Contributors.

Contributors.

Contributors.

Contributors.

John Rawls was remembered by his publishers with the following quotation: “The perspective of eternity is not a perspective from a certain place beyond the world, nor the point of view of a transcendent being; rather it is a certain form of thought and feeling that rational persons can adopt within the world.” In that spirit, CQ's annual nonthematic Open Forum issue offers a collection of provocative papers on a variety of topics chosen to stir rational debate and challenge the prejudices and intellectual mistakes that can so easily cloud ethical vision.

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.

There is power in the choices we make in that our choices exercise and express our values. Choices, as compared with preferences, which may be spontaneous, are acts of deliberate volition—ways of casting our lot between alternatives. For this Special Section, “The Power of Choice: Autonomy, Informed Consent, and the Right to Refuse” we've chosen a frontispiece showing a balance with one pan offset by a weight in the shape of a human head. It graphically depicts that what is really in the balance in health decisions is the reflection of who we are.

Modern war poses hard ethical problems for the practice of medicine, making it difficult to identify medical ethics during times of armed conflict with medical ethics during times of peace. This sets up an enduring challenge for medicine, as doctors and other healthcare professionals weigh their responsibilities as caregivers against other responsibilities and obligations that citizens must shoulder during war.

The battlefield and wartime conditions often challenge physicians as to their understanding and commitment to the ethics of medicine. In Homer's Iliad we read of the first physicians on the battlefield before the walls of Troy, the sons of Asclepius, Machaon, and Podalirius. In his 16th century autobiography, Ambroise Paré recounts the first case of battlefield euthanasia of the wounded and of posttraumatic stress disorder and was renowned for his skill and humanity in the care of his soldiers. Dominique Larrey established the principles of triage of the wounded during the Napoleonic wars. It is out of warfare that the Geneva Convention and the Red Cross emerged. But what does history tell us about the ethical dilemmas of the military physician? Should prisoners receive care equal to that given to one's own troops? Can torture be used to extract information that may save lives? Is it ethical to enslave captured soldiers? Is the doctrine of the double effect valid as originally applied to war? Should a physician's ethics require him or her to speak out against perceived violations? This paper explores these issues from a historical perspective and I seek the voices of soldiers in the field wherever possible.

This paper presents an analysis of the applicability of a principalist approach for a global, or cross-cultural, bioethics. We focus especially on the principle of individual autonomy, a core value in ethical discourse. We echo some long-standing criticisms of other anthropologists, sociologists, and many medical ethicists that the individualistic approach to autonomy is a Euro-American value and cannot be ethically applied in all settings. As a remedy, we suggest an adaptation of Kleinman's Explanatory Model approach to questions of decisionmaking. We argue that the analysis and resolution of ethical dilemmas might also benefit from forms of pedagogy that integrate anthropological and other social science perspectives, and the incorporation of ethnographic techniques in ethical practice.We appreciate the extensive efforts of Michelle Amoruso, doctoral candidate in anthropology, who assisted with the preparation of the manuscript.

On March 8, 2005, the General Assembly adopted the United Nations Declaration on Human Cloning in which Member States are called upon to

a) protect adequately human life in the application of life sciences

b) prohibit all forms of human cloning inasmuch as they are incompatible with human dignity and the protection of human life

c) prohibit the application of genetic engineering techniques that may be contrary to human dignity

d) prevent the exploitation of women in the application of life sciences

e) adopt and implement national legislation to bring into effect paragraphs a to d

f) take into account the pressing global issues such as HIV/AIDS, tuberculosis, and malaria, which affect in particular the developing countries. Katrien Devolder acknowledges the stimulus and support of the European project “CLEMIT: Developing an operational ethical framework to analyse and monitor the ethics of creating and redesigning human beings,” sponsored by the European Commission, DG-Research as part of the Science and Society research programme—6th Framework, in the preparation of this paper. The authors are also grateful to Norman Ford and Carolyn Cameron for their helpful comments on an earlier draft and to Konrad Hochedlinger for advice.

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.

