The growing interest in bioethics has given rise to a new group of experts: experts in bioethics. They come from different walks of life and their motives, claims, and qualifications for expertise are manifold. Various academic disciplines can be said to contribute to one's status as an expert in bioethics. Studies and research in, say, philosophy, law, anthropology, history, theology, and sociology with an emphasis on bioethical matters are often thought of as suitably qualifying a person as a bioethicist. In addition to these academic qualifications there are two routes to becoming a bioethicist. I will call these the self-nomination (self-styled) and the through-work-experience routes. Self-nominated expertise is most common with medics who have strong religious or other ideological views about ethical matters. Another path to self-nominated expertise starts with strongly held ideological views with interest in bioethical matters. For this category of bioethical experts there does not have to be any institutional acknowledgment of their status; they are experts because they think they are. The other nonacademic type of expert in bioethics emerges through administrative channels. When the various ethics committees and regulatory bodies that now abound were first founded, there were no experts in bioethics to sit on these committees. People became experts by serving in these institutions for sufficiently long periods of time. This still happens with ethics committees in which just a few of the members are experts in ethics. People join the committees as experts of other fields, but are thought to have become experts through the fact that they have served on such committees.

At its root meaning a “crisis” is a separation. In our everyday lives we use the term crisis to designate a period of decision. A crisis is a moment of separation when one must make a decision about a direction. To make a crisis decision, a person needs some criteria or set of norms to guide the decisions that are made. Sometimes, at a moment of crisis decisionmaking, there is chaos when one does not know which norm to use in making a decision. Without some norm a crisis is a significant loss of direction because there are different criteria for deciding which way to turn or how to decide. It is in this most fundamental sense that one can say that contemporary medicine is in crisis.

Until recently, many of Japan's medical and bioethical communities had ignored the issue of conflicts of interest (CIs). This is no longer the case. Discussion on the economic and ethical problems defined by CIs is now apparent in academic, political, and even industrial spheres. In June 2004, this debate was sparked by a scandal involving AnGes MG, Inc., a bioventure company set up by a faculty member at Osaka University Graduate School of Medicine. AnGes MG developed a gene therapy using the Hepatic Growth Factor for obstructive blood vessel disease. Japanese newspapers reported that “several physicians involved with clinical trials for AnGes obtained unlisted shares of stock. One physician allegedly received 32 million yen (U.S. $320,000) after AnGes MG went public on the ‘Mothers’ stock exchange” (a market for high-growth and emerging stocks).

There are, broadly speaking, two kinds of knowledge—analytic and intuitive, explicit and tacit. Analytic knowledge is arrived at by logical deductive thinking, and is a sequential thought process in which each step can be explained and defended. Intuitive knowledge, in contrast, is frequently alogical or nonrational (though not illogical or irrational), and often involves nonconscious mental processes. Though intuitive ways of knowing are essential to both scientific research and scientific medicine, the culture of medicine celebrates only the analytic, evidentiary kind of knowledge, while eschewing intuition as being “nonscientific.” The popularity and prevalence of what is known as evidence-based medicine reflects this bias in favor of the analytic and the explicit. Though the evidence-based approach has contributed greatly to standardizing medical care, favoring treatments for which there is evidence of effectiveness, it has limitations. An overreliance on evidence-based medicine is problematic, because this approach leaves out important factors in the actual practice of clinical medicine such as diagnosis (pattern recognition, hunches), nonverbal cures provided by patients, and the way the doctor–patient relationship bears on patient management and compliance, and because it is not appropriate for dealing with medical conditions that do not lend themselves to study by controlled clinical trials.

We will argue here that after more than 30 years of talk, theory, and clinical practice, we bioethicists still know far too little about what patients, subjects, and healthcare professionals are up to, morally. Bioethics is still near the beginning in grasping what it means to understand, much less to honor fully, the moral power and perspicacity of those bioethics is designed to serve. This is, of course, a serious charge, but one we will endeavor to show has merit. However, we want to be clear from the start that we do not gainsay the important work that has been done in and through the influence of bioethics, both as a field of practical engagement and as a cultural movement, in improving how healthcare is delivered and how human subjects are treated. Thirty or 40 years—depending on how one marks the beginning point—is a very short time, and it is hard to imagine that wholesale changes, all of them in the right direction, could be the outcome for a field this young. Hence, we do not intend the title, “One Cheer for Bioethics,” as a wholesale indictment, but as an indication that there is a great deal of work yet to be done, and that following the currently dominant direction of the field is not likely to get us there. Our aim is to indicate just where future work should be focused, and to do so we will need to be critical of some of the preoccupations of the last three decades.The authors thank Lida Anestidou, Mark Bliton, Ellen Clayton, Stuart Finder, Elizabeth Heitman, Joshua Perry, Annabeth Schenck, and Lucia Tanassi for helpful comments on earlier presentations and drafts of the ideas in this paper.

