Itself a topic of constant comment, the Internet's implications for healthcare remain unclear even while its boundaries incessantly expand. The WorldWide Web and allied technologies such as telephony are clearly permanent fixtures of our world. These technologies have changed our ways of life and demonstrate further dynamic capacities to do so. They speak of what we shall be, but know not.

Recently, when I was diagnosed with an incurable and terminal bone marrow disease, I was dismayed to hear my doctor tell me that there were only three treatments available, two of which were unavailable to me because of my already frail condition. Furthermore, only 15% of patients responded at all to the third treatment, which would not cure but only impede the development of the disease. My response was to verify this information by going to the World Wide Web, and to my delight I found some 20 other treatments (albeit experimental) that my doctor had not mentioned. My experience typifies one of the significant advantages to patients arising out of the development of Internet medicine, and particularly of web sites devoted to health issues: Information previously parceled out by one's doctor is now easily available to anyone with access to a computer.

In the past decade, digital technology, fiber optics, cellular phones, satellite television, home computers, and the Internet have substantially transformed business, education, and leisure practices. These technologies are becoming so integrated into our daily routines that their ubiquity often goes unnoticed. We are, nonetheless, in the midst of a telecommunications revolution, and the healthcare industry is becoming a major player. The burgeoning field of home-based telemedicine is evidence of this.

During a prostate exam, Mr. Watson, age 65, learns that his prostate appears to be abnormal. The family physician conducting the exam, Dr. Kleinman, informs Mr. Watson that he may have prostate cancer. Mr. Watson agrees to a variety of tests, including blood tests, bone scans, ultrasound scanning, and a biopsy. After learning about this possible diagnosis and these tests, Mr. Watson surfs the Web for information about prostate cancer and gathers data from many different sources, including the National Cancer Society, the National Institutes of Health, Johns Hopkins University, the Mayo Clinic, and “alternative” medicine sites. He also searches for information from medical journals using MEDLINE, visits several chat rooms on prostate cancer, and joins some e-mail lists. He arrives in Dr. Kleinman's office for a follow-up appointment with a stack of material and many questions. Dr. Kleinman is surprised, irritated, and offended. He recommends that Mr. Watson have a prostatectomy followed by radiation, but Mr. Watson does not want this operation. He would rather receive a form of radiation therapy recently approved by the FDA that he learned about through his own research. Dr. Kleinman admits that he does not know much about this new treatment, but he says that he would read up on it and consult an oncologist.

Physician-patient communication is not optimal. It suffers from an imbalance of information and power, misunderstandings and incomplete information transferred between the parties, and time constraints. Time constraints are due to patient volume, physician responsibilities, and explicit or implicit time restrictions imposed by patient insurers or physician employers. Communication is also complicated by a hesitancy to ask questions or give specific information, delays in accessing parties to transfer important information (usually, it is difficult to contact or recontact the physician), and poor communication skills. These difficulties do not universally exist among patients and clinicians—but are common enough to be discussed regularly in medical journals and in the popular media. Some of these problems are more frequently encountered in certain patient or physician subsets (e.g., certain medical specialties, practice locations, patient age groups, and cultural groups).

The advent of the Internet has had a significant impact on the formation of an information-driven, rapid-paced society. The number of Internet users reached 50 million in only five years compared to 13 years for television and 38 years for radio. Consumer expectation for access, convenience, and speed has made the cyberspace superhighway a medium for knowledge exchange and for e-commerce. The Internet offers a wide variety of health services and products to healthcare professionals as well as to the public. Online pharmaceutical sales are predicted to reach $20–25 billion over the next four years. This is a dramatic increase when compared to the $1.9 billion in 1999. At the click of the mouse, medications can be ordered and delivered conveniently to your door. Yet, consumer discomfort with the security of information provided via the Internet is growing, and recent incidents involving disclosure of healthcare information serve to heighten this concern.

As new information and communication technologies (ICTs) are being applied in healthcare, the most obvious and seemingly the only questions to ask would be if they are clinically effective and if they deliver positive outcomes for patients. In the medical tradition, outcomes are usually assessed in randomized controlled trials (RCTs) through clear and well-understood criteria of safety and clinical effectiveness. These seem to be suitable and fully adequate for evaluating drugs. (Although, of course, drug prescribing is more complex and includes, among others, economic considerations.) But are these criteria useful or sufficient when applied to the evaluation of ICTs in healthcare? In this paper we argue that they are not. ICT-related applications are complex and diverse and require a different and more encompassing approach to evaluation.

