A decision by the Supreme Court of California in the case Conservatorship of Wendland, issued in August 2001, forces us once again to confront the all-too-common situation in which an individual has, on multiple occasions, expressed strongly held personal convictions about life-sustaining interventions but failed to incorporate those convictions into a formal advance directive. Many courts have recognized that lay citizens do not consistently resort to written legal formalities in their day-to-day lives, and reasonable accommodation must be made to this fundamental fact about human nature. However, a small but apparently growing minority of courts adamantly insist on either formal written directives or prescience and prophetic precision on the part of the patient before a surrogate can direct the withdrawal of life-sustaining treatment. The chronology of cases that comprise this minority position in American medical jurisprudence raise important ethical issues.

Like Saint Paul, I was “born out of due time” insofar as the study of bioethics is concerned. (Incidentally, I prefer the term “healthcare ethics” to “bioethics” because the discipline in question addresses issues more far-reaching than medical issues, such as downsizing access to healthcare.) I spent 15 years in teaching and administration at the Aquinas Institute of Theology, then in Dubuque, Iowa, now on the campus of Saint Louis University. I was given a sabbatical study year in 1972–1973 to refresh my mind and spirit. Though my major study and research emphasis prior to the sabbatical study had been in the field of Church law and religious government, I determined to direct my attention to the study of moral theology and ethics, because at that time there was confusion in this area of discipline, especially insofar as the Catholic community was concerned. With this in mind, I chose the University of Chicago as the locale for my study and was awarded a postdoctoral fellowship.

T. L. Zutlevics has written a thoughtful response to my piece on the anxiety borne of cutting bodies. I am grateful for this opportunity to turn back to the pressing problem of organ shortages.

Charles Dickens began one of his many great works of literature with this seemingly paradoxical, self-contradictory statement. Reflecting on a jury verdict in Northern California in June of 2001, in the context of what has transpired during the decade of the 1990s with regard to the care of dying patients, observations in the genre of Dickens come readily to mind. In 1991, two of the most compelling books on the subject of pain, medicine, and society were published: Eric Cassell's The Nature of Suffering and the Goals of Medicine and David Morris's The Culture of Pain. Both works unflinchingly recognized and explored the implications of the vast clinical literature documenting the failure of modern medicine to respond compassionately and effectively to what had by then become an epidemic of undertreated pain.

Jean E. Chambers and Timothy F. Murphy responded to my article “Cloning and Infertility” and extended the debate over human cloning in interesting ways. I had argued that none of the objections to cloning by somatic cell nuclear transfer are successful in the context of infertile couples who use cloning to have genetically related children, assuming the issue of safety is overcome by scientific advances.

The history in which bioethics developed is well reviewed in a recent book written by Al Jonsen. This superb little volume gives a concise—even if a necessarily rather subjective—account of the development of the field. A more objective history of the contemporary development of the field cannot be expected from those who helped craft it and awaits historians of the future. What I have been asked to do here is to supply my own personal impressions of the development of this field as I have experienced it. What I have been asked to do here is to supply my own personal impressions of the development of this field as I have experienced it.

In the following paper, Annemiek Richters of the University of Leiden in the Netherlands addresses the dilemmas faced by health professionals who are asked to evaluate and provide supporting documentation for those refugees who seek political asylum in the countries of Europe. It is in the politically charged arena of asylum applications, government regulations, and public policy where bioethics, human rights, and health converge. Despite the 1951 Convention on Refugees, a treaty signed by nations around the world to safeguard the rights of those who are displaced, and other treaties that protect the rights of vulnerable populations, refugee and asylum policies have become increasingly strict in an effort to deter those who would seek safety. This tightening of borders in the countries of the West challenges physicians who find themselves caught between obligations to treat, to advocate, and to challenge policies that make treatment a potentially dangerous proposition. Unfortunately, the World Trade Center attacks have exacerbated the problem by labeling asylees and refugees as potential terrorists and subject to deportation.

Unlike the compassionate conservatism of George Bush, Compassionate Utilitarianism is not a confusing concept. Nor is it a newly minted version of Utilitarianism given that it is embedded in the writings of Jeremy Bentham, writings that have come to light only with the Oxford University Press publication of his Deontology in 1983 as edited by me. Bentham's An Introduction to the Principles of Morals and Legislation (IPML) expresses the standard interpretation of Hedonistic Utilitarianism. What he said in Deontology serves as the basis of Compassionate Utilitarianism.

For many commentators in bioethics and the law, safety is the fulcrum for evaluating the ethics of human reproductive cloning. Carson Strong has argued that if cloning were effective and safe it should be available to married couples who have tried to have children through various assisted reproductive technologies (ARTs) but been unable to do so. On his view, cloning should be available only as reproductive last resort. I challenged that limited use by trying to show that the arguments Strong adduces in favor of reproductive somatic nuclear transfer (SNT) for married couples extend to same-sex couples as well, who face a different kind of infertility. I also went on to argue that his justifications would in fact extend the legitimate use of SNT to any couples regardless of whether they had fertility difficulties or not.

Mental health professionals who care for asylum seekers in Western European countries increasingly encounter problems for which standard diagnostic and therapeutic protocols and institutional healthcare policies offer no ready answers. In the following case vignettes some of these problems can be identified.

