The Norman Rockwell image of the American physician who fixed the broken arm of a child, treated the father for hypertension, and brought an unborn child into this world is now almost nonexistent. Since the time of the Rockwell portrait, a highly technical medical industry has evolved. Now two-thirds of physicians are board certified in subspecialties, and patients visit an average of 3–4 different physicians per year. Today's physicians see themselves less as “benevolent and wise counselors overseeing the patient's welfare and more as objective scientists applying the latest technical methods to bring about the desired end.” The intimate patient-physician relationship that was once the norm in our society is rapidly disappearing.

Over the past several decades, conflicts between physicians and patients or patient surrogates concerning continued treatment or the withdrawal of treatment have received public and legal attention. In more recent years, there have been several prominent Instances in which physicians have refused to provide treatment requested by patient surrogates because such treatment was judged to be futile. The claim that a treatment is futile has far reaching consequences. It serves to justify the withholding or withdrawal of treatment and thus, perhaps, to also justify the rationing of healthcare. It limits the autonomy of the patient or patient surrogate by reducing their participation in the decision making process.

Populations around the world are aging at a very fast rate, so much so that care for the elderly will soon rupture even the most carefully planned, enlightened care provisions societies can offer. The demographics in advanced countries demonstrate this dilemma, even without projections based on antiaging medications that may be possible in the near future, and a healthier lifestyle that has preoccupied the yuppies for about 10 years.

Technological innovations have transformed our culture's ways of thinking about procreation and pregnancy, and about health and illness. Until not so long ago, the ongoing processes inside women's bodies as they gestated their future babies was up to conjecture. In Western industrialized countries, pregnancy was the slow process during which a woman gradually came to accept the fact that she was sharing her bodily space with another, and that now, as well as after the baby emerged, the primary responsibility for that new person's survival would be hers.

The principled approach to theory building that has been a conspicuous mark of bioethical theory for the past generation has in recent years fallen under considerable critical scrutiny. Although some critics have confined themselves to reordering the dominant principles, others have rejected a principled approach entirely and turned to alternative paradigms. Prominent among critics are antiprin-ciplists, who want to jettison the principle-based approach altogether and adopt a casuistic (case-specific) model, and communitarians, who favor an eclectic model combining features of both the casuistic model and a modified principled approach. Particularly conspicuous in virtually all such critiques is their challenge to the preeminence of the principle of autonomy. Critical barbs have been aimed not only at theories favoring a hierarchical ordering of moral principles that give first place to autonomy, but also at those that include autonomy among a set of ostensibly coequal principles. Though these critics have performed a valued function by displacing bioethical principles from their Olympian perch beyond actual decision-making contexts, some version of the principle of autonomy may, nonetheless, be well worth defending but for very different reasons than those put forward by its supporters.

When Jean-Paul Sartre, the French existentialist philosopher, declared some four decades ago that man makes himself, this assertion was based on Sartre's belief that human beings do not possess an essential human nature. Man's self creation had to do with his freedom to choose the roles that he played or could play, and their attendant effects on his attitudes and responsibilities. It said nothing about his freedom to alter his biological nature.

Ms. B. was a 70-year-old woman who presented with a chief complaint of “my belly got puffy.” She noted that her waistband got progressively tighter as her abdomen swelled up on the month prior to her admission. Although not painful, the swelling caused considerable discomfort and anorexia.

Ms. B. had come to the university hospital by referral from her primary care doctor. She was my first patient on my junior clerkship in internal medicine, a specialty I was particularly interested in going into. It is a rare opportunity for a medical student to pick up a mystery case. Ms. B. had come to us without a diagnosis.

In healthcare, it should be a primary requirement that we define accurately what we are trying to do. The necessity for this intensifies when we are under stress, a part of which is caused by increased technological ingenuity outstripping the general ability to pay for it. Dealing with human beings and their problems, we are person and event oriented; our creed has always been and is the best that can be done for an individual, at a point in time. Increasingly, we must modify this traditional approach by viewing episodic care of the individual as a part of two continua, of the individual in relation to their life span, and of the individual in relation to the community and healthcare system to which all belong. We are not skilled or practised in defining our overall aims.

