In the language of secular bioethics, autonomy is always accorded first place in the hierarchy of values that has come to be referred to as the “Georgetown mantra” A dictionary definition of mantra is “a verbal spell, ritualistic incantation, or mystic formula used devotionally,” and the value placed upon autonomy is largely of this nature: uncritical and uncriticised. That there should be and are limits to autonomy is obvious, but these boundaries are undefined, little discussed, and mostly unexplored. To use another metaphor, our emphasis on autonomy is an index of how far the pendulum has swung in an understandable and partly justifiable reaction from, earlier paternalism; has this swing approached its proper limit, and should we be seeking a less extreme and more balanced assessment of autonomy as a bioethical value?

Let us look at autonomy in a new way. Autonomy has a richly deserved place of honor in bioethlcs. It has led the set of principles that formed the basis of the discipline since the beginning. It is the leading principle In what is now regularly called “the Georgetown Mantra,” a phrase suggested by one of the first philosophers ever to be hired In a medical school, K. Danner Clouser. The phrase applies to the principled approach of autonomy, beneficence, nonmaleficence, and justice. This kind of bioethics was developed by scholars like Beauchamp and Childress, Veatch, and Engelhardt, during their association with Georgetown University.

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”

Over the past several decades, conflicts between physicians and patients or patient surrogates concerning continued treatment or the withdrawal of treatment have received public and legal attention. In more recent years, there have been several prominent Instances in which physicians have refused to provide treatment requested by patient surrogates because such treatment was judged to be futile. The claim that a treatment is futile has far reaching consequences. It serves to justify the withholding or withdrawal of treatment and thus, perhaps, to also justify the rationing of healthcare. It limits the autonomy of the patient or patient surrogate by reducing their participation in the decision making process.

The principled approach to theory building that has been a conspicuous mark of bioethical theory for the past generation has in recent years fallen under considerable critical scrutiny. Although some critics have confined themselves to reordering the dominant principles, others have rejected a principled approach entirely and turned to alternative paradigms. Prominent among critics are antiprin-ciplists, who want to jettison the principle-based approach altogether and adopt a casuistic (case-specific) model, and communitarians, who favor an eclectic model combining features of both the casuistic model and a modified principled approach. Particularly conspicuous in virtually all such critiques is their challenge to the preeminence of the principle of autonomy. Critical barbs have been aimed not only at theories favoring a hierarchical ordering of moral principles that give first place to autonomy, but also at those that include autonomy among a set of ostensibly coequal principles. Though these critics have performed a valued function by displacing bioethical principles from their Olympian perch beyond actual decision-making contexts, some version of the principle of autonomy may, nonetheless, be well worth defending but for very different reasons than those put forward by its supporters.

In this paper, I want to try to put what has been termed the “care ethics” into a different perspective. While I will discuss primarily the use of that ethic or that term as it applies to the healthcare setting in general and to the deliberation of consultants or the function of committees more specifically, what I have to say is meant to be applicable to the problem of using a notion like “caring” as a fundamental precept in ethical decision making. I will set out to examine the relationship between theoretical ethics, justice-based reasoning, and care-based reasoning and conclude by suggesting not only that all are part of a defensible solution when adjudicating individual cases, but that these three are linked and can, in fact, be mutually corrective. I will claim that using what has been called “the care ethic” alone is grossly insufficient for solving individual problems and that the term can (especially when used without a disciplined framework) be extremely dangerous. I will readily admit that while blindly using an approach based solely on theoretically derived principles is perhaps somewhat less dangerous, it is bound to be sterile, unsatisfying, and perhaps even cruel in individual situations. Care ethics, as I understand the concept, is basically a non- or truly an anti-intellectual kind of ethic in that it tries not only to value feeling over thought in deliberating problems of ethics, but indeed, would almost entirely substitute feeling for thought. Feeling when used to underwrite undisciplined and intuitive action without theory has no head and, therefore, no plan and no direction; theory eventuating in sterile rules and eventually resulting in action heedlessly based on such rules lacks humanity and heart. Neither one nor the other is complete in itself. There is no reason why we necessarily should be limited to choosing between these two extremes.

