The role of the healer is expanding. Attempts by physicians to enhance human capacity are but one among many new medical projects. The twentieth century ushered in significant changes in therapeutic modalities, and the past two decades have seen the role of the physician reshaped by economic, political, and dramatic new social mores. People ask new and different things of their clinicians. Under managed care, the primary care clinician is expected to have much more skill than was traditionally expected of a general internist, and new incentives force physicians to much more explicitly ration the care they provide to patients and to patient populations. But perhaps no change in the contemporary world of health portends more long-term effects than the introduction of enhancement technologies.

The treatment-enhancement distinction draws a line between services or interventions meant to prevent or cure (or otherwise ameliorate) conditions that we view as diseases or disabilities and interventions that improve a condition that we view as a normal function or feature of members of our species. The line drawn here is widely appealed to in medical practice and medical insurance contexts, as well as in our everyday thinking about the medical services we do and should assist people in obtaining.

Male cats mate happily with any female in heat in the neighborhood. Something similar occurs in colleges as nearness and availability overwhelm all other considerations. So we see young men and women marry people who happen to be at hand when the time is ripe.

As a philosopher interested in biomedical ethics, I find recent advances in genetic technologies both fascinating and frightening. Future technologies for genetic therapies and elimination of clearly deleterious genes offer us the ability to get rid of the cause of much human suffering, seemingly at its physiological root. But memories of past eugenics programs gone horribly awry (whether we speak of Hitler's program, California sterilization laws and practices of the 1920s, or even contemporary practices, such as attempts to work out deals that exchange sterilization for early prison release) must make cautious our initial optimism for these generally well-intentioned programs. Most often the scientist proceeds in research with the best of intentions, but that does not make all scientific investigation worth pursuing.

The word enhancement is value laden and potentially misleading in the context of genetics. Dictionary definitions of enhance include “increase in value,” “improve,” “appreciate,” and “inflate.” The term genetic enhancement would be better replaced with a more neutral term such as “genetic manipulation” to reflect the fact that the consequences of as yet largely untried technology may be beneficial, balanced, or harmful. The aim of this paper is to highlight some of the potential negative consequences of the use of “enhancing technology” and hence to challenge whether “enhancements” are actually always enhancements. Thus it is necessary to question whether what may appear to be a new means of enhancement may not actually result in any significant change or is less effective than existing means of enhancement; may actually make things worse; or may on some measures actually make some things better, but on other measures or in other senses make things worse (either for the person being enhanced or for others).

Cosmetic surgery is a fast-growing medical practice. In 1997 surgeons in the United States performed the four most common cosmetic procedures—liposuction, breast augmentation, eyelid surgery, and facelift—443,728 times, an increase of 150% over the comparable total for 1992. Estimated total expenditures for cosmetic surgery range from $1 to $2 billion. As managed care cuts into physicians' income and autonomy, cosmetic surgery, which is not covered by health insurance, offers a financially attractive medical specialty.

The therapy-enhancement distinction occupies a central place in contemporary discussions of human genetics and has been the subject of much debate. At a recent conference on gene therapy policy, scientists predicted that within a few years researchers will develop techniques that can be used to enhance human traits. In thinking about the morality of genetic interventions, many writers have defended somatic gene therapy, and some have defended germline gene therapy, but only a handful of writers defend genetic enhancement, or even give it a fair hearing. The mere mention of genetic enhancement makes many people cringe and brings to mind the Nazi eugenics programs, Aldous Huxley's Brave New World, “The X-Files,” or the recent movie “Gattaca.” Although many people believe that gene therapy has morally legitimate medical uses, others regard genetic enhancement as morally problematic or decidedly evil.

These CQ Sources were compiled by Bette Anton.

In the Netherlands, in 1995 approximately 9700 people explicitly requested euthanasia or assisted suicide (EAS), and EAS was performed approximately 3600 times (2.7% of all deaths). The most important reasons for not performing EAS when requested by a patient were that the patient died before EAS was performed, or that the physician refused the request.

