You wrote an editorial in JAMA giving a 30-year retrospective on bioethics. If you look ahead to the next 30 years, what are the issues you see facing bioethics in the future?

In recent years, bioethics has increasingly become an international area of inquiry with major contributions being made not only in North America but also in Europe and in the Pacific Rim countries. This general observation is particularly true for research ethics. Little attention has been paid, however, to this internationalization of bioethics in general and research ethics in particular, and there are few studies comparing what has emerged in the different countries.

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration (FDA) and Health and Human Services (HHS) regulations. When that equipoise ends, a drug is either not approved or becomes standard care.

Medical practitioners have traditionally seen themselves as part of an international community with shared and unifying scientific and ethical goals in the treatment of disease, the promotion of health, and the protection of life. This shared mission is underpinned by explicit acceptance of traditional concepts of medical morality, and by an implied link between individual human rights and the ethics of medical practice long enshrined in a range of World Medical Association (WMA) and other medical codes. These have been powerful instruments exhorting individual practitioners to promote health and to defend universal principles in order to protect their patients and the physician-patient relationship even in the face of authoritarian state coercion and imposed national ideologies and policies. There has been widespread support for this approach and this should be intensified.

Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls' A Theory of Justice in 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls' A Theory of Justice has been remodeled for healthcare philosophy by Norman Daniels. Nozick's libertarian manifesto Anarchy, State, and Utopia has been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare.

At the end of the most violent century in human history, it is good to take stock of our commitments to human and other life forms, as well as to examine the rights and the duties that might flow from their biological makeup. Professor Thomasma and Professor Loewy have held a long-standing dialogue on whether there are moral differences between animals and humans. This dialogue was occasioned by a presentation Thomasma made some years ago at Loewy's invitation at the University of Illinois, Peoria, Medical Center. During that presentation, Thomasma argued that human beings are sufficiently distinct from other animals genetically and otherwise to justify a moral difference in rights and obligations. In effect, he argued that there are species-specific rights. This essay will pick up the threads of that dialogue.

Community discourse about the moral status of animals is critical to the future of bioethics and, indeed, to the future of modern society. Thomasma and Loewy are to be commended for sharing thoughts and trying to attain some common ground. I am grateful to them for fostering discussion and allowing me to respond. I cannot endorse the negative tone of the end of their conversation, however. They end with serious concerns about the possibility of any agreement between themselves. Even though I perceive some moral differences between them, I do not believe that they are moral strangers. In this commentary I review the ways in which I agree and disagree with Thomasma and Loewy and conclude with some thoughts about the kind of broad ethical thinking we need to do to address our moral relationship to nonhuman, living creatures.

The restructuring of the healthcare marketplace has exerted pressure directly and indirectly on clinical ethics programs. The fiscal orientation and emphasis on efficiency, outcome measures, and cost control have made it increasingly difficult to communicate arguments in support of the existence or growth of ethics programs. In the current marketplace, arguments that rely on the claim that ethics programs protect patient rights or assist in the professional formation of practitioners often result in minimal levels of funding and preclude program growth. Where ethics programs could once sustain themselves on goodwill alone and values arguments in an expanding healthcare market they are now encountering—at least by anecdotal reports—cutbacks and even elimination. To respond to these challenges, we offer an economic model that can be used to demonstrate the “value” of an institutionally based ethics program.

The critical role of surrogates—commonly if erroneously called “Informal caregivers”—has been generally ignored by clinical and bioethical literatures. While assumed to provide no more than ancillary support, these patient representatives directly or indirectly affect patient care to the extent they inhibit or facilitate both home-based care and patient decisions regarding treatment alternatives. Members of this group include relatives and neighbors who may or may not act in consort as advisors, assistants, care providers, and surrogate decisionmakers acting on the patient's behalf with members of the medical community. Not only do they often possess a critical voice strongly influencing both patient care decisions and, after discharge, home care and rehabilitation, this paper argues they do so from a perspective that is often radically different from one endorsed by medical professionals.

In 1961 in Japan, the son of a hospitalized man suffering from severe pain after a stroke mixed a cup of milk with insecticide and arranged for his unsuspecting mother to give this to the patient, who had requested that his son assist him in dying. The son could not endure his father's condition and killed him in order to show his love.

A common tale of moral cacophony and euphemism on the city streets:

Each day, an owner of a small business decides, “once and for all,” how to respond to the “homeless person” panhandling for “spare change” as she makes her way to work in the morning. Today, she looks the other way and holds more tightly to her purse. Nearby, a building contractor waits impatiently for the traffic light to change as his van is approached by a small and shabby band of “street people” demanding to clean his windshield. He turns his wipers on to signal them away. Sometimes this works. At the next light, a woman carrying an infant swaddled to her torso offers a tube of three roses for a dollar. The driver smiles pleasantly, but does not stop. The businesswoman, now close to work, buys two tubes of roses and does not wait for the change from the five-dollar bill she earnestly presses into the mother's hand.