In this paper, I want to try to put what has been termed the “care ethics” into a different perspective. While I will discuss primarily the use of that ethic or that term as it applies to the healthcare setting in general and to the deliberation of consultants or the function of committees more specifically, what I have to say is meant to be applicable to the problem of using a notion like “caring” as a fundamental precept in ethical decision making. I will set out to examine the relationship between theoretical ethics, justice-based reasoning, and care-based reasoning and conclude by suggesting not only that all are part of a defensible solution when adjudicating individual cases, but that these three are linked and can, in fact, be mutually corrective. I will claim that using what has been called “the care ethic” alone is grossly insufficient for solving individual problems and that the term can (especially when used without a disciplined framework) be extremely dangerous. I will readily admit that while blindly using an approach based solely on theoretically derived principles is perhaps somewhat less dangerous, it is bound to be sterile, unsatisfying, and perhaps even cruel in individual situations. Care ethics, as I understand the concept, is basically a non- or truly an anti-intellectual kind of ethic in that it tries not only to value feeling over thought in deliberating problems of ethics, but indeed, would almost entirely substitute feeling for thought. Feeling when used to underwrite undisciplined and intuitive action without theory has no head and, therefore, no plan and no direction; theory eventuating in sterile rules and eventually resulting in action heedlessly based on such rules lacks humanity and heart. Neither one nor the other is complete in itself. There is no reason why we necessarily should be limited to choosing between these two extremes.

We know today that classical eugenics, of an essentially negative nature, was not only an aggressive and brutal practice but, like its positive counterpart, inefficient as well. In fact, numerous biological, sociological, and psychological events beyond our control arise to prevent the realisation of any eugenic plan. Thus, like all human beings, individuals whose procreation is encouraged by positive eugenics suffer unexpected mutations that are transmitted to their offspring by their gametes. Gene distribution among the gametes at meiosis is the result of an uncontrollable, natural lottery. As an effect of this lottery, positive eugenics could allow the birth of defective babies whereas negative eugenics precludes the birth of normal babies.

Many Japanese American Buddhist families in the San Jose, California area observe a series of late life celebrations in honor of their elders. The sixty-first, the seven-tieth, the seventy-seventh, and eighty-eighth birthdays are celebrated with special flourish. These celebrations mark milestones in life and underscore the respect and gratitude elders are accorded by the family and community. At these gatherings the talk among family and guests invariably turns to the life of the elder and they wonder how the elder was able to survive and even flourish amid the hard- ships and setbacks during his or her long life. Indeed, long-lived elders do seem to have a presence of being that can only come from many years of living. The idea of kyogai, “one's station in life,” is especially revered in the elder. Ordinarily, kyogai refers to one's place in society. Kyogai also suggests the spiritual maturity of being able to live with equanimity and ease in a transient and interdependent world. For Shiryu Morita (1912– ), a leading Japanese sho-artist or calligrapher and student of Buddhist thought and practice, kyogai is both a spiritual and an aesthetic quality. I reflect on Morita's notion of kyogai within the context of the Buddha's attitude toward aging and elders. I offer my reflections as a Buddholo- gist interested in elder ethics and as a Buddhist priest concerned with caring for and empowering elders. I begin with a description of the Buddha's attitude toward aging and elders outlined in the Sutta-Nipata, an early Buddhist document. The “Salla Sutta” in the Sutta-Nipata outlines the Buddha's attitude toward old age, elders and elder tasks. Old age is linked to the question of death and the unease of living in a transient world, in the passages cited below (p. 68).1

Domestic violence is an important social problem that strongly impacts the healthcare system. It is estimated that two to four million women are physically abused each year by their husbands, ex-husbands, or boyfriends. Many of these abused women enter the medical system as patients with physical injuries, somatic symptoms, or psychiatric problems. These patients represent a large proportion of women patients in a variety of clinical settings: 22–35% of women presenting to emergency departments, up to 37% of obstetric patients, and over 25% of women seeking primary care. Despite the significant health implications of marital abuse, healthcare providers often fail to identify and treat this problem when signs are present.

Physicians have a sacred commitment to dedicate themselves through their art and through science to the improvement of the human condition. They have the solemn responsibility to focus on both the prevention and the cure of disease. The human genome project, a 15-year effort to draw the first detailed map in human DNA, will inevitably lead to the widespread implementation of human-gene therapy for the treatment and prevention of disease. We are on the verge of nothing less than a biomedical revolution, the likes of which have not been encountered before. The human genome project will lead to profound changes in the ability to manipulate genes. It will change the way we are born, how we live, how we die, and how we view ourselves in relation to our destiny. Before us lies a difficult transition.