These CQ Sources were compiled by Judith Schaeffer Young.

Recent figures show that 151.7 million nonelderly Americans who had private insurance received that insurance from their employers (out of 167.5 million with private insurance). Employers who contract with health plans on behalf of their employees influence the health of their employees and, in turn, the nature and quality of the healthcare system in the United States. Despite the magnitude of their influence, they have been relatively free from both government and ethical guidance with respect to the specific substantive benefits they offer their employees. Employers have enormous discretion with respect to what substantive benefits they include in employer health plans because they are governed by the Employment Retirement Security Act (ERISA). But the decisions that employers make when they choose benefits for their employees are just as much rationing decisions in need of bioethical analysis as are the rationing decisions that are made at the bedside by patients, physicians, and their families. Moreover, even strong discretion, of the kind employers have, is subject to ethical standards.

Medical ethics has traditionally been governed by two guiding, but sometimes conflicting, principles—autonomy and benevolence. These principles provide the rationale for the two most commonly used standards for medical decisionmaking—the Substituted Judgment Standard shows our concern for autonomy, whereas the Best Interest Standard shows our commitment to benevolence. Both standards are vulnerable to criticisms. Further, the principles can seem to offer conflicting prescriptions for action. The criticisms and conflict figure prominently in discussion of advance directive decisionmaking and Alzheimer's disease. After laying out each of the current standards and its problems, with Alzheimer's issues as my central concern, I offer a new standard that avoids the problems while honoring our concerns for both autonomy and benevolence.

Carson Strong argues, in “Cloning and Infertility,” that if cloning of humans by somatic cell nuclear transfer were to become a safe procedure, then infertile couples should have access to it as a last resort. He lists six reasons such couples might desire genetically related children. Of these, two are relevant to justifying their access to cloning—namely, that they want to jointly participate in the creation of a person, and that having a genetically related child would constitute an affirmation of their mutual love. According to Strong, these reasons justify at least some infertile couples' freedom to clone themselves. He wants to prevent the widespread use of cloning technology by making it available to only infertile couples and only as a last resort. One way to enforce this restriction, he suggests, is to penalize physicians who carry out disallowed clonings. After all, fertile couples and many infertile couples can satisfy their need to have genetically related children in other ways.

The idea of cloning adult human beings often gives rise to objections involving mad dictators producing copies of themselves, or deranged billionaires who want to live forever. But what about situations where we can more readily understand and accept the reasons for creating a clone? Consider, for instance, the case of parents who have simultaneously lost their newly born child and found out that they cannot have any more children of their own by other known methods. Would it be wrong of them to want a new child, a genetic copy of the lost infant, if the child were healthy and could only be produced by cloning the infant who no longer lives? And would it be wrong of genetic engineers to assist them?

In an earlier edition of Cambridge Quarterly, in the “Networking News” section (CQ Vol 9, No 4), Larry Gottlieb sought advice on ethics committee assembly and policy implementation for a community mental health center. One concern mentioned is that staff members frequently encounter ethical issues—specifically, questions about competency, informed consent, and treatment refusal—regarding the care of clients whose decisionmaking abilities are impaired by chronic mental illness and/or substance abuse. My response offers a suggestion for policy development and implementation, which may be integrated into guiding staff members of community mental health centers toward a model of care planning that is centered on clients' experiences of their treatments and on relationship-building among clients, community members, and mental health professionals.

This is a book for reflective laypersons and health professionals who wish to better understand what the problem of healthcare rationing is all about. Ubel says clearly in the Introduction that it is unlikely that professional economists or philosophers are going to be very satisfied with this effort. For him it is more important “to draw people into the debates who might otherwise stand on the sidelines” (p. xix). This is a reasonable aim made achievable by Ubel's clear and engaging writing style. Probably the people who most need to be drawn into these debates are physicians and medical students, this because one of Ubel's central claims is that the need for “bedside rationing” is both inescapable and sometimes morally permissible. What he wants to reject is the view of many physicians that bedside rationing by physicians is never morally permissible and that healthcare costs can be contained without having to resort to rationing of any kind. Before I explore this point any further, it is necessary to summarize the larger argument of this book.

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.