Genetic engineering is a social invention as much as a biological one. Ordinary citizens interested in the well-being of life on the planet should therefore be involved in the ethical debates concerning the future of nonhuman animals. The creations of genetic engineers ought to be evaluated on a case-by-case basis by what the American philosopher R. G. Frey calls “a jury of concerned individuals.” Frey is an advocate for putting animals in perspective, which means that animals matter, but not as much as humans. He therefore supports the prevailing moral orthodoxy, which currently in the West means that animals can be eaten, dissected, hunted, and exhibited, provided that these things are done humanely and that the benefits to humans outweigh the harms to the animals. The “concerned individual,” he suggests, would have no objection to humans killing animals as long as the animals do not suffer. In the present paper, my aim is to raise some of the ethical, welfare, and social issues from an animal-protectionist perspective which ordinary citizens would need to consider if they were ever asked to vote on the benefits or otherwise of the impact of genetic engineering on animal welfare.

On April 10, 2001, after extensive committee deliberations, the Second Chamber of the Dutch Parliament passed a bill that was introduced in August 1999 legalizing physician-assisted death. The bill is officially called “The Evaluation of Ending Life on Request and Assistance in Suicide and a Change of the Penal Code and the Burial Act (Law Evaluating Ending Life and Assistance with Suicide).” It was passed by a majority vote in the Second Chamber of Parliament and was supported by the majority parties constituting the present coalition government (i.e., liberals and socialists). Opposition to the law came mainly from a minority of Christian parties. In this report we explore the meaning of this bill and describe some of its problematic and paradoxical items.

Medical ethics has traditionally been governed by two guiding, but sometimes conflicting, principles—autonomy and benevolence. These principles provide the rationale for the two most commonly used standards for medical decisionmaking—the Substituted Judgment Standard shows our concern for autonomy, whereas the Best Interest Standard shows our commitment to benevolence. Both standards are vulnerable to criticisms. Further, the principles can seem to offer conflicting prescriptions for action. The criticisms and conflict figure prominently in discussion of advance directive decisionmaking and Alzheimer's disease. After laying out each of the current standards and its problems, with Alzheimer's issues as my central concern, I offer a new standard that avoids the problems while honoring our concerns for both autonomy and benevolence.

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.

Carson Strong argues, in “Cloning and Infertility,” that if cloning of humans by somatic cell nuclear transfer were to become a safe procedure, then infertile couples should have access to it as a last resort. He lists six reasons such couples might desire genetically related children. Of these, two are relevant to justifying their access to cloning—namely, that they want to jointly participate in the creation of a person, and that having a genetically related child would constitute an affirmation of their mutual love. According to Strong, these reasons justify at least some infertile couples' freedom to clone themselves. He wants to prevent the widespread use of cloning technology by making it available to only infertile couples and only as a last resort. One way to enforce this restriction, he suggests, is to penalize physicians who carry out disallowed clonings. After all, fertile couples and many infertile couples can satisfy their need to have genetically related children in other ways.

In pseudo-patient study (PPS), fieldworkers cloak their identities and intentions and pose as “patients.” This enables them to observe the practice of healthcare from within a naturalistic, nonreactive research setting. Rosenhan and his assistants conducted the most famous PPS, where they faked symptoms of schizophrenia so that they could gain admittance to a mental-health facility and observe the treatment that genuine patients were receiving. More subtle pseudo-patients might arrange “appointments” over the phone, after reporting varying levels of health insurance. Others might provide dummy lab specimens or test a physician's response to technical questions. A few genuine patients have transformed their legitimate stays in the hospital into fieldwork, transforming themselves into disguised participant-observers.

As a medical student doing a rotation, I was feeling positive as we knocked on the door of an elderly lady who I'd seen just 2 days earlier. Even though seriously ill for many months, this patient had always lived life in her own way, refusing to go to a nursing home. It was clear that her condition had deteriorated rapidly, and the nurse informed me privately that she was dying, sooner rather than later.

The methodological device of “deception,” or, as sometimes euphemistically labeled, “less than full disclosure,” does not enjoy much support among institutional review boards (IRBs) and a large portion of scholars in bioethics. The reasons for this have been documented sufficiently, beginning with the now-paradigmatic attack on the well-known study by Milgram and the unsavory study of Laud Humphries on male homosexual activities in public restrooms. But are the current attitudes interfering with some worthwhile approaches to data gathering that seem to have no other methodology of equal effectiveness?