In this paper, an attempt is made to give patient autonomy added conceptual clarity. A concept of patient autonomy grounded in both negative and positive freedoms is defended. Amartya Sen's capabilities approach is used as a conceptual framework in which patient autonomy and fairness are defined compatibly. It is argued that in a socially fair healthcare system, everyone should have at least the degree of patient autonomy that affords access to those healthcare services necessary for survival and a minimally adequate level of quality of life, consistent with each person's naturally endowed health characteristics.

The Spring 1999 issue of Cambridge Quarterly (Volume 8, Number 2) adds to the growing body of academic inquiry into the goals of neonatal intensive care practices. Muraskas and colleagues thoughtfully presented the possibility of nontreatment for neonates born at or under 24 weeks gestation. Jain, Thomasma, and Ragas explained that quality of future life must not be ignored in clinical deliberation. And Hefferman and Heilig described once again the dilemmas nurses face when caring for potentially devastated neonates kept alive by technology. These authors take brave steps by publicly questioning the trend of intensive medical support for most every American-born product of conception. But many questions addressing the goals of neonatal intensive care remain, and few authors have actually tried to distill these goals.

Telemedicine encompasses medical practice, teaching, and research with real-time interactions over distances too great for unaided communication. It includes audio and video transmissions, either separately or combined, and can be done through mechanical (e.g., signal flags or lights) or electronic means (e.g., telecommunications). In many ways, telemedicine is a subset of medical informatics, itself a rapidly developing field. Prior definitions have been broader, including not only medical practice over distance, but also simple information transfer.

In brief compass, I will touch on three of the central ethical and public policy issues that divide those who are opposed to physician-assisted dying from those who are supportive of this practice. These are: (1) the moral distinction (if any) between actively hastening death and passively allowing to die; (2) how to interpret the Hippocratic tradition in medicine with respect to physician-assisted death; and (3) whether physician-assisted suicide can be effectively regulated. I shall summarize the arguments pro and con with respect to each issue, and also indicate my own position.

Post-exposure prophylaxis (PEP) in the form of combination drug therapy is now recommended for healthcare workers following occupational HIV exposure. The expansion of this form of preventive medicine to include other types of HIV transmission, notably through sexual activity, raises a number of ethical concerns.

As a way of contributing to bioethics' understanding of itself, and, more particularly, to invigorate conversation about how we can best educate future colleagues, we present here a sketch of the quarter-century-old graduate concentration in medical ethics housed in the Department of Philosophy at the University of Tennessee, Knoxville. Our hope is to incite other programs to share their histories, strategies, problems, and aspirations, so as to help the field as a whole get a clearer sense of how we are putting together our future, and of how we might best go about this important job.

Even if the term bioethics is used all over the world, its meanings are multiple and different, especially between American and European countries, depending on local cultural and medical contexts. These differences concern the issues discussed or the institutional form bioethics takes. In France, bioethics was used from the end of the 1970s and focused on research ethics and issues at the beginning of life. At the national level, a permanent commission, the “national consultative ethics committee on life sciences and health” (Comité Consultatif National d'Ethique, CCNE) was created by President François Mitterrand in 1983. Its recommendations dealt essentially with procreative medicine and biomedical research ethics.

In his professional life, Richard Posner is addressed as “Your Honor,” inasmuch as he is Chief Judge of the U.S. Court of Appeals for the Seventh Circuit. He is also a senior lecturer at the University of Chicago Law School. Finally, he is a prolific author of books and articles in scholarly journals in which he expounds at length and with copious footnotes his particular views of jurisprudence and public policy. One of his frequent intellectual adversaries, legal philosopher Ronald Dworkin, wryly described Judge Posner as “the lazy judge who writes a book before breakfast, decides several cases before noon, teaches all afternoon at the Chicago Law School, and performs brain surgery after dinner.”

Ram Dass is one of America's most renowned spiritual teachers. Born Richard Alpert, he received his Ph.D. in psychology from Stanford University and taught there and at Harvard University before going to India and receiving the name Ram Dass (“Servant of God”) from his guru. He has long been involved in many charitable service organizations, particularly those devoted to providing healthcare for underserved populations. Among his many books are Be Here Now (currently in its fortieth printing), How Can I Help, and Compassion in Action; his newest book is Still Here: Embracing Aging, Changing, and Dying (Putnam, 2000).

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 feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.