These CQ Sources were compiled by Bette Anton.

If you buy and read only one book this year, make it this one. Then, after you read and reread this book, buy and read, if you have not done so already, it's prequel, Cosmopolis. When you've done that you may find yourself wondering one thing and worrying about another (at least, where medical ethics is concerned). Why do we hear so little about Montaigne and Wittgenstein? And why do we bother so much with Descartes and his followers? Did philosophy take a wrong turn somewhere? Has ethics gone in one direction, philosophy in another? Did we moderns zig, when we could, and should, have zagged?

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.

Fair warning to the reader: Culture of Death: The Assault on Medical Ethics in America, by Wesley J. Smith, is hard for me to review. I work at Rush–Presbyterian–St. Luke's Medical Center, where in April 1989, Rudy Linares removed his son, Sammy, from a ventilator at gunpoint. I took the criticism hard and was critical of others who were in the outcry. In fact, some of the people Smith criticizes are people with whom I had differences. Yet, Smith's views are so harsh and alien to my understanding of the culture and practice of healthcare that I find them off-putting. Further, he and I participate in the same listserv, where I often disagree with his postings.

Since the decade of the 1970s, and particularly since the first successful test-tube baby in 1978, the development and use of assisted reproductive technologies (ARTs) have grown exponentially. Would-be parents—including those in so-called traditional male-female marriages, unmarried adults, postmenopausal women, and same-sex partnerships—who just over 20 years ago had no recourse for their (in)fertility issues can now pursue their desires to have children with at least a partial, if not, total, genetic and/or biological relationship. Ovulation-stimulating medications, artificial insemination using the sperm of a husband or unrelated donor (AIH or AID, respectively), in vitro fertilization with embryo transfer (IVF-ET), intracytoplasmic sperm injection (ICS), and gamete and zygote intrafallopian transfers (GIFT and ZIFT) are but a few of a host of treatment options ranging in complexity, invasiveness, and expense. And on the horizon are genetic techniques such as cloning—which was once considered “pure” science fiction but in 1997 became what some call an inevitability, with the development of mammalian cloning in the form of the now-famous (if not infamous) Dolly the sheep.

In 1992, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) passed a mandate that all its approved hospitals put in place a means for addressing ethical concerns.Although the particular process the hospital uses to address such concerns—ethics consultant, ethics forum, ethics committee—may vary, the hospital or healthcare ethics committee (HEC) is used most often. In a companion study to that reported here, we found that in 1998 over 90% of U.S. hospitals had ethics committees, compared to just 1% in 1983, and that many have some and a few have sweeping clinical powers in hospitals.

(Note: This consensus statement appeared in somewhat differing format as an editorial in the Western Journal of Medicine 2001;175 [October 2001]. The full text and list of cosigners is published here for the first time.)

Bioethics is the formal discipline concerned with ethical and broader issues arising in the practice of medicine and the other healthcare professions and science as a whole. Bioethicists are concerned not only with the impacts and quandaries faced by individual patients and their caregivers, but the impacts of healthcare on society and the broader natural world. Although bioethicists approach such issues from many different theoretical perspectives, most if not all agree that the healthcare professions and industry should seek to minimize any real or potential health risks associated with providing healthcare.

Admittedly, productivity is valued in American society. For jobs that involve manufacturing, each minute of production is calculated in formats of cost and profit. Management sets goals for individual and team performance that foster competition and an ever-fervent culture of output. Industry and academia have gone to great lengths to develop tools that measure productivity as a variable, and certainly, in the manufacturing setting, productivity is a value because it promotes competition (thus more output) and efficiency (less waste). But is it ethically appropriate for productivity-based values and goals to cross over to healthcare allocation? Can other constructions of productivity be valued in terms of healthcare allocation or is the American work ethic (benefiting people in the prime of their productive years) an ethically appropriate route?

Old habits die slowly. Hence there is little surprise that attorneys fashioning the Model State Emergency Health Powers Act preserved much of their own standard operating procedure. This model statute was designed for the worst of times—for horrific scenarios in which terrorism, infectious disease, or natural calamity threaten to derail the machinery of civilization while snuffing out thousands or even millions of human lives. Such grave threats seem to justify grave measures aimed at restoring order and maximizing survival. So, the model statute bestows sweeping power on state governors and public health officials, allowing them to seize private property, obtain clinical services through impressment, and enact quarantine and isolation measures without the usual due process. Yet amid all these drastic measures, certain standards persist.

Camaraderie is what I remember most about my anatomy course in medical school. There were six of us to the cadaver; six strangers who, during the course of endless hours of dissection and study, formed unique bonds. As time went on, we developed closer friendships with others, but none of these included that special sense of having been together at the beginning. We named our cadaver Ernest so we could kid about telling our parents that we were working in dead earnest. I can still visualize the man's sharp, rough face, gray and emaciated. I see his ravaged black lungs. As I write this review, the trenchant odor of formaldehyde reaches out from 36 years in the past and makes my eyes water. Nowadays, I could no more list the skull's foramina than I could speak Sanskrit, but I haven't forgotten most of the lessons that Ernest taught me.