No healthcare issue has generated as much ethical debate on the relationship between the individual and society as HIV Infection. In this debate, an appeal is most often made to such principles as autonomy and confidentiality to protect individuals who are HIV positive or who have AIDS from an invasion of privacy thought to be justified by society's need for information. In the first years, this emphasis on the protection of the individual was essential. Even today, there are risks in disclosing one's HIV status. However, as more and more persons become Infected, live longer, and move within the healthcare industry for non-HIV related care, as both patients and healthcare workers, the terms of the debate need to be redefined.

Crucial problems exist in understanding Japanese traditional customs with regard to autonomous decision making by patients in Japan. These problems are difficult to comprehend because they seem, by western standards, to defy logic. Questions that baffle those outside the Japanese tradition, include: Why do many Japanese patients hesitate to make medical treatment and care decisions for themselves without consulting family, close friends, or someone viewed as being in a superior position? Why do many Japanese physicians fail to disclose the truth directly to the patient, instead customarily conveying information to family members, despite the doctors' awareness of their legal obligation to protect the patient's privacy? Why do many Japanese physicians continue to question whether patients should be told the truth at all? What perpetuates Japan's widespread, but often unnoticed, neglect of the individual's right to self-determination in healthcare decision making?

The healthcare system in the new Russia is in an agonizing flux of political, economic, and ideological turmoil. The individual in this system, comfortable with the long-established policies of the former Soviet system, is now confronted with instability, rapid change, and an uncertain future.

Few ethics committees were in place when the New Jersey Supreme Court announced its ruling on the Quinlan case in 1976. Today, the vast majority of hospitals have formed ethics committees and their use in nursing homes and other healthcare facilities is growing. Given the increasing commitment to the use of ethics committees and their increasing influence on healthcare decision making, the careful evaluation of committee performance should be a high priority. Yet to date ethics committees appear to have undergone relatively little scrutiny. While professional articles on ethics committees do appear and at least one journal (CQ) sets aside a regular section for the discussion of “Ethics Committees at Work” articles to date have primarily been limited to essays, philosophical inquiries, reports, case studies, and, occasionally, surveys. The use of more structured research methodologies has been lacking. As a result, it is not yet clear, for example, what characteristics describe the best functioning ethics committee. Indeed, what constitutes best functioning lacks careful definition as well. Committee impact on medical decision making and patient outcomes, while discussed, has not been systematically measured and analyzed.

The problem of physician-assisted death (PAD), assisted suicide and active euthanasia, has been debated predominantly in the ethically familiar vocabulary of rights, duties, and consequences. Patient autonomy and the right to die with dignity vie with the duty of physicians to heal, but not to kill, and the specter of “the slippery slope” from voluntary euthanasia as a last resort for patients suffering from terminal illness to PAD on demand and mercy killing of “hopeless” incompetent patients. Another dimension of the debate over PAD concerns the evaluative question of what constitutes a good death. At stake are Issues of character and virtue in the face of death and dying and their Implications for legitimizing the practice of PAD. Critics of PAD argue that “natural” death in the context of comfort care, as provided by hospice programs, is the good death. In contrast, PAD amounts to an easy way out, an evasion of the ultimate human challenge and task of dying. Because hospice care is clearly preferable to PAD, the former should be encouraged and the latter remain prohibited.

The question of whether Do Not Resuscitate (DNR) orders should be sustained in the operating room was brought to our ethics committee by a pulmonologist and involved one of his patients for whom he serves as a primary care physician. His patient, a woman with chronic obstructive lung disease (COPD) was electing, for comfort purposes, to have a hip pinning following a fracture. At the same time, she wished to have a DNR order covering her entire hospital stay. The anesthesiologist described her direction as “improper” and refused to participate in surgical procedures if DNR orders extended to the operating room. The patient refused to rescind the order during surgery. As a result, the surgery was canceled to the great chagrin of the patient.

As ethics committees become involved in discussing the propriety of euthanasia and assisted suicide, and as healthcare providers begin to seriously consider whether they might ever have a role in hastening the dying process, many have looked to The Netherlands as the only real example of a nation that permits (or, at least, excuses) euthanasia in limited circumstances. Unfortunately, partisans in the Dutch debate have often written about the Dutch experience as advocates rather than as neutral observers. Some have argued that euthanasia, which, they claim, is rarely actually practiced, is universally accepted within The Netherlands; others have reported that the Dutch social fabric has been rended irreparably by what they claim, is a practice far more widespread than is generally understood. The debate in the United States has also been colored by a misunderstanding of the legal regulation of euthanasia in The Netherlands.