Autonomy is good for you. A strong sense of competent self-control and effective choice-making promotes both physical and psychological well-being. Loss of autonomous control—and a sense of helplessness—causes depression, increased sensitivity to pain, greater vulnerability to disease, and death. Well established by a wide range of psychological and physiological studies, the positive effects of patient autonomy (and the harms of autonomy deprivation) are well known to competent physicians, nurses, and therapists. Conscientious caregivers are thus moving beyond grudging acceptance of informed consent toward clinical respect for patient autonomy.

Over the past decade, genetic tests have become available for a wide variety of disorders. As a result we are able to predict, with some degree of certainty, whether or not an individual will develop such diseases as breast cancer, Huntington's disease, polycystic kidney disease, and familial adenomatous polyposis. The ability to predict disease poses several unique ethical considerations for clinical decisionmaking regarding the provision of genetic testing. Patients must be able to comprehend the complexities of genetic testing and the potential meaning of the results. Patients must consider the emotional, social, and economic consequences of revelations regarding their risk status. Also, obtaining information on risk status may have implications for persons other than the individual seeking genetic testing.

A pilot center for clinical ethics in France opened with the establishment of the “Centre d'éthique clinique” at Cochin Hospital in Paris, September 2002. Unlike the longer history in the United States of providing ethics consultation for ethical issues deriving from physician–patient interactions, this center marks a new development in bringing clinical ethics to Europe.

“Globalisation is the Yeti of … newspapers. Everybody knows it, but nobody has ever seen it. What does it look like? Tall, monkeyish, hairy? Or rather weasel-like? With glasses? Like a ferret or a marten?” Globalization means different things to different people, a laudable development uniting humankind or an epidemic crushing the vulnerable peoples of the earth. Whether it is something we can control remains to be seen, but it is certainly upon us. The move to “go global” is such a strong force that hardly any human activity is exempt. We have global treaties, global media, global celebrities, global bookstores, and even a global antiglobalization movement!We thank the Centre for the Study of Global Ethics, University of Birmingham, UK, for inviting one of us (DS) to present this paper at their research seminar. The subsequent discussions were most helpful. Also, thanks to Dr. Armin Schmidt for comments on an earlier draft and to Tomi Kushner for inviting us to write this paper.

Despite the fact that ethics consultations are an accepted practice in most healthcare organizations, many clinical ethicists continue to feel marginalized by their institutions. They are often not paid for their time, their programs often have no budget, and institutional leaders are frequently unaware of their activities. One consequence has been their search for concrete ways to evaluate their work in order to prove the importance of their activities to their institutions through demonstrating their efficiency and effectiveness.

Canada is one of the few countries in the world—China is another—that has decriminalized abortion. In Canada, there are no legislative or judicial restrictions whatsoever on abortion: When, where, and under what circumstances abortions can be performed are all unregulated. In sharp contrast, abortion is generally illegal in South American and predominantly Catholic countries, as well as in African and Muslim countries. And the countries that do allow legal abortions, including most in Europe along with America, Australia, and Russia, typically permit it only up to a certain time or make it subject to circumstances such as risk to the woman. In what follows we will first explain how Canada came to decriminalize abortion and then go on to assess that position from an ethical point of view.

These CQ Sources were compiled by Bette Anton.

In a recent article in this journal, we argued that living organ donation from a parent to a child should be described as a beneficent rather than an altruistic act. Emotional relationships can generate an obligation of beneficence to help those with whom we have these relationships. This may involve an obligation for a parent to donate an organ to a child, even though it entails some risk to the parent. The parent's donation is not altruistic because altruistic acts are not obligatory but optional, and they are motivated solely or primarily by other-regarding concerns. In contrast, donor parents' other-regarding concerns are inseparable from their own self-regarding concerns. An individual who donates to a stranger is acting altruistically. She may choose to help others to whom she is not emotionally related for a variety of reasons—sympathy, compassion, generosity, or a desire to give something back to humanity. But she does not have an obligation to do so. Although she may benefit as a consequence of donating, this is not her reason for donating. Instead, her action is motivated by a concern for the recipient's own sake. This is what makes the donation altruistic, and it can be justified without any expectation of benefit to the donor. However, although the potential competent donor decides whether the donation is in her best interests, physicians have the right to refuse to perform a transplant if the risks to the donor are too great or the potential benefits to the recipient are too small.