On both sides of the debate on the use of embryos in stem cell research, and in reproductive technologies more generally, rhetoric and symbolic images have been evoked to influence public opinion. Human embryos themselves are described as either “very small human beings” or “small clusters of cells.” The intentions behind the use of these phrases are clear. One description suggests that embryos are already members of our community and share with us a right to life or at least respectful treatment, whereas the other focuses on the differences between embryos and adult human beings with normal capacities, that is, their lack of sentience and of personal identity. The research on stem cells has been nicknamed “Frankenstein science” or presented as “research that could stop Parkinson disease.” Again, one description reminds us of scary science-fiction scenarios where the scientist is guilty of “playing God,” whereas the other description highlights the worth and potential benefits of the research outcomes.The authors 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 programme–6th Framework in the preparation of this paper.

When Hippocrates (or perhaps a contemporary) wrote these words, some time after 430 BC, he and his colleagues could do little for either good or harm to sufferers from infectious disease. Indeed, they themselves were at particular risk. Thucydides, describing the so-called plague of Athens of 430 BC (probably not bubonic plague, but unidentified) in his History of the Peloponnesian War, writes that “mortality among the doctors was the highest of all, since they came more frequently in contact with the sick.”I am grateful to Prof. Malcolm Dando for helpful comments on an earlier draft of this article.

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.

For over four decades, knowledge that symptoms of some inherited diseases can be prevented or reduced via early detection and treatment in newborns has underpinned state-funded screening programs in most developed countries. Conditions for which newborn screening is now a recognized preventative public health initiative include phenylketonuria (PKU), congenital hypothyroidism (CHT), and, more recently, cystic fibrosis (CF) and sickle cell disorder (SCD). The use of tandem mass spectrometry to detect conditions such as amino-acidopathies and fatty-acid oxidation defects is also becoming increasingly prevalent.The author thanks Dr. David Aitken, Dr. Richard Ashcroft, Professor Carol Dezateux, Dr. Katrina Hargreaves, Dr. Sandy Oliver, Dr. Rosalind Skinner, Ruth Stewart, and two anonymous referees for their valuable comments in drafting this paper.

By the end of the Second World War the advancing allied forces discovered a new nerve gas in Germany. It was called Tabun. Codenamed GA, it was found to be extremely toxic. British experts were immediately dispatched to examine the agent. On arrival, they discovered that German scientists had also developed even more toxic nerve agents, including Sarin, known as GB. The first organized testing of Sarin on humans began in October 1951 at Porton Down in Wiltshire, Britain's biochemical warfare establishment since the First World War. In February 1953, volunteer number 562 experienced the first recorded serious adverse reaction. Testing continued. Two months later, on April 27, six subjects were given 300 milligrams of Sarin. One of the volunteers, a man named Kelly, suffered serious ill effects, fell into a coma, but then recovered. Although asked by their superiors to reduce the amount tested to the “lowest range of dosage”—which would have been somewhere in the region of 10–15 milligrams—Porton's scientists continued their tests with a “lower” dosage, reducing it from 300 to 200 milligrams.I thank the two referees for their helpful and constructive suggestions. The paper was written as part of a Wellcome Trust-funded project on “Cold War at Porton Down: Medical Ethics and the Legal Dimension of Britain's Biological and Chemical Warfare Programme, 1945–1989.” I thank the Wellcome Trust for its generous support.

In a recent essay, George Annas, the legal columnist for The New England Journal of Medicine, observed that the resuscitation of extremely premature infants, even over parental objection, is not problematic because “once the child's medical status has been determined, the parents have the legal authority to make all subsequent decisions.” Annas himself is quick to concede that treatment in a high-technology neonatal intensive care unit (NICU) frequently takes on a life of its own. He also acknowledges that although bioethicists and courts agree that there is no ethical or legal difference between withholding or withdrawing a respirator from a patient, parents and physicians find the withdrawal much more emotionally troubling.

Sara Goering has suggested that familiar Rawlsian ideas can be pressed into service to distinguish morally permissible from impermissible forms of genetic engineering. My project is to develop and to assess this idea. Specifically, I argue that, when developed, Goering's Rawlsian resources fail to distinguish permissible from impermissible genetic engineering.This paper was written with assistance from the Social Sciences and Humanities Research Council of Canada. I am grateful to audience members at the 2005 meetings of the Pacific Division of the American Philosophical Association in San Francisco and at the 2005 meetings of the Canadian Philosophical Association at the University of Western Ontario for helpful discussion. Special thanks go to Anita Ho and Chris MacDonald.

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.