Some time ago, Ian Kennedy asked whether consent was

the great bulwark of “patient's rights”? Is it a necessary nuisance granted as a concession to modish thinking? Is it simply a figment of some lawyer's (or—awful word—medical ethicist's) imagination which practitioners know is meaningless in practice? Is it just part of the rhetoric of “patient power”, sent to try doctors' patience and challenge their authority?I thank Professor Matti Häyry for his extremely perceptive and helpful comments, which have added much to this paper.

On June 3, 2003, the European Council of health ministers rejected a proposal from the European Commission to allow drug manufacturers to advertise directly to particular groups of patients; the proposal had already been rejected by the European Parliament subsequent to a heated public debate in which consumer and patient groups almost unanimously argued that it was not the role of drug companies to provide information to patients. The pilot scheme suggested by the Commission would only have applied to patients with three chronic diseases, AIDS, diabetes, and asthma, and would, it was argued, not undermine an overall ban. Drug companies would have been required to abide by a special code of conduct and clear any information given to patients—on web sites or in specialized publications—with national authorities.

Point:

Wars must be won if our country … is to be protected from unthinkable outcomes, as the events on September 11th most recently illustrated…. This best protection unequivocally requires armed forces having military physicians committed to doing what is required to secure victory…. As opposed to needing neutral physicians, we need military physicians who can and do identify as closely as possible with the military so that they, too, can carry out the vital part they play in meeting the needs of the mission.

Counterpoint:

We believe the role of the “physician–soldier” to be an inherent moral impossibility because the military physician, in an environment of military control, is faced with the difficult problems of mixed agency that include obligations to the “fighting strength” and … “national security.”This paper is based on the Dual Loyalty Project (1998–2000), which was funded by the Greenwall Foundation to develop guidelines that protect the human rights of patients in situations where health professionals face dual loyalty conflicts. The intellectual contributions of the International Dual Loyalty Working Group, as well as the assistance of Ms. Kathy Mallinson and Dr. Joanne Stevens in preparing this manuscript are gratefully acknowledged.

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.

Military conflicts inevitably lead to the detention and interrogation of adversaries (or perceived adversaries), and American military action in Afghanistan and Iraq has resulted in the protracted and scrutinized detention and interrogation of varied personnel. Detention and interrogation, in turn, inevitably lead to moral and legal questions, and these questions have been especially poignant during and following the aforementioned campaigns. Controversially, the Bush administration did not afford Geneva Convention protections to so-called enemy combatants; these protections would have increased the standard of care (e.g., legally, medically) afforded to detainees and would have limited the interrogation options available to military personnel. Also controversially, reports have alleged that military interrogators have practiced “stress and duress” tactics that include “sleep management” (i.e., sleep deprivation), “dietary manipulation” (i.e., food withholding), “environmental manipulation” (e.g., exposure to extreme temperatures, presence of dogs), forced maintenance of uncomfortable positions for extended periods of time, isolation (sometimes for longer than 30 days), hooding, and so forth.I thank the following people for their helpful discussions and feedback on the ideas in this paper: Jean Maria Arrigo, William Casebeer, Michael Davis, Jan Goldman, Michael Gross, David Guinn, Kenneth Kipnis, Justin List, Jonathan Marks, Albert Pierce, Michael Pritchard, Len Rubenstein, Allen Weiner, Matthew Wynia, John Yoo, Daniel Zupan, and two anonymous reviewers. Their correspondences should obviously not be taken to imply that any of them agrees with my conclusions. This paper was presented at The Australian National University and at the 2005 meeting of the Australasian Association of Philosophy; I thank those present for their comments, especially Dirk Baltzly, Jeanette Kennett, and Thomas Pogge.

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 first reported case of postmortem sperm retrieval occurred in 1978, involving a man who became brain dead after a motor vehicle accident and whose wife requested removal of his sperm so that she could be artificially inseminated. Physicians performed the retrieval by surgically excising the ducts that transport sperm from the testes (the epididymis and vas deferens) and removing sperm from them. Since that time, several other methods for retrieving sperm from such patients have been reported, and at least 141 cases have been documented in which requests were made for removal of sperm from men who were dead or irreversibly unconscious. Moreover, there have been several reports of pregnancies and births resulting from assisted reproduction using sperm retrieved in such cases.

In the United States, people may donate organs and tissues to a family member, friend, or anyone whose specific need becomes known to them. For example, in late 2003 dozens of people came forward to donate a kidney to a professional basketball player known to them only through his sports performances. People may also donate a kidney to no one in particular through a process known as nondirected donation. In nondirected donation, people donate a kidney to the organ allocation system rather than to anyone known to them personally. There are limits, though, to generosity. People are usually not allowed to donate to groups of people, no matter the contours of the group, whether white, black, Catholic or Presbyterian, third-time liver recipient, and so on. As the agency that oversees national transplantation policy, the United Network for Organs Sharing (UNOS) does not allow this sort of restricted donation, though it appears that some regional Organ Procurement Organizations (OPOs) occasionally bend the rules when donors insist that their organs go to children or to first-time recipients. Those ad hoc arrangements are, however, the exception to the rule.