Important bioethcs changes are underway in the Netherlands that carry, for better or worse, far-reaching social consequences. The two major areas of change involve (1) economics and containing soaring health costs and (2) end-of-life care as reflected in several high-profile cases: in a decision handed down by the Dutch Supreme Court on reviewing the procedures for the termination of life, in the discussion surrounding The Groningen Protocol and the active ending of lives in neonatology, and in a report of a Royal Dutch Medical Society's Committee on the role of physicians in ending life in cases of requests to die outside the area of terminal diseases.

The issue of prenatal testing and selective abortion has never received open public appraisal. This is somewhat regrettable. The interest in this area, however, is rapidly growing. In part this is a result of concerns about the rate of development in genetic knowledge and questions as to its application. For instance, there will be a huge increase in the scope of conditions or features for which we will be able to screen, some of which could hardly be described as significant. Further, for some time now, people with disabilities have had concerns about the practice of prenatal testing and selective abortion. This article looks at the relationship between reproductive autonomy, prenatal testing and associated practices, and the interests of people with disabilities. It asks whether such practices negatively affect the interests of such individuals, and if so, how. This is an important question for the formulation of public policy in this area. Although some groups have studied this issue in detail, policy bodies do not necessarily fully engage with their analyses. This may be a reflection of public confusion about this issue. To some degree, fear of causing offense may also inhibit both expression of public opinion and, in turn, policy analysis. This is unfortunate and needs to be acknowledged.I am grateful to participants of the Mt. Sinai School of Medicine—King's College London—Oxford Consortium on Bioethics, 2003, for comments on an earlier draft of this paper and particularly to Professor Jonathan Glover and Dr. Bobbie Farsides for conversations relating to it.

Predicting future trends in bioethics depends on the recognition of contemporary innovations. Because of the extraordinary challenges brought on by the HIV/AIDS pandemic, bioethics has had to undergo a critical examination of its own effectiveness. This essay examines 10 developments that have helped shape the future of bioethics in a time of HIV/AIDS.

American bioethics began in the late 1960s, stimulated by a plethora of new medical technologies and biological knowledge and by a scandal-induced interest in human subject research. Although it was understood that there would be ethical debate (which had already broken out between the theologians Joseph Fletcher and Paul Ramsey), no one thought the disputes would be ideological in character, as if part of one's voting pattern as liberal or conservative, Democrat or Republican. There were arguments, often sharp, but no culture wars.

According to Glannon and Ross, for an act to be considered altruistic, it cannot be obligatory nor motivated by expectation of self-reward. Given that parents are obligated to help their children and stand to benefit greatly from donating, the authors conclude that parent to child organ donation is not altruistic. Are they correct? I am not sure. In my view, this is a semantic question and the answer depends upon how one defines altruism. Altruism is a complex subject that means different things to different people. If we say that an altruistic act is one that is performed voluntarily, is risky or costly to the actor, and is designed only to benefit others with no expectation of self-reward, then it may be difficult or impossible to identify any such acts. When one risks her own life to save a stranger, others may ask: “Did she really act solely to benefit another or was she motivated, at least in part, by a need to satisfy her conscience or a desire to feel good about herself?” This question is relevant to the motivation of living organ donors. In contrast to the authors' answer that strangers who donate organs do so only out of concern for other people, Carl Fellner argued that many living organ donors, even those who are not related to their recipients, act to benefit themselves. If Fellner is correct, and if organ donation by parents is not altruistic because of the possibility of self-reward, perhaps the same is true of organ donation by strangers.

A demographic revolution is taking place in Europe and worldwide. According to World Health Organization (WHO) estimates, the number of people aged 60 and over is growing faster than any other age group. This change in the population structure affects disease patterns and is deemed to cause an increase in the demands on healthcare systems. This raises concerns about the ethics of healthcare delivery (among others). What criteria should direct healthcare distribution? Is it right to meet the demands of an ageing population, to the detriment of the younger strata of population?This paper has been written thanks to the support of the European Union, which has sponsored my project on ageism with a Postdoctoral Marie Curie Fellowship. More details on this project are available at the website http://les.man.ac.uk/simona/. I thank Prof. John Harris for our discussions on the topic and for his comments on this paper.

These CQ Sources were compiled by Bette Anton.