Contributors.

One of bioethics' most singular strengths is fostering debates on human conundrums, not those relegated to dusty archives, but those forming the moving, developing present. Bioethics is future looking, not quite crystal ball gazing but struggling to ascertain what the consequences of our choices and actions will be. And, although the methodology is still to be fully articulated (see CQ Vol. 16, No. 4, Fall 2007 “An Ethical Competition: The Method in Bioethics Research”) a challenge is to navigate intellectual errors such as a Manichaean oversimplification of seeing things in black and white or falling prey to moral relativism where we are blind to blurred distinctions.

The recent success in generating live offspring from embryonic stem cell (ESC) –derived gametes in mice sparked visions of growing tailor-made sperm for men faced with infertility. However, although this development will almost certainly lead to new insights into the processes underlying spermatogenesis and thus in the possible causes of male infertility, it is less certain if deriving sperm from ES cells, which are in turn derived from a sterile man, can make someone a genetic parent. As the gap between newly envisioned reproductive technologies and natural reproduction widens, the question thus needs to be asked if these possible therapies still lead to genetic parenthood.

The number of legal and nonlegal ethical regulations in the biomedical field has increased tremendously, leaving present-day practitioners and researchers in a virtual crossfire of legislations and guidelines. Judging by the production and by the way these regulations are motivated and presented, they are held to be of great importance to ethical practice. This view is shared by many commentators. For instance, Commons and Baldwin write that, within the nursing profession, patient care can be performed unethically or ethically depending on the professional standards the nurses have set for themselves. They also hold that such standards are set when nurses become aware of the ethical codes available. As nurses are often not familiar with the codes, they do not all conform to them. Commons and Baldwin argue that nurses' ability to deal with ethical dilemmas is effectively secured with education on guidelines, creating a “barrier” between personal and professional values (p. 5).

There are deep structural conflicts between the mission of healthcare as cooperative care to the sick and injured and that of healthcare as a business whose mission is maximizing profits. These conflicts come to the fore in the medical pharmaceutical industry. I first set these out in a context that addresses the mission of healthcare, then examine the relative roles of competitive and cooperative systems of distributive justice, and then argue for the creation of nonprofit pharmaceutical companies and the transformation of many for-profit companies into companies subject to public oversight and profit curbs. The recommendations are aspirational for the United States (because it does not yet offer universal health coverage) but it is meant to be action guiding for those industrialized countries wealthy enough to provide universal health coverage.

Many different factors influence our health prospects. The food we consume, the lifestyle we live (e.g., sedentary or active), our economic prospects, our love prospects, our gender, our age, and our education all influence our expected lifetime acquisition of what John Rawls calls the “natural primary goods” (e.g., health, vigor, imagination, and intelligence). Our well-being is also influenced by the natural endowments we inherit from our parents. All people have two copies of most genes, one from their mother and one from their father. Genes are the fundamental physical and functional unit of heredity; they “specify the proteins that form the units of which homoeostatic devices are composed.”Earlier versions of this paper were presented to the Department of Philosophy at the University of Waterloo, the James Martin Advanced Research Seminar at Oxford University, and the Department of Politics at Manchester University. I am grateful for the helpful feedback that I received on those occasions.

Through a number of studies recently published in the psychology literature, T.D. Wilson, D.T. Gilbert, and others have demonstrated that our judgments about what our future mental states will be are contaminated by various distortions. Their studies distinguish a variety of different distortions, but they refer to them all with the generic term “affective forecasting.” The findings of their studies on normal volunteers are remarkably robust and, therefore, demonstrate that we are all vulnerable to the distortions of affective forecasting.We are grateful for the questions and useful comments we received from our audience when material from this paper was originally presented. The insightful remarks helped us to appreciate what we needed to explain further and to see how our ideas applied to additional domains of medicine: Rhodes R. Affective forecasting and the implications for medical practice. Presented at Medicine Grand Rounds, North General Hospital, New York, Apr 19, 2006. Rhodes R, Strain JJ. Affective forecasting and its implications for medical ethics. Presented at Oxford-Mount Sinai Consortium on Bioethics, St. Thomas's Hospital, King's College London, Apr 24, 2006. Rhodes R. Affective forecasting and its implications for medical ethics near the end of life. Presented at Responding to End-of-Life Decisions: Perspectives from Medicine, Law, and Ethics, International Academy of Law and Mental Health, University of Montreal, May 5, 2006 and at the David Thomasma International Bioethics Retreat, Pellegrue, France, Jun 15, 2006.

