Contributors.

There is power in the choices we make in that our choices exercise and express our values. Choices, as compared with preferences, which may be spontaneous, are acts of deliberate volition—ways of casting our lot between alternatives. For this Special Section, “The Power of Choice: Autonomy, Informed Consent, and the Right to Refuse” we've chosen a frontispiece showing a balance with one pan offset by a weight in the shape of a human head. It graphically depicts that what is really in the balance in health decisions is the reflection of who we are.

This paper presents an analysis of the applicability of a principalist approach for a global, or cross-cultural, bioethics. We focus especially on the principle of individual autonomy, a core value in ethical discourse. We echo some long-standing criticisms of other anthropologists, sociologists, and many medical ethicists that the individualistic approach to autonomy is a Euro-American value and cannot be ethically applied in all settings. As a remedy, we suggest an adaptation of Kleinman's Explanatory Model approach to questions of decisionmaking. We argue that the analysis and resolution of ethical dilemmas might also benefit from forms of pedagogy that integrate anthropological and other social science perspectives, and the incorporation of ethnographic techniques in ethical practice.We appreciate the extensive efforts of Michelle Amoruso, doctoral candidate in anthropology, who assisted with the preparation of the manuscript.

For over four decades, knowledge that symptoms of some inherited diseases can be prevented or reduced via early detection and treatment in newborns has underpinned state-funded screening programs in most developed countries. Conditions for which newborn screening is now a recognized preventative public health initiative include phenylketonuria (PKU), congenital hypothyroidism (CHT), and, more recently, cystic fibrosis (CF) and sickle cell disorder (SCD). The use of tandem mass spectrometry to detect conditions such as amino-acidopathies and fatty-acid oxidation defects is also becoming increasingly prevalent.The author thanks Dr. David Aitken, Dr. Richard Ashcroft, Professor Carol Dezateux, Dr. Katrina Hargreaves, Dr. Sandy Oliver, Dr. Rosalind Skinner, Ruth Stewart, and two anonymous referees for their valuable comments in drafting this paper.

In a recent essay, George Annas, the legal columnist for The New England Journal of Medicine, observed that the resuscitation of extremely premature infants, even over parental objection, is not problematic because “once the child's medical status has been determined, the parents have the legal authority to make all subsequent decisions.” Annas himself is quick to concede that treatment in a high-technology neonatal intensive care unit (NICU) frequently takes on a life of its own. He also acknowledges that although bioethicists and courts agree that there is no ethical or legal difference between withholding or withdrawing a respirator from a patient, parents and physicians find the withdrawal much more emotionally troubling.

Some time ago, Ian Kennedy asked whether consent was

the great bulwark of “patient's rights”? Is it a necessary nuisance granted as a concession to modish thinking? Is it simply a figment of some lawyer's (or—awful word—medical ethicist's) imagination which practitioners know is meaningless in practice? Is it just part of the rhetoric of “patient power”, sent to try doctors' patience and challenge their authority?I thank Professor Matti Häyry for his extremely perceptive and helpful comments, which have added much to this paper.

The first reported case of postmortem sperm retrieval occurred in 1978, involving a man who became brain dead after a motor vehicle accident and whose wife requested removal of his sperm so that she could be artificially inseminated. Physicians performed the retrieval by surgically excising the ducts that transport sperm from the testes (the epididymis and vas deferens) and removing sperm from them. Since that time, several other methods for retrieving sperm from such patients have been reported, and at least 141 cases have been documented in which requests were made for removal of sperm from men who were dead or irreversibly unconscious. Moreover, there have been several reports of pregnancies and births resulting from assisted reproduction using sperm retrieved in such cases.

These CQ Sources were compiled by Bette Anton.

The precautionary principle is frequently referred to in various momentous decisions affecting human health and the environment. It has been invoked in contexts as diverse as chemicals regulation, regulation of genetically modified organisms, and research into life-extending therapies. Precaution is not an unknown concept in medical contexts. One author even cites the Hippocratic Oath as a parallel to the precautionary principle.“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].

