Contributors.

Resolving competing claims in bioethics dilemmas is never easy. On the assumption that vigorous debate is the most effective ground for reaching reasonable decisions, this annual Open Forum issue is devoted to timely controversies in a number of areas: governmental regulations and reproductive rights, determining fair compensation for gamete donation, balancing responsibilities in the doctor–patient relationship, violating rules to benefit patients, persistent problems in end-of-life care, and professional standards of conduct and bioethics consultation, as well as insights into the shifting landscape of oversight in clinical research and directions for the future.

Sex selection technologies have become increasingly prevalent and accessible. We can find them advertised widely across the Internet and discussed in the popular media—an entry for “sex selection services” on Google generated 859,000 sites in April 2004. The available services fall into three main types: (1) preconception sperm sorting followed either by intrauterine insemination of selected sperm (IUI) or by in vitro fertilization (IVF); (2) preimplantation genetic diagnosis (PGD), by which embryos created by IVF are tested and only those of the desired sex are transferred to the woman's uterus; and (3) prenatal testing of fetuses through ultrasound or chromosomal analysis, followed by selective abortion of fetuses detected to be of the undesired sex.Victoria Seavilleklein's research was supported by the following grants: Izaak Walton Killam Memorial Scholarship, Social Sciences and Humanities Council Doctoral Fellowship, and CIHR Training Program in Ethics of Health Research and Policy. Earlier versions of this paper were read to the Philosophy Department at Dalhousie University and to the participants of the CIHR Training Program in Ethics of Health Research and Policy. We are grateful for the helpful feedback we received on both occasions. We also appreciate the comments made by Micah Hester and two anonymous reviewers.

In August 2005, the United Kingdom's Human Fertilisation & Embryology Authority (HFEA) launched a public consultation, seeking views on the use of preimplantation genetic diagnosis (PGD) for the detection of cancer genes. The issue was considered by the Authority to be a possible source of particular controversy because it involved extending the range of conditions for which PGD can be licensed in a potentially important way: As well as testing for genes that would definitely cause disease traits, such as cystic fibrosis and muscular dystrophy, this would involve genes that would only possibly manifest themselves phenotypically. In other words, there is a very real chance that such an application of PGD would result in the destruction of perfectly healthy embryos.

In Canada, laws and policies consistently reject the commodification of human organs and tissues, and Canadian practice is consistent with international standards in this regard. Until the Assisted Human Reproduction (AHR) Act of 2004, gamete donation in Canada was an exception: Canadians could pay and be paid open market rates for gametes (sperm and egg) for use in in vitro fertilization (IVF). As sections of the AHR Act forbidding payment for gametes (Section 6) and permitting only reimbursement of receipted expenses (Section 12) gradually came into effect in 2005, Canada did away with this anomaly. Medical practice and legal prohibitions in assisted human reproduction are now consistent with other areas of medicine where tissues and organs are taken from one person to benefit others: Altruistic donation, rather than selling and buying, will be the norm.The authors thank Françoise Baylis, Jocelyn Downie, and members of the Novel Tech Ethics Research Team at Dalhousie University for their assistance with and feedback on earlier drafts of this paper. We also thank Tim Krahn for assistance in formatting this paper.

In The Healer's Power, Howard Brody placed the concept of power at the heart of medicine's moral discourse. Struck by the absence of “power” in the prevailing vocabulary of medical ethics, yet aware of peripheral allusions to power in the writings of some medical ethicists, he intuited the importance of power from the silence surrounding it. He formulated the problem of the healer's power and its responsible use as “the central ethical problem in medicine.” Through the prism of power he refracted a wide range of ethical problems, from informed consent to truth-telling, from confidentiality to futility, from the physician's fantasies to the physician's virtues. At times this prism shed new light on old problems, enabling us to see from an unexpected angle the elements of which the problem was composed. At other times it exposed issues of ethical significance that had been neglected in the bioethics literature.