Informed consent has passed through three stages. The first paternalistic stage lasted for many centuries: The doctor's diagnosis and healing arts were kept secret, and informing patients was regarded as professionally and ethically wrong. Second came the legal stage, when the right of patients to make informed decisions concerning their own treatment was imposed by the courts and reluctantly tolerated by medical professionals. The third informed consent stage emerged more recently: the general therapy stage. The therapeutic benefits of informed consent have been well established, and informed consent is widely recognized as an important element in sound medical practice. When patients are effectively informed and can exert knowledgeable control over their own treatment decisions and therapy processes, that enhances recovery, strengthens the immune system, promotes better pain tolerance, prevents depression, and encourages patient cooperation and fortitude in treatment, rehabilitation, and preventative procedures. As the medical community has absorbed greater knowledge of this research, informed consent has been recognized as both ethically essential and therapeutically sound: the hallmark of the current general therapy stage of informed consent.

The current main source of transplantable organs is from heart-beating donors. These are patients who have suffered a catastrophic brain injury, been ventilated, declared dead by neurological criteria, and had their vital functions maintained mechanically until the point of transplantation. But the demand for organs far outstrips the supply, and these patients are not the only potential donors. The idea behind non-heart-beating transplantation is to expand the donor pool by including in it patients who are in hopeless conditions but who are not dying because of brain injury and hence will not suffer the neurological death necessary to become heart-beating donors. As long as we continue to hold the so-called dead donor rule, according to which dying donors cannot have their organs taken before they are dead, this requires that death be able to be declared by alternative criteria, specifically by cardiopulmonary criteria. The challenge is to find such criteria that will identify a state that the public will readily recognize as death and that will facilitate non-heart-beating transplantation.I am grateful to Don Brown for encouragement, advice, and stimulating discussion and to Michael Feld for reminding me just how resilient a theory utilitarianism is.

In a provocative 1974 article entitled “Harvesting the Dead,” Willard Gaylin explored potential uses of “neomorts,” or what are currently referred to as “heart-beating cadavers”—that is, humans determined to be dead by neurological criteria and whose cardiopulmonary function is medically maintained by ventilators, vasopressors, and so forth. Medical research was one of the potential uses Gaylin identified. He pointed out that tests of drugs and medical procedures that would have unacceptable health risks if performed on living human subjects could be performed on neomorts without any health risks. According to Gaylin, the potential benefits of such research could be enormous, including not subjecting patients to ineffective or harmful medical procedures and eliminating delays in providing effective therapies to dying patients.

“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].I thank Professor Solomon Benatar (Center for Bioethics, University of Cape Town), Dr. Walter Robinson (Department of Social Medicine, Division of Ethics, Harvard Medical School, Boston), Dr. Carolyn Hayes (Brigham and Women's Hospital, Harvard Medical School, Boston), and Professor Patricia Illingworth (Department of Philosophy, Northeastern University, Boston) for reading the manuscript and for their valuable critical comments.

“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].

Many transplant programs are willing to provide a contrived medical excuse for potential organ donors who wish to say no but feel unable to do so publicly. The availability of these excuses is thought to facilitate freedom of choice—a necessary component of informed consent—by allowing donor candidates to bow out gracefully. In a recent editorial, Simmerling et al. discuss possible harms raised by this practice and note that there is no empirical evidence to support it. Given the importance of this issue for transplant centers that accept living donors, a review of the authors' concerns is in order. After careful consideration, I conclude that although some of their points are valid, much of their analysis is flawed.

In his response to our treatment of the medical excuse, Spital claims that we offer a flawed analysis of the practice of offering excuses to potential living organ donors. Spital's criticisms help sharpen our position and more clearly lay out the issues. In what follows, we address each of his concerns and replies and clarify our earlier analysis.The authors acknowledge Matthew Devitt for his contributions to this reply.

Bioethics and Armed Conflict: Moral Dilemmas of Medicine and War, by Michael Gross. Cambridge, Mass.: MIT Press, 2006. 384 pp. $26.00.

To the uninitiated, the phrase “military medical ethics” probably signals triage (methods for sorting casualties) and the neutrality of medical personnel in battle zones. There is, however, a lot more to it than that, as this excellent book by Michael L. Gross shows. Gross is a professor in the Department of Political Science at the University of Haifa and has published extensively in bioethics and the ethics of war.

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.