Many years ago, the esteemed patriarch of bioethics, Joseph Fletcher, spoke loud and clear in favor of rationality in reproduction. By rationality, he meant not merely limiting population growth, which he certainly favored, but bringing to bear human analytic and creative intelligence on the random and instinctive activities of sexual intercourse and procreation that we share with all mammals. In his 1974 book, The Ethics of Genetic Control: Ending Reproductive Roulette, he foresaw most of the issues that we are facing today. He reflected on artificial insemination, prenatal diagnosis, cloning, eugenics, ectogenesis, ovum transfers, and genetic engineering. He examined these innovations to the extent that he felt that each of them represents a way of exercising rational and responsible control over life and reproduction. The subtitle of his book, “Ending Reproductive Roulette,” proclaims his faith. Dr. Fletcher's dedication to rationality led him to make the astonishing statement, “Man is a maker and the more rationally contrived and deliberate anything is, the more human it is. Therefore, laboratory reproduction is radically human compared to conception by ordinary heterosexual intercourse.”

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

In September 1994, the New York Times carried a front page article declaring healthcare reform dead in Congress. The obituary on healthcare followed a Congressional decision not to pursue the issue further in 1994. Although Congress and the President will likely revisit healthcare reform during 1995, the choices may be between various incremental steps, rather than substantive changes to bring about universal coverage.

The problem that I will discuss in this essay is marvellously illustrated in the title given to me by the editors. The word “interface” is itself part of the jargon of technology, the technospeak needed by those who develop, use, and discuss functions, things, and relationships that had not existed previously in the human world. They must make up new words to describe new realities (and, unfortunately, allow new and ugly words to obscure old ones). An “interface” presumably describes the way in which one electronic system contacts another so that the first energizes the second. In the old world of human experience, an “interface” is impossible. The face of one human being is visible to another; two faces, smiling or frowning at each other, communicate. The mind behind one face can interpret the movements of another. Never does one human face interpenetrate or merge with another.

The essays in this Special Section are about the ethics of Commercialism in Medicine. They are written, for the most part, by bioethicists, with the support of several prominent physicians and a health policy lawyer. This journal is, of course, devoted to ethics. Thus, our intent is to subject the question of commercialism in medicine to ethical scrutiny. Much has been written about commercialism in healthcare but very little about the ethics of commercialism in healthcare. One of our authors, Dr. Jerome Kassirer, has encouraged a national dialogue about these issues. We hope to start that dialogue in the bioethical community and, through that community, into the nation.Special thanks to J. Westly McGaughey for his editorial assistance in preparing this collection of papers.

These last words are titled “Conclusion,” but they should be “Inception.” Professor Jacob Needleman encourages a vigorous conversation about commercialism in medicine. An honest conversation, he maintains, will spur understanding, indignation, and reformation. We do sincerely hope that such a conversation begins and is carried on to meaningful change. However, as the essays in this collection show, that conversation must take place in many different places and about many different things. All of our authors acknowledge that the problem of commercialism is extremely complex. It cannot be understood as a simple fact or a single feature of modern healthcare. Thus, the conversation that discusses it must be varied and diverse.

This is the God Squad. It is faceless, impersonal, unmoved by tragedy, almost terrorist in aspect. The photo appeared in LIFE magazine on November 9, 1962, and it depicted the Admissions and Policy Committee of the Seattle Artificial Kidney Center. The Committee had been established in 1962 to select those few persons who would be admitted to the new and tiny dialysis unit that was created by Dr. Belding Scribner, inventor of the arteriovenous shunt. It consisted of seven anonymous members – a minister, a lawyer, a businessman, a homemaker, a labor leader, and two physicians. Each month they received a pile of charts about persons with end-stage renal disease. A prior medical evaluation had rated them all medically suitable for dialysis. The Committee’s task was to select one or two out of a dozen or so to take the available spots. The others were left to die. After several years of this agonizing work, the amendments to the Social Security Act provided financial support for renal dialysis and transplant, allowing the Admission Committee some peace of mind.

The profession of medicine has developed codes of ethical conduct for thousands of years. From the Hippocratic Oath of ancient Greece onward to modern times, a universal and central element of such codes has expressed the imperative that a physician shall “Do no harm.”

Jeremy Bentham, the founding father of utilitarianism, would have been delighted by technology assessment. Contemporary health policy planners are, unwittingly, aping the great man's felicific calculus, as they attempt to discern the efficacy and safety of magnetic resonance imaging or cardiac bypass surgery or extracorporeal shockwave lithotripsy. They try to design methods to calculate the effects of these technologies on mortality and morbidity and to compare the costs of one to the costs of alternatives. In recent years, the methods of technology assessment have been refined, but they remain, in essence, a copy of Bentham's proposal to plan and effect a rational course of action and to create a rational world.

The great philosopher and social reformer is, of course, still with us in a dessicated form. He bequeathed his body to the fellows of University College, London, and to this day his mummified figure is encased in a glass box, sitting in his favorite chair, dressed in his own clothes, his waxen face peering out with a bemused smile.

The Report of the Massachusetts Task Force on Organ Transplantation can be described as an incunabulum. This strange word, properly referring to a book produced in the first decades of printing with movable type, literally means “in the cradle.” The Task Force document appears in the infancy of a discussion that is certain to grow: the public policy debate over the allocation of scarce resources. The debate was born several years ago, but until now has either been argued in general terms or by way of administrative devices. The Task Force addresses a quite particular issue: how to or whether to make available to the citizens of the Commonwealth and their neighbors the medical technology of organ transplantation. It approaches the problem with a vivid awareness of the expense of this technology as well as the constraints on health care resources and financing.

The Report of the Massachusetts Task Force on Organ Transplantation can be described as an incunabulum. This strange word, properly referring to a book produced in the first decades of printing with movable type, literally means “in the cradle.” The Task Force document appears in the infancy of a discussion that is certain to grow: the public policy debate over the allocation of scarce resources. The debate was born several years ago, but until now has either been argued in general terms or by way of administrative devices. The Task Force addresses a quite particular issue: how to or whether to make available to the citizens of the Commonwealth and their neighbors the medical technology of organ transplantation. It approaches the problem with a vivid awareness of the expense of this technology as well as the constraints on health care resources and financing.

At the outset of his “Report on the National Commission,” Professor Annas quotes a satire on federal commissions. He then hastens to add that the quoted passage is an unfair and untrue characterization of the National Commission for the Protection of Human Subjects. This could be said of Annas' entire article. His central theme — that the Commission was biased in favor of research — is supported by poor evidence, and contrary evidence is neglected. For an accurate description of the Commission and its work, readers must turn elsewhere. We would suggest starting with the Commission's own reports, which include detailed explanations of the bases for its recommendations as well as the data that were considered by the Commission in arriving at the recommendations.