Some weeks ago, we learned that the matriarch of a family, my good friend Anna, is dying. She is 75 and has inoperable esophageal cancer, and the doctors say it will only take a few more weeks or months. Anna is dying the way I want to die–at home, surrounded and lovingly tended by her family: her devoted husband of 54 years, her three daughters, her three worshipful sons-in-law, her adoring granddaughters. All of them see her every day. All of them are a part of a mutual struggle to give Anna a “good death” Anna, too, is a part of it. And, in a very small way, I am part of it, because I have been invited to be. Every few days, I walk next door and spend a few minutes talking to Anna.

I end with another parable, but it is also a true story. Harvey Gushing, the famous surgeon after whom the Gushing Lectures are named, made an international reputation in his allegiance to quality. He badgered his profession to a higher standard of self-effacement and railed against the debasement of clinical skills and overemphasis on research and pursuit of personal gain. We honor him to this day because those were, and remain, important points. Yet, Harvey Gushing served as a surgeon during World War I and at Ypres. Although the Allied mortality was as much as 50,000 soldiers a day, not counting the wounded, Gushing refused to operate on any more than two patients each day, arguing that to do so would have lowered his standard of care for his patients a – standard that made sense in one time but that became strikingly insensitive, and I suggest even unethical, in another when confronted with a different reality.

A variety of cases of scientific misconduct have been documented since the 1980s among biological scientists. These cases have focused the attention of the public and scientific community on this behavior and made it the centerpiece of the concern about ethics in the biological sciences. In contrast, the ethics movement in clinical medicine, which arose in the 1960s, was not basically directed at the problems of wrong-doing. Instead it concentrated on the difficult ethical choices that had to be made In the practice of medicine.

In this essay, I discuss the two movements. The attention given to misconduct In the biological sciences has become excessive and diverts its ethics movement from exploring and teaching about the difficult ethical decisions scientists must make in weighing obligations to self, science, and society. A more balanced and selective approach to developing an ethical framework in the biological sciences is needed.

I have been a member of the Loyola University of Chicago, Medical Center Institutional Review Board (IRB) for 12 years and Chair for the last 4 years. The Medical Center Campus is a full-service academic medical center, providing tertiary and primary care to Chicago and its western suburbs. The campus houses a 520bed hospital, outpatient facilities, a cancer center, the graduate medical sciences, a nursing school, and the Loyola University Stritch School of Medicine.

The exportation of Western biomedicine throughout the world has not resulted in a systematic homogenization of scientific ideology but rather in the proliferation of many forms and practices of biomedicine. Similarly, in the last decade, bioethics has become increasingly an international enterprise. Although there may be consensus regarding the inherent value of ethical discourse as it relates to health and medical care, there are disagreements about the nature and parameters of medical morality. This lack of consensus exists because our beliefs about morality are culturally constituted, embedded in social, religious, and political ideologies that influence particular individuals and communities at specific historical moments.

Richard Lamm is an eloquent and insistent advocate for healthcare reform. In his paper, he argues that if reform is to be effective, a radical metamorphosis in the values underlying our present system must take place. “New realities” have made the “old values” unsustainable. Unless they are replaced by “new values,” we face a future of disastrous overspending, gross inequities in accessibility, poorer health for many, and more expensive dying.

Past ages of medical care are condemned in modern philosophical and medical literature as being too paternalistic. The normal account of good medicine in the past was, indeed, paternalistic in an offensive way to modern persons. Imagine a Jean Paul Sartre going to the doctor and being treated without his consent or even his knowledge of what will transpire during treatment! From Hippocratic times until shortly after World War II, medicine operated in a closed, clubby manner. The knowledge learned in medicine was not shared with the patients, who were in general poorly educated and for the most part completely ignorant of the craft of medicine and the physicians (but not, perhaps, of folk medicine). Physicians were cautioned against telling patients too much about their Illness and/or their recovery, perhaps because physicians themselves did not have an enormous armamentarium to confront disease.

Today's ever-widening expert/novice gap–in technology generally but in healthcare technology especially–has been implicated as both cause and consequence of a sharp rise in fundamental misunderstandings between medical professionals and lay populace. Recently created social roles (e.g., clinical medical ethicists) and institutions (e.g., hospital ethics committees) have further prompted critics to suggest that a multiplication of “disinterested” experts not only fails to resolve such misunderstandings, it compounds them. As a result, it should come as no surprise that the problem of paternalistic expertise has emerged as an ethical issue of immense interest from both a theoretical and practical standpoint. For this reason, a critical inquiry in healthcare today centers on finding a practical model that most adequately and accurately characterizes patient–physician relationships.

The mission of the Indian Health Service (IHS) affects what research is done and how It is reviewed and managed and in turn affects the forms and process used to obtain informed consent. Consent forms must be Informative and understandable to American Indian and Alaska Native (AI/AN) potential volunteers; the process used to obtain informed consent must minimize any institutional pressure to participate. The IHS Institutional Review Boards (IRBs) developed seven research Model Volunteer Consent Forms (available from the author).

Much of recent medical, legal, and ethical focus has been directed toward the unborn or newly born. Guidelines and frameworks for decision making are in the early stages of evolution and are likely to shift as the politics, ethics, and economics of caregiving move beyond technologic accomplishments and debates into a more compassionate construct that may include input (when necessary and appropriate) from an institutional bioethics committee. Beyond that, the courts may continue to be the place where unresolved issues are settled, and with each passing year new and often divergent legal decisions are being generated that further complicate the physician's role as care giver and healer.

It should surprise no one familiar with the problems in rural healthcare that 87% of a randomly selected sample of Nebraskans recently called for either fundamental or complete change of the healthcare system. Rural communities in the United, States have been hard hit by the rising cost of healthcare at a time of economic and demographic decline. Unable to sustain operating costs and personnel needs, rural hospitals and medical, practices have been forced to close their doors at an, alarming rate.

Furthermore, rural patients are decreasingly able to afford what services are available to them. Most must purchase insurance privately because they are unlikely to be insured through employment. Therefore, they pay dearly because they are not eligible for corporate rates and because insurance companies use experience instead of community rating to assess risk.