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.

It is a reality today that people die waiting in line for transplant organs. Something needs to be done to remedy this dire situation and alleviate the suffering. Broadly speaking, barring scientific progress that might make artificial organs and stem cell therapy viable alternatives, three options are available to us: increase voluntary donation, compel access to organs via government policy, or open up for a commercial market in organs.This article could not have been written without the help of Dr. Martin Petersson and Professor Sven Ove Hansson.

These CQ Sources were compiled by Bette Anton.

We are living in a time of war on multiple fronts. This is as true metaphorically as it is geographically. In particular, we live in an age in which war has been declared against disease, and war has been declared against terror. This essay considers in tandem the costs of those wars—more precisely, the costs of those metaphors of war.The author gratefully acknowledges contributions to this paper from conversations at a colloquium of the “town-gown” medical ethics discussion group at Indiana University's Poynter Center for the Study of Ethics and American Institutions, with special thanks to Richard Miller (Poynter Center director), Jennifer Girod, Caitlin Kelly, Gates Agnew, and Byron Bangert, and from conversations at Tokyo University's 21st Century COE Project for Death and Life Studies, with special thanks to Susumu Shimazono and Miyako Takahashi.

The terrorist attacks of 2001 were a reminder that individual and collective safety cannot be taken for granted. Since then, physicians, alongside public health professionals and other healthcare professionals as well as nonhealthcare personnel, have been developing plans to enhance the protection of public health and the provision of medical care in response to various threats, including acts of terrorism or bioterrorism. Included in those plans are strategies to attend to large numbers of victims and help prevent greater harm to even larger populations.The Council on Ethical and Judicial Affairs of the American Medical Association formulates ethical policies for the medical profession through its interpretations of the AMA's Principles of Medical Ethics. The Council at the time this report was adopted consisted of Michael S. Goldrich, M.D. (Chair); Priscilla Ray, M.D. (Vice-Chair); Regina M. Benjamin, M.D., M.B.A.; Daniel Higginson (student member); Mark A. Levine, M.D.; John M. O'Bannon, III, M.D.; Robert M. Sade, M.D.; Monique A. Spillman, M.D., Ph.D. (resident member); and Dudley M. Stewart, Jr., M.D. Staff to the Council at the time the report was adopted were Audiey Kao, M.D., Ph.D. (Vice President, Ethics Standards Group); Karine Morin, L.L.M. (Secretary); and Sara Taub, M.Be.

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.

Mr. Paul Mills suffered from cancer of the esophagus (the passage between the mouth and the stomach). Three major surgeries were unsuccessful in correcting the problem, and other treatment methods likewise failed. His condition deteriorated to the point where there was no longer any hope of recovery. Dr. Morrison, who was Mr. Mills's intensive care physician at the Queen Elizabeth II Health Sciences Centre in Halifax, and Mr. Mills's family (Mr. Mills was incompetent by this time) agreed that active life support should be discontinued. Dr. Morrison then removed Mr. Mills's ventilator. To everyone's surprise, and dismay, Mr. Mills did not die. He continued to breathe spontaneously and started to show signs of distress. Dr. Morrison increased the dosage of morphine, to no effect. She increased it again to the point where death could reasonably be expected to occur; signs of distress continued. Dr. Morrison at this point administered a dose of potassium chloride and Mr. Mills died.I am grateful to Don Brown for very helpful comments and conversation.

The precautionary principle is frequently referred to in various momentous decisions affecting human health and the environment. It has been invoked in contexts as diverse as chemicals regulation, regulation of genetically modified organisms, and research into life-extending therapies. Precaution is not an unknown concept in medical contexts. One author even cites the Hippocratic Oath as a parallel to the precautionary principle.“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].

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.

In “A Paradox out of Context: Harris and Holm on the Precautionary Principle,” Sandin criticizes the earlier paper “Extending Human Lifespan and the Precautionary Paradox” wherein John Harris and I argued that the precautionary principle (PP) is incoherent. These criticisms offer me the possibility to briefly expand and clarify some of our previous arguments, and to show that the paradox of precaution is not dispelled by attention to context as Sandin maintains. Even when context is fully acknowledged, application of the PP will still lead to paradox and paralysis.“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].

Physicians have special professional obligations to respond to medical emergencies. A bioterrorism attack would be a medical emergency. Thus, it seems that physicians would have an obligation to respond to a bioterrorist attack. However, the scope of those obligations, and their limits, are vexed topics. General rules may be comforting but the details and nuances of particular situations will always be relevant.This work was supported by the MacLean Center for Clinical Medical Ethics. The funding source had no role in the analysis or in the decision to submit the manuscript for publication.

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated.

The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration.

All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].