Clinical ethics, like the broader field of bioethics from which it emerged, is at a critical crossroads in its development, with conflicting paths ahead. It can either claim its distinctive place in the clinical arena, insisting unapologetically on certain minimal standards of professional training, practice and competence, addressing head on debates about various models of and methodological approaches to consultation, and establishing a shared vision of the purpose and meaning of the enterprise of clinical ethics itself. Or, it can devolve into a hobby that untrained, albeit interested, and generally well intentioned individuals can dabble in for fun or even profit, as they see fit, and without regard to the deep history and rich disciplinary roots of the field, the serious debates in the academic literature of bioethics, the foundational case histories and legal theories, or even any sense of professional accountability.

American policymakers and health policy analysts have a love-hate relationship with job-based health insurance. The policy press routinely runs articles about the demise of the current system of voluntary employer-sponsored health insurance coverage. Conservatives argue that it ought to be replaced with individually-purchased insurance, such as tax-favored spending accounts (see Mark Pauly’s article this issue). Liberals assert that government insurance ought to supplant it.

Meanwhile, as the debate rages on about the future of employer coverage, states and the federal government pass legislation buttressing and building on the existing employment-based system. Most recently, California has passed an employer mandate requiring employers to cover their workers (and many other states have contemplated similar legislation) and Maine has adopted a universal coverage initiative that includes a voluntary small employer insurance program offered through a state agency (Dirigo Health Care).

In recent years, a number of prominent scholars have touted the use of litigation as an effective tool for making public health policy. For example, Stephen Teret and Michael Jacobs have asserted that product liability claims against car makers have played a significant role in reducing automobile-related injuries, Peter Jacobson and Kenneth Warner have argued that litigation against cigarette manufacturers has advanced the cause of tobacco control, and Phil Cook and Jens Ludwig have suggested that lawsuits against the firearms industry can reduce gun violence. Critics have attacked this use of litigation as doing more harm than good to public health and as a misuse of the courts. This debate involves two distinct controversies: one over whether the public health benefits of litigation outweigh its costs and the other over the proper role of courts within our system of government.

This paper organizes the question of gun controls as violence policy under two quite different headings. The first issue to be discussed is the relationship between gun use and the death rate from violent crime. The second question is whether and how firearms control strategies might reduce the death rate from violence. When we review the evidence on the relationship between guns and violence, it seems clear that gun use, usually handgun use, increases the death rate from violence by a factor of three to five. Nobody in mainstream social science or criminology argues against such weapon effects these days, although some are more skeptical of the magnitude estimated than others (one example is Lance Stell; please see his essay in this issue). Thus the problem is both genuine and important.

Not so very long ago - in historical terms - the politics of Medicare were thought to be stable and well-established. Medicare’s 1965 enactment culminated an epochal political battle that spanned fifteen years and involved mass mobilization, millions of dollars in lobbying expenditures (including the development of such techniques as “grass-roots lobbying” and targeted direct mail), and bitter partisan controversy. By the late 1980s those seemed to be distant birthing pains long since overshadowed by the program’s robust health and popularity. Medicare politics had devolved into a model of pluralist “normalcy” in which a relatively specialized and autonomous group of subject-matter experts in the federal bureaucracy, the Congress, and affected interest groups largely made policy by negotiating among themselves, primarily on issues of provider reimbursement. Even the extraordinary events involving the 1988 enactment of the “Medicare Catastrophic Coverage Act” legislation (which, among other things, established good coverage for prescription drugs), and the ensuing public firestorm that led to its partial repeal in 1989, could be seen as an aberrational deviation from a more placid pattern.

“Strict gun control”(SCG) has no clear meaning,so it is necessary to clarify it.I define SGC as an array of legally sanctioned restrictions designed to impose firearm scarcity on the general population. SGC’s public policy goal, gun scarcity, commonly rests on the predicates that “dangerous criminal control” is not the central problem for reducing the problem of criminal gun violence but rather that it is the social prevalence of the distinctively-lethal instruments (guns) by which both supposedly “good citizens” as well as violent criminals inflict a staggeringly high percentage of injury and death.

Professor Zimring (who also has an essay published in this issue) is one SGC’s most distinguished, prolific and comprehensive theorists. He has advocated for handgun scarcity among the general population since at least 1969.

Empirical research in bioethics can be defined as the application of research methods in the social sciences (such as anthropology, epidemiology, psychology, and sociology) to the direct examination of issues in [bioethics]. As such, empirical work is a form of descriptive ethics, focused on describing a particular state of affairs that has some moral or ethical relevance. For example, empirical research can help to describe cultural beliefs about the appropriateness of providing health-related information, such as the diagnosis of a life-threatening illness, which informs deliberations about the extent to which it is morally important for clinicians to provide comprehensive information to patients in different cultural contexts. Similarly, empirical research can delineate popular attitudes and experiences related to contentious issues such as abortion, cloning, stem-cell research, and physician-assisted suicide to enlighten discussions and policy formulations regarding them.