We have a philosopher friend who was quite ill and required surgery, but she was not ill enough to be admitted to hospital under the “life, limb, and organ preservation” guidelines that control surgical admissions. Her surgeon told her to go to emergency and gave her a list of symptoms to tell the physicians there. Those, he said, would get her a bed, and he would then come and perform the necessary surgery. And that is how our friend (who, ironically, taught ethics out of a textbook called Virtue and Vice in Everyday Life) got her surgery.We are grateful to Don Brown for extremely helpful comments and conversation on the philosophical matters of our paper and to Dan McDonald for stimulating discussion on the culture of healthcare providers.

In a recent special supplement to the Hastings Center Report entitled “Improving End-of-Life Care—Why Has It Been So Difficult?” Robert Burt wrote the following in an essay ominously entitled “The End of Autonomy”:

(1) No one should be socially authorized to engage in conduct that directly, purposefully, and unambiguously inflicts death, whether on another person or on oneself.

(2) Decisions that indirectly lead to death should be acted upon only after a consensus is reached among many people. No single individual should be socially authorized to exercise exclusive control over decisions that might lead to death, whether that individual is the dying person, the attending physician, or a family member acting as health care proxy.

Although bioethics consultation has always drawn the ire of critics, its extension into areas such as paid consultation with private industry has raised new concerns. Critics of consulting relationships with industry question the sincerity of for-profit corporations who seek ethical advice, alleging that a desire for improved public relations is a primary motivation of these corporations. They also question whether compensation for ethical advice creates insuperable conflicts of interest that bias the work produced. The decision of two influential professional societies to establish a joint task force to examine bioethics consultation with industry reflects the seriousness of these and other concerns about this practice. The report of this task force, although controversial, has stimulated broad discussion about the ethical commitments of bioethicists and highlighted the need for clearer professional standards of conduct.The authors thank John Walsh, President and CEO of the Alpha-1 Foundation, for his thoughtful comments on an earlier draft. The contents are solely the responsibility of the authors.

The understanding of appropriate ethical protections for participants of biomedical research has not been static. It has evolved over time, with the evolution of biomedical research as well as social values. Since World War II, there have been four major paradigms of research and research oversight operative in the United States (Table 1). These paradigms incorporate different values and provide different approaches to research oversight and the protection of research participants.

On September 30–October 2, 2005, a group of individuals drawn from civil society organizations, governments, international agencies, and academic institutions came together in Montréal, Québec, Canada, for an international workshop entitled “Human Rights and Access to Essential Medicines: The Way Forward.” At the conclusion of the workshop, we drafted the “Montréal Statement on the Human Right to Essential Medicines.” This “Statement” is reprinted at the end of this comment, which offers some background on the problem addressed at the workshop.Many thanks to Patricia Illingworth, Mira Johri, Doris Schroeder, and Michael Selgelid for their helpful critical comments.

Commerce can be defined as an exchange of goods and services using money as the medium for the exchange. People engage in commerce to make money. It has the potential to remain morally neutral. But when the emphasis on making money becomes the goal or value that directs the process, rather than the value of the endeavor itself, things can become distorted. Making money as a primary goal is understood and recognized for the venture capitalist, but it is less attractive when identified as the goal of medical care. Society, or at least medical practitioners, hold their profession to duties beyond the pursuit of personal gain. Medical duties toward beneficence, justice, and respect for autonomy are deemed far too important to be distracted by the desire for financial reward. Any conduct that seems to place the physician's self-interest above that of the patient's reduces the respect and moral authority claimed by the profession.

A Field Guide to Good Decisions: Values in Action, by Mark D. Bennett and Joan McIver Gibson. New York: Praeger, 2006. 216 pp. $39.95.

Decisions are something we all face. Decisions change our lives. As parents, as community members, as professionals, we find ourselves daily in complex situations that require good decisionmaking. Most decisions impact not only the decision maker, but also a network of others whose lives they affect. For healthcare providers and clinical bioethicists, decisions lie at the heart of daily practice and are particularly challenging as they touch the lives of individuals who are often vulnerable and in need of guidance and clarity.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.

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.