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.

The moral and professional anguish experienced by the medical student in response to the request “Help me die” is a fundamental sentiment that needs to be retained within the ethos of the medical community. Especially as laws on professional assistance in dying undergo increasing liberalization, society should not want its physicians (or its prospective physicians) to either be so callous, so lacking in compassion that they would dismiss such a patient request out-of-hand, or to be so cavalierly accustomed to acquiescing in such requests that it simply becomes a routine pattern. Either approach on its own betrays the moral integrity of medicine. We instead want those professionals who are present to us in our dying to express both care and respect, to display both compassion and dignity for the dying person, even when, as in this circumstance, these core values come into conflict. In such a situation, moral anguish protects both the professional and the patient, not to mention society, from callous paternalism and/or callous indifference.

The idea of cloning adult human beings often gives rise to objections involving mad dictators producing copies of themselves, or deranged billionaires who want to live forever. But what about situations where we can more readily understand and accept the reasons for creating a clone? Consider, for instance, the case of parents who have simultaneously lost their newly born child and found out that they cannot have any more children of their own by other known methods. Would it be wrong of them to want a new child, a genetic copy of the lost infant, if the child were healthy and could only be produced by cloning the infant who no longer lives? And would it be wrong of genetic engineers to assist them?

This case is both an excellent as well as a sad illustration of the complexities, intensities, and foibles of the issue of “helping” sick people to die. Although the reaction expressed here is that of a student, it is also, sadly, the reaction of many an experienced physician in being emotional, irrational, and hasty. The description is a perfect example of the student's dilemma: “I would like to help but I can't because to do so would threaten my position”—altruism versus egocentric motivation.

Public health and human rights are complementary—and, at times, conflicting—approaches to protecting and promoting human well-being and dignity. Public health addresses the needs of populations and seeks, through intervention and education, to prevent the spread of disease. Enshrined in international law, human rights describe the obligations of governments to safeguard their citizenry from harm and to create conditions where each individual can achieve his or her full potential. Human rights norms lie at the core of public health theory and practice, and their enforcement can help to ensure an equitable distribution of health resources.

In an earlier edition of Cambridge Quarterly, in the “Networking News” section (CQ Vol 9, No 4), Larry Gottlieb sought advice on ethics committee assembly and policy implementation for a community mental health center. One concern mentioned is that staff members frequently encounter ethical issues—specifically, questions about competency, informed consent, and treatment refusal—regarding the care of clients whose decisionmaking abilities are impaired by chronic mental illness and/or substance abuse. My response offers a suggestion for policy development and implementation, which may be integrated into guiding staff members of community mental health centers toward a model of care planning that is centered on clients' experiences of their treatments and on relationship-building among clients, community members, and mental health professionals.

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.

This is a book for reflective laypersons and health professionals who wish to better understand what the problem of healthcare rationing is all about. Ubel says clearly in the Introduction that it is unlikely that professional economists or philosophers are going to be very satisfied with this effort. For him it is more important “to draw people into the debates who might otherwise stand on the sidelines” (p. xix). This is a reasonable aim made achievable by Ubel's clear and engaging writing style. Probably the people who most need to be drawn into these debates are physicians and medical students, this because one of Ubel's central claims is that the need for “bedside rationing” is both inescapable and sometimes morally permissible. What he wants to reject is the view of many physicians that bedside rationing by physicians is never morally permissible and that healthcare costs can be contained without having to resort to rationing of any kind. Before I explore this point any further, it is necessary to summarize the larger argument of this book.

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.

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 Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will igve you an opportunity to respond in the letters section. Your input is desired and anticipated.

Late in the afternoon of July 11, 1995, the Bosnian Serb army, under the command of General Ratko Mladic, seized the northeastern Bosnia town of Srebrenica. Declared a “safe area” by the United Nations two years earlier, the predominately Muslim community had swollen from a prewar population of 9,000 to over 40,000, many of whom had been “cleansed” from elsewhere in Bosnia. As Mladic's troops swarmed over the town, the women, children, elderly, and many of the men took refuge two kilometers away in the United Nations's Srebrenica headquarters, staffed by a Dutch battalion, in the village of Potocari. Meanwhile, the remaining Srebrenica men and boys—some 10,000 to 15,000—fled through the woods on foot, trying to reach Muslim-controlled territory, nearly 40 miles away.