Severe Acute Respiratory Syndrome (SARS) garnered a great deal of public attention because it was novel and its potential for spread was unknown. However, the SARS corona virus is significantly less virulent than pandemic influenza viral infections.

If the evolution of American health policy (in both its purposeful and its accidental forms) is compared to the children’s game of Crack the Whip, then there is no question that the Medicaid program is the tail of the line. When those at the head of the line (e.g., employer-based insurance, Medicare, managed care plans, and pharmaceutical companies) start to move. Medicaid receives whatever shocks and unintended consequences result, and when the line “begins to run wildly in any direction,” it receives them faster and harder than the players at the center.

Shocks also come from other sources. When the economy slumps, an epidemic arises, or a path in another part of the system becomes a cul-de-sac, new twists and turns occur, with Medicaid absorbing much of the change.

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health.

Interest in the ethics of research on human subjects, stimulated by atrocious human experimentation during WWII and the resultant Nuremberg Code, has been sustained by examples of unethical research in many countries and by proliferation of codes and guidelines. Such interest has intensified in recent years in association with expanding international collaborative research endeavors. The ongoing controversy in international research ethics takes place at two levels. At the practical level it is about the competing concerns of those predominantly interested in doing research to advance knowledge and those who, while supporting the need for research, are more acutely aware of the potential to exploit vulnerable participants, especially in developing countries. At the level of theory the controversy pits ethical universalism against moral relativism.

In her recent review of agreements and controversies in international research ethics, Ruth Macklin has concluded that, despite seeming agreement on several issues, many different viewpoints persist. In her view it is unlikely that these will be resolved easily.

Violence sells, Americans have what sometimes seems to be an insatiable appetite for it. Depictions and descriptions of violence saturate our culture. songs urge us to rape women, kill police officers, and commit suicide. Movies portray-indeed they glorifyviolence as an intrinsic element of every imaginable plot line.

Despite substantial evidence that an individual’s repeated exposure to portrayals of violence is associated with significantly increased likelihood that the individual will commit aggressive acts against others, no legal regime currently regulates such portrayals either on television, in music, in movies, or in video games. Neither Congress, the Federal Communications Commission, the Federal Trade Commission, nor any state legislature has yet mustered the political will to impose substantial or systematic legal constraints upon producers or purveyors of violent images. Official censorship is rightly to be feared, but unreflective invocations of our commitment to freedom of speech provide incomplete justification for our legal regime’s apparent indifference to the possibility that media-induced violence may impose substantial costs on innocent victims.

First, to what level of quality can medical ethics a spire, if it ignores callous discrimination in medrcal practice against large populations of the innocent poor? Second, how effective can such theories be in addressing the critical issues of medical and clinical ethics if they are unable to contribute to the closing of the gap of sociomedical disparity?

Millions of Americans are dependent on what is often called the “safety net.” These loosely-organized networks of health and social service providers serve the many Americans who are uninsured, dependent on public coverage, or for a variety of reasons unable to access other private systems of care. The Institute of Medicine (IOM) report, America’s Health Care Safety Net: Intact but Endangered, called attention to both the fragility and the resilience of this health care safety net. The IOM report underscored the critical importance of the safety net to the health and well-being of millions of individuals and called for efforts to strengthen it and improve the nation’s ability to monitor its viability. Given this central role, any health care reform efforts need to be fully informed by an understanding of what the safety net includes, how it is financed, and how it is responding to a series of challenges it now faces.

How to respond justly to the dangers persistent violent offenders present is a vexing moral and legal issue. On the one hand, we wish to reduce predation; on the other, we want to treat predators fairly. The central theme of this paper is that it is difficult to achieve both goals without compromising one of them, and that both are being seriously undermined. I begin by explaining the legal theory, doctrine and practice governing dangerous offenders (DO) and demonstrate that the law leaves a gap in the ability to confine them. Next I explore the means by which the law has overtly or covertly sought to fill the gap. Many of these measures, especially the new form of civil commitment for sexual predators, dangerously conflate moral and medical categories. I conclude that pure preventive detention is more common than we usually assume, but that this practice violates fundamental assumptions concerning liberty under the American constitutional regime.

Amongst Professor Dickens’ extensive writings on medical law and medical jurisprudence are a host of distinguished contributions on the subject of the proper legal and ethical limits on human experimentation. As early as 1975, Professor Dickens was examining the legal aspects of human experimentation. A few years later he was promoting the responsibility of researchers to recognize and protect human rights in medical experimentation. In the last two decades, Professor Dickens has penned a rich flow of scholarly contributions on the legal and ethical rights and duties in medical experimentation and the need to do better as a research community. His articles have considered a broad range of issues in medical experimentation including the imperative of voluntary consent, the ethical unacceptability of co-ercion or inducement of research participants, embryonic research, epidemiological research and the protection of vulnerable research participants, particularly children.