The patient's right to informed consent is grudgingly acknowledged by medical professionals, firmly established in law, and brandished as a shibboleth by most bioethicists. But questions remain concerning genuine patient autonomy, and the doctrine of informed consent offers inadequate answers. In addition to the continuing controversy over what counts as “informed,” the passive acquiescence implied by “consent” seems a pale shadow of genuine autonomy.

Contemporary bioethics begins with the perception that medical values are a matter of public, rather than merely professional, interest. Such was the message of delegates in Helsinki and of the New Jersey court that decided for Quinlan. It is a theme that lurks within almost every major bioethical treatise since the first edition of Principles of Bioethics. This perception also undergirds the increasingly popular suggestion that moral authority in the patient-physician relationship resides neither in the medical profession, nor in the singular will of the patient, but in moral communities that link both parties with higher social orders.

The first book on my shelf at the newly created Program on Human Values and Health Sciences at the University of Tennessee Center for the Health Sciences in Memphis was by Van Rensselaer Potter on Global Bioethics. He was a cancer specialist at the University of Wisconsin and had the vision that bioethics should be a global concern—global in terms of scope, disciplines involved, and relationship to the environment and cultural context. This view has shaped my own career as well as influencing many others.

In the United States, organ transfer has generated a highly selective and overly specialized approach to bioethics. A dominant assumption is the myth of medical democracy: whereas professionals involved in this highly technocratic arena publicly embrace notions of medical equality, particularized practices expose another reality. The more specific ideological tenets of medical democracy read as follows: First, all potential transplant patients are equally deserving of replacement organs. Further, all citizens are entitled to equal access to these unusual commodities, which are regularly described as precious and scarce “national resources.” Whether the premises of medical democracy are in fact played out in daily practice, however, is another matter entirely. Organ donation is driven by a universalized sense of humanity, whereby all bodies are assumed equal beneath the surgeon's knife. Yet the social worth of individuals varies radically: children, pregnant women, the unemployed, and prisoners, for example, expose a wide spectrum of responses to certain categories of bodies. So, too, do the cultural origins of organ donors. By drawing on anthropological knowledge of sociomedical practices relevant to organ transfer, this essay explores this theme of medical democracy specifically in reference to the needs of Latinos in New York City.

Unlike many philosophers who write on biomedical ethics, John Hardwig is not primarily concerned to test our intuitions about the limits of normative theories by thought experiments or problematic borderline cases. Rather, he presses us to accept the conclusions to which our most firmly held principles commit us. But these conclusions, if Hardwig is right, turn out to be quite startling claims about moral duty that would undermine much of contemporary bioethical theory regarding end-of-life decisions. On his view, we must face squarely the moral implications of our present arrangement of healthcare funding in the United States, where more and more of the financial responsibility of care is being shifted onto the families of patients, often with disastrous results. Yet, in the context of this increasingly unstable arrangement, our chief principle of medical decisionmaking also holds that their interests are not morally relevant at all in deciding what should be done for the patient, and only the patient's wishes count (insofar as we can determine them). Now Hardwig thinks that this rule is irrational in the present circumstances, and that it would make more sense to admit the moral relevance of the interests of family members, but also that if we do give appropriate weight to their concerns, we shall be led in some cases to the conclusion that the patient has a duty to die.

The field of bioethics is by definition based on the presupposition that questioning, arguing, interruption, and response are the means by which we evaluate the truth claims of medicine and healthcare policy. The field began with the premise that another voice, one of at least critique, if not dissension, was just what was needed in any arena in which hegemonic expertise held sway. The field of the humanities is similarly based on the idea that both the literary and cultural canon—and the disputation and resistance to the canon—are acknowledged, taught, and honored. In situ in the clinic, on national boards, or in the literature, when a philosopher perceives a unanimity, she begins to be uneasy and begins to do the very thing she is trained for: to raise the questions of definition, method, data, motive, and goal.

The single most important intellectual event in my career in medical ethics occurred the day I realized that the Hippocratic ethic for medicine was not merely outdated and irrelevant but actually in conflict with all the dominant religious and secular moral traditions of our day. Whether one stood in any of the great modern religious traditions or in any of the camps of secular philosophy—the liberal tradition of political philosophy, Marxism, or more recent feminist or communitarian views—the Hippocratic ethic was wrong, both metaethically (epistemologically) and normatively.

These CQ Sources were compiled by Bette Anton.

In 1999, a case was described on national television in which a woman had enlisted onto an international bone marrow registry with the altruistic desire to offer her bone marrow to some unidentified individual in need of a transplant. The potential donor then was notified that she was a compatible match with someone dying from leukemia and gladly donated her marrow, which cured the recipient of the disease. Years later, though, the recipient developed end-stage renal disease (ESRD), a consequence of the high-dose chemotherapy she received earlier to destroy her stem cells and prepare her for the bone marrow transplant. Finding a suitable donor for a kidney transplant proved extremely difficult. Desperate, she requested that the donor registry personnel help her locate the individual who earlier was determined to be a compatible donor and asked this now-identifiable individual to consider donating one of her two normally functioning kidneys for a kidney transplant.

It has been a pleasure to read these papers and to contemplate their importance for what I believe to be a useful and provocative prism though which to view the field of bioethics: the nature of moral consensus. In my own most extended contribution to this literature, Deciding Together, I did not attempt to prescribe so much as to understand the role of moral consensus in the practice of bioethics. At the end of the book, I expressed the hope that it might help trigger an examination of bioethics and moral consensus. Though a few others shared my interest at that time (in particular Tris Engelhardt, for whose early encouragement I remain deeply grateful), with this set of stimulating papers the conversation has finally begun in earnest.

