In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature.

An icy wind blows through your cotton shirt while you sit outside the hospital door, waiting for your wife to bring up the car. The warm August day, when you entered the emergency room, has transformed into a gray November one. Your mind returns to Dr. Snipe.

Persons who experience severe brain injury often suffer significant disorders of consciousness. Anoxic injuries from cardiac arrest or strokes and traumatic injuries from falls, vehicular crashes, or assaults can result in several conditions in which patients lose or have diminished consciousness for an extended period of time. Two such conditions that create considerable public confusion and controversy are the vegetative state (VS) and the minimally conscious state (MCS). Although these conditions have generated significant medical and academic research, the general public and policymakers are often confused about the nature of VS and MCS. The most recent evidence for this confusion is the acrimonious public debate, the extensive media coverage, the prolonged litigation, and the attempts of various governmental officials to intervene in dealing with the plight of Terri Schiavo.I thank my legal researcher, Tejal Banker, J.D., LL.M., for her assistance.

Revolutions in semiconductor device miniaturization, bioelectronics, and applied neural control technologies are enabling scientists to create machine-assisted minds, science fiction's “cyborgs.” In a paper published in 1999, we sought to draw attention to the advances in prosthetic devices, to the myriad of artificial implants, and to the early developments of this technology in cochlear and retinal implants. Our concern, then and now, was to draw attention to the ethical issues arising from these innovations. Since that time, breakthroughs have occurred at a breathtaking pace. Scientists, researchers, and engineers using differing methodologies are pursuing the possibilities of direct interfaces between brains and machines. Technological innovations as such are neither good nor evil; it is the uses devised for them that create moral implications. As there can be ethical problems inherent in the proper human uses of technologies and because brain chips are a very likely future technology, it is prudent to formulate policies and regulations that will mitigate their ill effects before the technologies are widespread. Unlike genetic technologies, which have received widespread scrutiny within the scientific community, national governments, and international forums, brain–machine interfaces have received little social or ethical scrutiny. However, the potential of this technology to change and significantly affect humans is potentially far greater than that of genetic enhancements, because genetic enhancements are inherently limited by biology and the single location of an individual, whereas hybrids of human and machine are not so restricted. Today, intense interest is focused on the development of drugs to enhance memory; yet, these drugs merely promise an improvement of normal memory, not the encyclopedic recall of a computer-enhanced mind combined with the ability to share information at a distance. The potential of brain chips for transforming humanity are astounding. This paper describes advances in hybrid brain–machine interfaces, offers some likely hypotheses concerning future developments, reflects on the implications of combining cloning and transplanted brain chips, and suggests some potential methods of regulating these technologies.We are grateful to Prof. Michah D. Hester for helpful comments on this article.

The 1990s “Decade of the Brain” stimulated research on many fronts and resulted in considerable advancement in neuroscience. Unfortunately, we have been slow to develop a policy dialogue to anticipate and deal with vast implications. Simply put, our political and social institutions have not kept pace with these advances. At the base, policy issues center on how we interpret the implications of these developments, especially given the complexity of the subject and the speculative nature of much of the evidence to date. The issues discussed here go to the heart of the major problems facing the world today and challenge basic assumptions on both the right and the left of the political/ideological spectrum as well as the standard social science model of behavior. As a result, the findings of neuroscience are open to ideological maneuvering designed to put the most expedient spin on their meaning.

We have a philosopher friend who was quite ill and required surgery, but she was not ill enough to be admitted to hospital under the “life, limb, and organ preservation” guidelines that control surgical admissions. Her surgeon told her to go to emergency and gave her a list of symptoms to tell the physicians there. Those, he said, would get her a bed, and he would then come and perform the necessary surgery. And that is how our friend (who, ironically, taught ethics out of a textbook called Virtue and Vice in Everyday Life) got her surgery.We are grateful to Don Brown for extremely helpful comments and conversation on the philosophical matters of our paper and to Dan McDonald for stimulating discussion on the culture of healthcare providers.

Society has already seen multiple potential futures of neurotechnologies through the multifaceted lens of science fiction. We do not know which of those futures we will come to live, but the strong force in society's evolutionary process will likely continue to be the insight and oversight developed by the bioethics community, pushing and being pushed by the advances of technology, improvements in medical care, and market competitiveness.The author thanks the “Ethical Dimensions in Neuroscience” Program of the Stanford University BioX Interdisciplinary Initiative and the Stanford Center for Biomedical Ethics for supporting this work.

