Philosophy is generally considered to be very abstract. How philosophical and abstract Is ethical thinking In clinical situations? This paper sketches an answer In the form of a case study (I am the case) and offers me the chance for some self-reflection and readers the chance to eavesdrop on that self-reflection. Aside from any Intrinsic worth of the questions and answers, they also have Implications for how clinical ethicists should be educated or trained, i.e., how abstract should one's work in moral philosophy be?

Over a 20-year period, the United States has developed a consensus of legal opinion concerning living wills and other advance directives. At the heart of this consensus are two interconnected principles. First, the state should minimally interfere with the wishes of patients and surrogates and the decisions of physicians about foregoing life-sustaining treatments. Second, state interference is permissible for the sake of protecting a compelling state interest. The overwhelming majority of states with advance directive laws have attained this balance of minimal interference and compelling state interest in developing their laws.

Recent contributions to the literature on the topic of futility have focused primarily on two areas: 1) definitions of the term and 2) the suggestion that cardiopulmonary resuscitation (CPR) may be futile in certain patients. This suggestion is based on “scientific” measures and analyses of outcomes, describing the low probability of success of CPR in patients over age 70, those with cancer, those with multiorgan failure, etc. The research reported suggests that with such patients the physician need not get the patient's (or the surrogate's) consent to withhold resuscitation; the physician need only inform either the patient or the surrogate that CPR will not be Instituted in the event of an arrest.

For the past 3 years, since acquiring formal training in healthcare ethics and philosophy, I have been one of those physicians who “does” ethics. I teach medical students and residents, write articles, speak at conferences, chair an ethics committee, and informally consult with colleagues on cases where they request advice related to ethical issues in the care of patients. These activities have been a rewarding and challenging part of my practice. There has also been a fair amount of frustration. Unfortunately, both in teaching and patient care, it has been a frequent experience to finish a discussion with physicians only to be told that what I said was nice but had no bearing in the real world. In the words of a medical resident: 'You know, this ethics stuff is really a lot of crap, isn't it?'

Television pictures of starvation and depredation are not the only way that famine and political instability in the horn of Africa have affected the United States. Many people from that region of the world are seeking political or economic refuge here, and they are exposing us to a culture that is in some ways — most notably, in the practice of female circumcision – so radically different from the prevailing American cultures that we have been stunned. They are also forcing hospital ethics committees to face issues that cannot be resolved by the facile application of the settled principles that have guided those institutions for the past several years. Autonomy and multiculturalism, long the foundations of most ethics committee decision making, have started to give way to a list of formally articulated rights and wrongs – perhaps to a restatement and adoption of rules said to be based in natural law. Female circumcision, argues one newspaper letter writer, “is just a sickening display of male power disguised as legitimate dogma.

As the concept of universal access to healthcare comes to America, an ethical paradox emerges. “Access” is the code word for being assured that sick people without financial resources get appropriate medical care. There is an ethical imperative to provide care for the sick – whether paying or not – and this value ought to give direction to any reformed system.

Mrs. A. is a 50-year-old woman, originally from Greece, who came to the United States with her family in 1973. A widow, with three grown children, she has been living near two of her sons and their families. For many years, Mrs. A. has suffered from, non-insulin-dependent diabetes, emphysema, and hypertension. On the day of a family picnic, she developed a high fever and vomiting. She was taken by her oldest son, Thomas, to the emergency department, where evidence was discovered of a severe infection of her kidneys that had spread to her blood.

The paper by Dr. Myles Sheehan “Why Doctors Hate Medical Ethics” (which would, I think, perhaps have been better entitled “Why Doctors in Training Hate Medical Ethics”) highlights some of the problems of teaching ethics to an extremely weary group of house officers who may look at ethics as a waste of time, as a requirement that must be overcome, or as “a lot of crap” Although Dr. Shee-han's paper offers a number of interesting and valuable insights, it really fails to say why residents hate the teaching of medical ethics any more than they may hate any other conference which, inevitably, intrudes on their time. In this response, I do not so much want to take issue with Sheehan's paper as to comment and to offer some of my own experiences teaching ethics. To do so, I am fully aware, may be regarded as matching anecdote with anecdote, a tiresome and ultimately futile process.

Has the private body of biethics become a microcosm of the body politic? Politics is ethics writ large. Ethics is politics writ small. However we turn it, the practice of bioethics is increasingly attuned to developments in public policy. The establishment of a “Health Policy Watch” in these pages is an invitation for research and reflection on these issues.

At the September 1992 Birth of Bioethics conference observing the 30th anniversary of the Seattle kidney dialysis program, Warren Reich discussed the “bilocated” birth of the term bioethics. He showed that the term bioethics was coined in Michigan by Van Rensselaer Potter and that the term was also apparently conceived of independently at about the same time in 1970–1971 in Washington, D.C., by Andre Hellegers and Sargent Shriver. Potter's work, like many similar works in the early 1970s, was concerned with the growing global biological crisis of human overpopulation, the destruction of species, and how to respond to these. He prefaced his book Bioethics with a “Bioethical Creed for Individuals,” outlining duties to respond to this crisis in a meaningful and scientific way. Hellegers and Shriver used the neologism to name the new Joseph and Rose Kennedy Institute for the Study of Human Reproduction and Bioethics. The Center was to study concerns somewhat different from Potter's: the technological revolution in healthcare and its impact on reproduction, investigator-patient relations, and medical ethics.

Bioethics Common Market is an international bulletin board to post notices regarding such things as networking contacts among people interested in a specific area of concern, hospitality, research underway for which collaboration is desired or possible, sources of scarce or hard-to-find materials, reports or papers available in sufficient numbers to share, textbooks or study materials desired, and, for travelers to any state or country, names of local people with possible common interests.

Hospital ethics committees must be knowledgeable if they are to perform consultations, advise administrators on policy, or offer educational programs. Because the membership of the committee is interdisciplinary, with most drawn from the healthcare professions, the individuals who join cannot be expected to bring knowledge of bioethies with them. Therefore, a new committee must spend time developing expertise before it can appropriately serve the hospital community. Although the need for committee self-education is generally recognized, it is seldom discussed in any detail. When discussed at all, expertise in bioethies is usually described as composed of a familiarity with an identifiable body of knowledge and mastery over techniques of moral reasoning. It is assumed that a committee can develop this expertise early in its life through a short course of study.