In “A Paradox out of Context: Harris and Holm on the Precautionary Principle,” Sandin criticizes the earlier paper “Extending Human Lifespan and the Precautionary Paradox” wherein John Harris and I argued that the precautionary principle (PP) is incoherent. These criticisms offer me the possibility to briefly expand and clarify some of our previous arguments, and to show that the paradox of precaution is not dispelled by attention to context as Sandin maintains. Even when context is fully acknowledged, application of the PP will still lead to paradox and paralysis.“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].

On September 28, 2002, 11-year-old Jakob von Metzler, a banker's son, was abducted on the way to his parents' house in Frankfurt. A sum of one million Euro was demanded for his release. Three days after Jakob's disappearance, Magnus Gäfgen, a 32-year-old law student, collected the ransom from the arranged tram stop in Frankfurt during the night. While under observation by the police, he ordered a new Mercedes and booked a holiday abroad. Seventy-six hours after Jakob's disappearance, the police arrested Gäfgen and his 16-year-old girlfriend while simultaneously searching his flat. There they found the missing ransom, but no sign of Jakob.I would like to thank participants of the Newport, University of Wales, Research Seminar, the Amsterdam Bioethics Retreat, and the London School of Economics Political Theory Seminar for very valuable comments. Thanks also to Peter Herissone-Kelly, Armin Schmidt, and Katrin Flikschuh for comments on an earlier version.“Health and Human Rights,” edited by Doris Schroeder, welcomes contributions on all areas outlined below. Submitted papers are peer-reviewed (short discussion papers will be reviewed by at least one, full papers by at least two reviewers). To submit a paper or to discuss suitable topics, please e-mail Doris Schroeder at [email protected].

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.”

Sick to Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life, by Joanne Lynn. Berkeley: University of California Press and New York: Milbank Memorial Fund, 2004. 217 pp. $24.95.

According to Joanne Lynn, the author of Sick to Death and Not Going to Take It Anymore: Reforming Health Care for the Last Years of Life, those of us spared an accidental or traumatic death will experience one of three trajectories of health and decline toward the end of our lives. People experiencing the first trajectory will remain active and comfortable until only a few weeks prior to death, when a severely debilitating decline will occur. Those experiencing the second will live for years with relatively minor debilitations associated with chronic illness, but these will be exacerbated at intervals over time, and death will occur unexpectedly. Those experiencing the third trajectory—nearly half of all Americans—will dwindle away slowly, becoming increasingly incapacitated from frailty and/or dementia over years or even decades.Readers are invited to contact Greg S. Loeben in writing at Midwestern University, Glendale Campus, Bioethics Program, 19555 N. 59th Ave., Glendale, AZ 85308 ([email protected]) regarding books they would like to see reviewed or books they are interested in reviewing.

Ethics rounds in clinical ethics have already taken hold in multiple venues. There are “sit-down rounds,” which usually consist of a bioethicist setting a specific, prescheduled time aside for residents and/or others to bring a case or two for discussion with the bioethicist. Another kind of rounds that occurs on an ad hoc or infrequent basis is to have either a staff or outside bioethicist give hospital-wide and/or departmental “grand rounds.” Grand rounds is a traditional educational format in medicine and adding bioethics to the topics covered in grand rounds is an important means of elevating ethical awareness within a department or throughout a healthcare organization. Newer is the rounding practice of adding a bioethicist to other established rounding processes, such as case management and utilization review rounds. All of these kinds of ethics rounds are important opportunities to elevate the level of moral discourse within a healthcare setting and are becoming part and parcel of any full-service hospital bioethics program.Some of the content of this paper was delivered by DeRenzo in her talk, “Having a Bioethicist Round Weekly in the Intensive Care Unit: Benefits to Patients and Staff of Upstream Preventive Ethics versus Conflicted Downstream Consultations,” presented at the Second International Conference on Clinical Ethics Consultation, Basel, Switzerland, March 2005.

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.