Money plays a powerful role in modern medicine, both in terms of how health services are organized and delivered and increasingly in how physicians understand themselves and their work. The phrase “the hegemony of money” is intended to capture that power.

As neural implants transition from engineering design and testing into human subjects research, careful consideration must be paid to the ethical elements in developing research protocols. Although these ethical aspects may be framed by the design choices of the engineering, a number of challenging choices arise. In spite of many ethical considerations for neural implant technologies being shared with generic research ethics questions, there are subsets needing special attention. Even in considerations requiring increased attention, substantial overlap can be found with research ethics questions for general medical implants and for psychiatric pharmaceuticals. The special attention to specific ethical questions in neural implants exists because of the value placed on preserving cognition and control as well as our continued memory of significant past research abuses in neurosurgery. This paper focuses on three issues of particular saliency to neural implant testing: inclusion/exclusion of subjects with psychiatric conditions, consent withdrawal of research subjects, and enhancement as a goal.

Justifying his proposal for “health savings accounts,” which would allow individuals to set aside tax-free dollars against future healthcare needs, President Bush has said that “Health savings accounts all aim at empowering people to make decisions for themselves.” Who could disagree with such a sentiment? Although bioethicists may be among those who express skepticism that personal health savings accounts will be part of the needed “fix” of our healthcare financing system, self determination has long been part of their mantra. Indeed, the field of bioethics played an important role in advancing this idea in the medical world when physician paternalism was regnant. Has its popularity caused it to become so vapid as to be ripe for misuse?

In a recent special supplement to the Hastings Center Report entitled “Improving End-of-Life Care—Why Has It Been So Difficult?” Robert Burt wrote the following in an essay ominously entitled “The End of Autonomy”:

(1) No one should be socially authorized to engage in conduct that directly, purposefully, and unambiguously inflicts death, whether on another person or on oneself.

(2) Decisions that indirectly lead to death should be acted upon only after a consensus is reached among many people. No single individual should be socially authorized to exercise exclusive control over decisions that might lead to death, whether that individual is the dying person, the attending physician, or a family member acting as health care proxy.

Direct-to-consumer advertising (DTCA) of healthcare products refers to a variety of marketing practices based on a combination of information and promotion strategies directed at consumers through different media such as radio and television broadcasts, newspaper and magazine ads, and, more recently, through the Internet. The principal form of marketing used by the pharmaceutical industry is the distribution of free samples to physicians but DTCA is an increasing part of global promotional spending for prescription drugs. Latest estimates suggest that DTCA now represents an annual $3.2 billion enterprise for the U.S. pharmaceutical industry. Findings from the literature show that these substantial efforts are geared toward the newer pharmaceuticals for chronic conditions with huge market potentials. The lion's share is going to the 20 most prescribed pharmaceuticals.We thank the Henry J. Kaiser Family Foundation (J.I.) for funding of this project and Dr. Patricia King for her support. Writing of this paper was supported by NIH/NINDS R01 #NS045831 (J.I.) and the Social Sciences and Humanities Research Council of Canada (E.R.). We also acknowledge Dr. Pamela Schraedley-Desmond, Shilpa Gulati, Neil Mukhopadhyay, and Sarah Waldman.

In April 2005, the U.S. National Academy of Sciences (NAS) published its Guidelines for Human Embryonic Stem Cell Research. These voluntary guidelines are among the most permissive in the world—in a country that prohibits federal funding of research to derive human embryonic stem (hES) cells (cells that can self-renew or differentiate into most cells in the human body). One of the few research prohibitions in the NAS guidelines concerns the creation of certain kinds of human–nonhuman chimeras. A chimera is an organism with a mixture of cells from two different organisms, from the same or different species. Figure 1 provides a useful overview of different types of chimeras.This work was supported, in part, by a Stem Cell Network grant to Françoise Baylis and Jason Scott Robert and a CIHR grant to Françoise Baylis. We sincerely thank Alan Fine, Rich Campbell, Cynthia Cohen, and Tim Krahn for helpful comments on an earlier draft of this paper. Thanks are also owed to Tim Krahn for his research assistance. An earlier version of this paper was presented to the Department of Bioethics and the Novel Tech Ethics research team (www.noveltechethics.ca). We thank the participants at each of these meetings for their helpful comments.