How does a self-described “simple teacher of religion” at the College of the Holy Cross get involved in bioethics? Nothing in my training or experience had prepared me for involvement in medicine. Much like that of my moral theology professor and then mentor, Richard McCormick, my training was in moral theology and social ethics. I also had an abiding interest in the courts and constitutional law. That interest led to a doctoral dissertation at the University of Southern California's Program in Social Ethics on “The Supreme Court's Understanding of Religion in Conscientious Objector Cases.” Interestingly, doctoral work in the late 1960s on the ethical dimension of war was the starting point for other ethicists such as Leroy Walters and James Childress who subsequently became early voices in bioethics.

The principle of respect for autonomy is increasingly under siege as a valuable component of healthcare ethics. Its critics charge that it has been elevated to a position out of proportion to its contribution, so that the individual's wishes and rights have come to dominate healthcare decisionmaking, while obligations and responsibilities are ignored or devalued. If we are to salvage respect for autonomy we must find a way to reconnect the individual and the community, rights and responsibilities, in the way we think about, discuss, and make healthcare decisions.

Albert Jonsen in The Birth of Bioethics notes that his career in bioethics began with a phone call to him from soon-to-be colleagues at the University of California at San Francisco Medical Center. Bioethics didn't begin with a bang but as an accident in the root sense—something that happened, not by necessity, but rather by chance. Indeed, the opening chapters of Jonsen's book chronicle a series of accidents that helped to create the field of bioethics. Principal among these was the fact that physicians and biomedical scientists who became puzzled about the moral dimensions of their work and began to think about these puzzles sought help in doing so from moral theologians and philosophers. These physicians and scientists, for the most part, were university people. They thought broadly, not just deeply, about their work, but they just as well could have defined themselves by their academic discipline and departments and not reached beyond these familiar and comfortable intellectual confines to the “culture” of the humanities disciplines and departments. The theologians and philosophers whom these physicians and scientists sought out were also university people who also happened to have generous views of the intellectual life in their disciplines—atypical of the time, especially in philosophy. If C. P. Snow had been altogether right and if ungenerous self-understanding of their work by physicians, scientists, philosophers, and theologians had prevailed, bioethics might not have happened at all.

These CQ Sources were compiled by Bette Anton.

The notion of “relational” autonomy—as described by feminist scholars such as Susan Sherwin and Anne Donchin—has been the subject of a significant body of literature over the last few years and has recently generated some interest within the field of bioethics. Although the focus of this interest has been the autonomy of ordinary moral agents, the analysis of relational autonomy can usefully be extended to apply to the autonomy of professionals, not only as individual moral agents, but in their roles as professionals as well. In this paper, I argue that professional autonomy, rightly understood, is relational in nature. This understanding of professional autonomy stands to improve our understanding of professional ethics, as well as providing a particular, concrete example of what we mean when we call autonomy “relational” and “socially embedded.

Few early debates in bioethics invigorated the field to the same extent as the one concerning whether or not young children could be used in nontherapeutic research. Though some of the issues in the debate were never fully settled, a consensus emerged, reflected in the Common Rule—that surrogates could consent to use children in such research, although once the level of risk rises above minimal, additional stipulations are required. Nontherapeutic research on cognitively impaired elderly people raises equally complex ethical issues, but there has been a dearth of debate in the literature about whether such research is ethically permissible. Instead, there have been many published recommendations regarding the circumstances under which such research can occur.

I was the graduate student that Albert Jonsen so aptly describes. Bronx born and educated at the City College of New York, I emigrated to the Midwest to study at the Minnesota Center for the Philosophy of Science, where May Brodbeck, Herbert Feigl and other “logical positivists” were engaging in an ongoing dialogue with postpositivists like Paul Feyerabend and Karl Popper. In this environment, I studied philosophy of science, epistemology, and metaethics—the epistemology and logic of ethical concepts and language. I even wrote my thesis on the ur-text of the metaethical turn, G. E. Moore's Principia Ethica. Then, like other epistemologists and metaethicists, “a public disaster, the American military involvement in Southeast Asia,” as well as the burgeoning civil rights movement, drew me into the sphere of public debate.

John Portmann attributes the current shortage of organs for transplantation to the dual effects of bioethics' reverence for autonomy and a general anxiety in the public about cutting bodies. Contrary to Portmann, I argue that attributing even partial blame to autonomy for organ shortages wrongly locates the problem. Indeed, there is reason to believe that waiting lists would be considerably shortened by respecting people's autonomy. I also question Portmann's explanation of the general aversion to organ donation in terms of a deep-seated anxiety about cutting bodies.

These CQ Sources were compiled by Judith Schaeffer Young.

Carson Strong's article “Cloning and Infertility” has initiated a conversation in this journal about the ethical and policy issues surrounding the question of who, if anyone, should be allowed access to human reproductive cloning technology, should somatic cell nuclear transfer ever become technically feasible and safe. Strong's position in that article is that infertile opposite sex couples for whom cloning is the last resort for having a genetically related child are the only people who should be granted access to such technology, primarily because this need to have a genetically related child would give such couples respectable reasons for cloning themselves. Also, every child has a basic right to a “decent minimum opportunity for development.” Thus it would be morally wrong, other things being equal, to clone a person with cystic fibrosis or spina bifida but morally permissible to clone a nearsighted person, because nearsightedness is not sufficiently disabling to violate the child's birthright. With this caveat, he concludes that protecting reproductive freedom requires that physicians be allowed to provide cloning services only to that small subset of infertile opposite sex couples who would need it as a last resort, should human reproductive cloning ever become safe and feasible.