Contributors.

Bioethics is increasingly a globe-spanning endeavor. Since the inauguration of our annual “Special Section: International Voices,” there has been inexorable progress toward closing the informational “tectonic gaps” that separate bioethicists and prevent a truly international exchange of ideas and practices. This gap narrows each year as new reporters come on board to share the inner life of bioethics in their countries and as our continuing contributors keep us up to date on subsequent developments.

In early 2005, at the same Academy Awards ceremony in which Clint Eastwood's Million-Dollar Baby was named best film, a Spanish movie called Mar adentro (The Sea Inside) by the young director Alejandro Amenábar received the Oscar for best foreign film of 2004. Though worlds apart esthetically, both films explore the themes of paraplegia and lives deemed not worth living, a cinematic coincidence that speaks of the enduring importance of issues such as these.The authors thank The Hastings Center for beginning our collaboration, Diego Gracia for having fostered it, and the Weill Cornell Medical College in New York and Doha for sustaining it.

Since the early 20th century, bioethics in South Africa has moved through several stages, responding to the same forces and developments as elsewhere, for example in the United Kingdom and United States. In addition, some unique developments in South Africa, for example the death of Steve Biko (the Black Consciousness leader), the HIV/AIDS pandemic, and a peaceful transition to democracy with increased focus on human rights have given bioethics in South Africa its own dimension. Bioethics in South Africa reflects the general concerns of the field elsewhere, but it also stands at the intersection of the concerns of both developed and developing worlds. Thus, issues such as resource allocation, HIV/AIDS, and medical research take on an urgency and character that reflect South Africa's particular historical, geographical, and social conditions.

Stakeholder consultation is part of the democratic process, embraces respect for persons, and is necessary for upholding the principle of justice. People are more likely to uphold standards they have participated in setting, so stakeholder consultation encourages adherence to societal and institutional standards as these evolve. Stakeholder consultation is also responsive to the call to “resocialize” ethics by contextualizing dilemmas and involving the destitute in choices about their healthcare. In resource-poor settings, such consultation promotes local “ownership” of, and leadership within, development programs, which enhances effectiveness and sustainability. Stakeholder consultation is, therefore, a form of capacity building. To succeed, it must be responsive to regional, national, and individual constraints, including socioeconomic, cultural, and political ones. Several such constraints impact on the demand for, and availability of, palliative healthcare in the Caribbean.David Joranson and Jody Garthwaite at the Pain and Policy Studies Group kindly provided morphine consumption data and Figure 1. Bert Braithwaite and Trevor Noel provided useful comments on the manuscript.

Advance directives enable individuals to project their healthcare preferences into a period of anticipated incapacity. With advance directives, individuals can designate whom they would like to have make healthcare decisions for them (proxy directives), or give their healthcare provider advice on what to do (instructional directives), or both. Canada has an unusually wide variety of legislative approaches to advance directives. In what follows we describe and evaluate these, with the aim of pointing the way toward the ideally best legislation and policies on such directives.

From 2002 to 2003, the United Kingdom's Human Fertilisation and Embryology Authority (HFEA) carried out a review of the available methods of sex selection, the central aims of which were, in the words of the subsequent report:I gratefully acknowledge the assistance offered by Dr. Peter Mills of the HFEA in helping me to understand the sometimes complex regulatory framework surrounding the practice of sex selection in the United Kingdom.

The past five years have brought important and rapid developments for the scientific bioethics community in Germany. Bioethics was institutionalized as an obligatory part of the undergraduate and graduate schedule in medical schools. Clinical ethics committees are spreading all over the country, and research on ethical issues of biomedicine is sponsored on a large scale, for example, by the German Ministry of Education and Research (BMBF). Two main institutions, dealing with bioethics and biopolicies, were established and have worked on central bioethical issues, mostly ending up with diametrically opposed recommendations: the Enquetekommission Recht und Ethik der Modernen Medizin (Parliamentary Commission on Law and Ethics of Modern Medicine), composed of parliamentarians of all political parties and appointed external experts, and the National Ethics Council, composed of experts, politicians, several stakeholders, and representatives of the Catholic and Protestant churches.

Concepts that refer to trends like globalization and medicalization have, of late, become a hallmark of public debates. The logic of such concepts is that the same word can refer both to good and bad developments, partly depending on the chosen viewpoint. Hardly anyone opposes the global enforcement of human rights, but the global liberation of trade is sometimes viewed with suspicion. In a similar vein, advances in medicine are seldom seen as a bad thing, but medical solutions to social issues can be seen as problematic.This research was funded by Ethical and Social Aspects of Bioinformatics (ESABI), a project coordinated by Professor Matti Häyry and financed between 2004 and 2007 by the Academy of Finland (SA 105139). The authors also acknowledge the stimulus and support of the European project on delimiting the research concept and the research activities (EU-RECA) sponsored by the European Commission, DG-Research, as part of the Science and Society research program—6th Framework in the preparation of this paper.