Although bioethics consultation has always drawn the ire of critics, its extension into areas such as paid consultation with private industry has raised new concerns. Critics of consulting relationships with industry question the sincerity of for-profit corporations who seek ethical advice, alleging that a desire for improved public relations is a primary motivation of these corporations. They also question whether compensation for ethical advice creates insuperable conflicts of interest that bias the work produced. The decision of two influential professional societies to establish a joint task force to examine bioethics consultation with industry reflects the seriousness of these and other concerns about this practice. The report of this task force, although controversial, has stimulated broad discussion about the ethical commitments of bioethicists and highlighted the need for clearer professional standards of conduct.The authors thank John Walsh, President and CEO of the Alpha-1 Foundation, for his thoughtful comments on an earlier draft. The contents are solely the responsibility of the authors.

The application of neurostimulation techniques such as deep brain stimulation (DBS)—often called a brain pacemaker for neurological conditions like Parkinson's disease (PD)—has generated “currents of hope.” Building on this hope, there is significant interest in applying neurostimulation to psychiatric disorders such as major depression and obsessive-compulsive disorder (OCD). These emerging neurosurgical practices raise a number of important ethical and social questions in matters of resource allocation, informed consent for vulnerable populations, and commercialization of research.The authors acknowledge the help of Dr. Jarrett Rosenberg, Ofek Bar-Ilan, Stacey Kallem, Allyson Mackey, and Cynthia Forlini. This study was supported by the Institut de recherches cliniques de Montréal (E.R.), SSHRC (E.R.), and NIH/NINDS R01 #NS045831 (J.I.)

I briefly discuss three components of the media that play a role in the commercialization of medicine: advertising, television dramas, and journalism.

Neuroethics to date has tended to focus on social and ethical implications of developments in brain science, especially in functional neuroimaging. Within clinical neuroethics, the emphasis has been on ethical issues in clinical neuroscience practice, including informed consent to neuroimaging; the development of ethical research protocols for functional magnetic resonance imaging especially, and especially in children; and the ethical clinical management of incidental findings. Within normative neuroethics, we have witnessed the more philosophical and/or social scientific study of the meanings of developments in neuroscience, including concerns about the impact of neuroimaging on privacy, freedom of thought, moral culpability, and sense of self. In this piece, I argue for an expansion of neuroethical attention to the interface of neuroscience and psychiatry, where brain science meets the clinical sciences of the mind. My particular focus is the development of psychiatric classification systems.I am grateful to Jenny Brian, Carl Craver, Thane Plantikow, Claire Pouncey, and Ken Schaffner for discussion of many of the themes presented here. Early research on which portions of this article are based was funded by the Canadian Institutes of Health Research in the form of an operating grant and salary award. My current research is supported by the Institute for Humanities Research, the Center for Biology and Society, and the School of Life Sciences, Arizona State University.

Once a neural implant has shown some efficacy during initial research trials, it begins to enter the world of clinical application. This culminates when the implant becomes approved for a particular indication. However, the ethical challenges continue as the technology is adopted as a standard of practice. Patient eligibility criteria, as documented by inclusion and exclusion criteria with any new treatment, are not always clearly quantified and defined. These vagaries can result in considerable debate regarding who should or should not proceed with surgery. There is often considerable room for clinical judgment that can result in extension of the treatment to a wider range of patients. The ethical questions that arise in clinical decisionmaking differ significantly from those inherent in engineering design and research development.

The understanding of appropriate ethical protections for participants of biomedical research has not been static. It has evolved over time, with the evolution of biomedical research as well as social values. Since World War II, there have been four major paradigms of research and research oversight operative in the United States (Table 1). These paradigms incorporate different values and provide different approaches to research oversight and the protection of research participants.

There is a palpable malaise in American medicine as clinical practice veers off its moorings, swept along by a new commercialism that is displacing medical professionalism and its attendant moral obligations. Although the sociology of this phenomenon is complex and multifactorial, I argue that this move toward medical commercialism was accelerated by the abortive efforts of the Clinton Administration's Health Security Act. Through an analysis of performative speech I show that, although the Clinton plan drew on many strands of speech about healthcare, it favored the discourse of health policy and health economics over that of clinical practice and professionalism. Though the Clinton plan failed, this new vocabulary of health economics has led us to imagine a new descriptive framework, which has commodified healthcare and commercialized the clinic.I am grateful to Drs. William Andereck and Al Jonsen and the California Pacific Medical Center's Program in Medicine and Human Values for the invitation to participate in their deliberations on “Commercialism in Medicine,” my fellow colloquialists for their helpful comments, Dr. Pablo Rodriguez del Pozo for his insights, and Dr. Jonsen, in particular, for his astute editorial advice and guidance.