and nonmaleficence—that I will scrutinize in this paper.

These CQ Sources were compiled by Bette Anton.

Abortions are legally permitted in most Western societies if there is a reasonable expectation that the child, if born, would be physically or mentally disabled. Even late-term abortions, which would not be allowed in the case of healthy fetuses, are accepted on the basis of foreseen disability.

Ben Rich, J.D., Ph.D., presents a scholarly, passionate view of the ethics of the “barriers to effective pain management.” His manuscript is detailed, analytical, and compassionate. No reasonable sensitive person, especially a physician committed to caring for patients, can disagree with the proposal that human beings should have their physical, emotional, and spiritual pain tended to aggressively, meticulously, and compassionately. Similarly, the same individuals advocating for such pain management would agree that no one should go to jail unless he or she is guilty of a serious crime, that decent people should not be robbed or murdered, that children should not be hungry or homeless, and that all citizens of the United States deserve healthcare. Our society attempts to achieve these goals. Laws are written, discussed, and approved by state and federal congresses, voted on by citizens, and theoretically upheld by the courts, churches, and decent individuals. But, unless the world suddenly becomes inhabited by virtuous, ethical humans who can unfailingly differentiate “good” from “bad,” then, in spite of an abundance of laws and lawyers, doctors, and nurses, this world will continue to have pain and suffering. And, although we want to hold our doctors, politicians, educators, champion athletes, and others to “higher standards” than the average citizen, it is best to remind ourselves frequently that all humans can be weak and are bound to make imprecise judgments, that there is not a homogenous definition of “good,” that values and religious beliefs are variable.

Pain management continues to pose a challenge to the healthcare profession in the United States. There are a host of barriers and many of these are very well laid out in the article by Dr. Rich. As a hospice physician, I confront these challenges daily.

Because we are often nagged by the thought that we might not have behaved any differently than those good citizens whose respect for the law and fear of punishment led them to support the Nazi regime, we are fascinated with the behavior of ordinary Germans. Careful to first strip away the pathological explanations of German behavior, Pellegrino and Thomasma ask simply whether ordinary Germans could have reasoned and, by implication, acted differently. Although their affirmative answer is consistent with the activism we have all come to demand of the Germans, it is not clear whether we, ourselves, can lay full claim to the moral high ground.

Proponents commonly justify the legalization of physician-assisted suicide (PAS) in terms of a patient's wanting to die (autonomy) and the patient's having a medically established good reason for suicide. These are the common elements of the standard justification offered for the legalization of PAS. In what follows, I argue that these two conditions exist in significant tension with one another, operating according to distinct dynamics that render the justification for PAS an unstable “let it be so” basis for public policy. Moreover, no natural connection keeps these two criteria united. Indeed—as I argue—the two elements of the justification oppose and threaten to exclude one another. Thus, the PAS justification is too labile a basis for sound public policy.

From 1991 to 1994 the Dutch Health Insurance Council financed research on Extracorporeal Membrane Oxygenation (ECMO). This is a technique for providing cardiopulmonary bypass to patients with pulmonary and/or cardiac failure. Most often, these patients are premature neonates. During ECMO, blood is drained from the right atrium, pumped along a membrane where gas exchange takes place, and then redirected to the aorta. To prevent blood clotting, heparin is added. However, with the heparin added, the risk of hemorrhage is considerably increased. Therefore, both the chance of surviving and the chance of severe disability are higher with ECMO than with conventional treatment (i.e., ventilator support).

This book is for those searching for an ethics engine with enough philosophical power to drive healthcare reform toward a balance between medical technology and human compassion. Jos Welie's project is to “develop a foundation for a patient-centered, non-procedural, clinically grounded but methodologically sound ethics.” This is an important goal that has eluded others. Jos Welie has more nearly succeeded in this book than any other author who has come to my attention.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.