Sweden is probably one of the most secularized nations in the world. Therefore religious arguments tend to play a smaller role in the public bioethical debate than in most other countries. Issues such as abortion, stem-cell research, and therapeutic cloning have been far less controversial in Sweden than elsewhere. Instead, other issues have dominated recent bioethical debates in Sweden, in particular those concerning privacy and the control over biological information about individuals.

Scientific misconduct can jeopardize scientific progress and destroy the credibility and reputation of academic institutions and their faculty and students; ultimately it can compromise scientific integrity and result in a loss of confidence for the entire scientific community. Only recently in Japan has scientific misconduct become a central public topic. This increased attention to the topic, in turn, has highlighted a paucity of ethical standards within the Japanese scientific community and a lack of an apt process for conflict resolution. In this brief report, we first provide an overview of several high-profile cases of scientific misconduct recently uncovered in Japan. Next we consider how a recent rise in competition within the academic and scientific communities is possibly related to a concurrent increase in reported cases of scientific misconduct. Last, after discussing what actions have already been taken, we recommend further actions needed to deal with the problem of scientific misconduct in Japan.

These CQ Sources were compiled by Bette Anton.

Rationing and patient selection is inevitable in medical care, but in its most extreme form—when doctors and nurses decide about life and death—it is an almost unbearable burden for the profession. Eric Goemare, the Head of the South African Mission of Médicins Sans Frontières (MSF) and his staff faced three equally difficult selection issues when rolling out antiretroviral treatment to HIV/AIDS patients in South Africa. Initially, the treatment had to be rationed due to lack of financial resources. Today, rationing is mostly due to lack of human resources. But at the same time, patients are being deselected because of nonadherence to the treatment regime to avoid the creation of multi-drug-resistant strains of the HIV virus.

In 1999, Médecins Sans Frontières (MSF) set out to explore and demonstrate the feasibility of preventing and treating HIV/AIDS in a so-called resource-poor, economically and socially disadvantaged setting. The first MSF mission to incorporate antiretroviral (ARV) treatment into its HIV-AIDS-oriented medical program was undertaken in Bangkok. The second project was launched in Khayelitsha where MSF has been providing ARV treatment for persons with HIV/AIDS since May 2001. Khayelitsha is an enclave of some 500,000 inhabitants, most of whom live in corrugated-iron shacks, without running water or electricity. Unemployment is extremely high; crime and violence (including robbery, domestic violence, rape, and murder) are rampant. The general prevalence of HIV/AIDS is 26%, measured among pregnant women. The tuberculosis incidence rate is one of the world's highest for open-space sites (1,380/100,000). Unsurprisingly, TB/HIV coinfection is very high too: 63% of those with TB are also infected with HIV. Renée C. Fox made two field research trips to the Khayelitsha HIV/AIDS project in connection with her ongoing sociological study of Médecins Sans Frontières, which centers on moral dilemmas associated with medical humanitarian action. Her research has been supported by grants from The Acadia Institute, the Honorable Walter H. Annenberg Chair in the Social Sciences Research Fund at the University of Pennsylvania, and the Andrew W. Mellon Foundation in the United States, and from the Nuffield Foundation in the United Kingdom. We express our gratitude to Nicholas A. Christakis, M.D., the late Willy De Craemer, Ph.D., Robert L. Klitzman, M.D., and especially to Judith P. Swazey, Ph.D., for their astutely critical and encouragingly helpful comments on earlier drafts of this article. Disclaimer: Patients' consent and permission to publish are not required, because no research was conducted on patients, and the cases described in the article do not reveal the patients' identity or breach their privacy.

Any program seeking to provide antiretroviral treatment (ART) to the many patients in need is bound to confront ethical dilemmas. Dilemmas, as we know, are situations in which decisionmakers are faced with a choice between equally unsatisfactory alternatives. Yet those in charge must make a decision or establish a policy that takes one pathway to the exclusion of another. Reasonable people may disagree over the choice, arguing that an alternative selection would have been ethically superior.

It is widely acknowledged that the HIV and AIDS pandemic is a global emergency and that cheap, effective treatment should be provided for as many people as possible worldwide. But there are many challenges to rolling out antiretroviral (ARV) treatment in resource-poor settings. These include the cost of drugs (although these are falling rapidly), sustaining their supply and distribution, the complexity of treatment regimens, selection of patients for treatment, shortage of medical and nursing personnel, inadequacy of healthcare facilities, the need for uninterrupted, lifelong treatment, and monitoring for drug resistance. Great efforts, nationally and internationally, are required to meet these challenges.This work was supported in part by the University of Toronto and a grant from the United States National Institutes of Health's Fogarty International Center to the University of Cape Town's capacity-building program in International Research Ethics in southern Africa (Program Director S. R. Benatar).

In a short rejoinder, I thank Macklin and Benatar for their very helpful and thought-provoking comments and at the same time, I want to provide some additional information, which might be of interest to Macklin and our readers.

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.