This paper will discuss the role of compassion in ethics in general and in healthcare ethics in particular. My thesis is that compassion:

1) as Rousseau pointed out, is a natural trait common to all higher animals (human as well as nonhuman);

2) can and does serve as one of the most important motivators and modulators of ethics in both theoretical and applied aspects;

3) must be controlled by, and in turn control, reason if it is to serve its ethical as well as natural purposes; and

4) as a natural trait has survival value and, by virtue of being a natural trait, cannot be an obligation although there may very well be an obligation to do all that is necessary to nurture and not crush this sentiment.

No healthcare issue has generated as much ethical debate on the relationship between the individual and society as HIV Infection. In this debate, an appeal is most often made to such principles as autonomy and confidentiality to protect individuals who are HIV positive or who have AIDS from an invasion of privacy thought to be justified by society's need for information. In the first years, this emphasis on the protection of the individual was essential. Even today, there are risks in disclosing one's HIV status. However, as more and more persons become Infected, live longer, and move within the healthcare industry for non-HIV related care, as both patients and healthcare workers, the terms of the debate need to be redefined.

With the passage by virtually every state legislature of healthcare proxy laws, the medical profession increasingly can expect to rely on the participation of surrogates in making decisions on behalf of incompetent patients. Several concerns about the legitimacy of proxy decision making have been discussed in the ethical and general medical literature: the lack of concordance between the views of patients and their surrogates have been documented on multiple occasions, and cases of abuse by proxies or potential conflict of interest have been reported. Another dilemma that deserves discussion arises when proxies demand withdrawal of treatment that physicians and nurses regard as essential to the wellbeing of the patient. The following case highlights this dilemma.

The increasing incidence of ethical dilemmas in long-term care settings, in concert with recommendations from the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, has prompted long-term care institutions to develop mechanisms to address these concerns. Some facilities have chosen to set up an ethics committee, although estimates obtained in the past few years indicate that only between 2 and 27% of institutional long-term care settings have such committees. Ethics committees are responsible for assisting staff, residents, and families with the resolution of ethi- cal concerns, and typically engage in policy review and development, case review, and education. Such committees usually count among their membership representatives from a variety of disciplines, with family members, patients, and representatives from patient advocacy groups supplementing the professional component of the committee.

The combination of genuine ethical concerns and fear of learning to use germ-line therapy for human disease must now be confronted. Until now, no established techniques were available to perform this treatment on a human. Through an integration of several fields of science and medicine, we have developed a nine step protocol at the germ-line level for the curative treatment of a genetic disease. Our purpose in this paper is to provide the first method to apply germ-line therapy to treat those not yet born, who are destined to have a life threatening, or a severely debilitating genetic disease. We hope this proposal will initiate the process of a thorough analysis from both the scientific and ethical communities. As such, this proposal can be useful for official groups studying the advantages and disadvantages of germ-line therapy.

Crucial problems exist in understanding Japanese traditional customs with regard to autonomous decision making by patients in Japan. These problems are difficult to comprehend because they seem, by western standards, to defy logic. Questions that baffle those outside the Japanese tradition, include: Why do many Japanese patients hesitate to make medical treatment and care decisions for themselves without consulting family, close friends, or someone viewed as being in a superior position? Why do many Japanese physicians fail to disclose the truth directly to the patient, instead customarily conveying information to family members, despite the doctors' awareness of their legal obligation to protect the patient's privacy? Why do many Japanese physicians continue to question whether patients should be told the truth at all? What perpetuates Japan's widespread, but often unnoticed, neglect of the individual's right to self-determination in healthcare decision making?

On one side of his sign board, a nineteenth century surgeon depicted a physician operating on a patient's leg; the other side showed the Good Samaritan taking care of the victim's wounds. Christ's parable has often been quoted and depicted as a primary example of human compassion, to be followed by all persons and, a fortiori, by so-called professionals such as physicians and nurses. If we grant that the parable has not lost its narrative power for 20th century “postmodern” readers living in a “pluralistic” society, it merits a closer analysis.