Our attitudes toward aging change in that “old” depends on where you are. When I was 16, and my sister Nancy was 29, I suddenly realized, to my horror, that one of us was about to be 30. I went around saying to everyone, “Poor Nancy, she's almost 40,” because to me at that time, 30 and 40 were about the same. Later, when Nancy was 40, she said she didn't mind because, according to me, she had been 40 for a decade.

Many years ago, the esteemed patriarch of bioethics, Joseph Fletcher, spoke loud and clear in favor of rationality in reproduction. By rationality, he meant not merely limiting population growth, which he certainly favored, but bringing to bear human analytic and creative intelligence on the random and instinctive activities of sexual intercourse and procreation that we share with all mammals. In his 1974 book, The Ethics of Genetic Control: Ending Reproductive Roulette, he foresaw most of the issues that we are facing today. He reflected on artificial insemination, prenatal diagnosis, cloning, eugenics, ectogenesis, ovum transfers, and genetic engineering. He examined these innovations to the extent that he felt that each of them represents a way of exercising rational and responsible control over life and reproduction. The subtitle of his book, “Ending Reproductive Roulette,” proclaims his faith. Dr. Fletcher's dedication to rationality led him to make the astonishing statement, “Man is a maker and the more rationally contrived and deliberate anything is, the more human it is. Therefore, laboratory reproduction is radically human compared to conception by ordinary heterosexual intercourse.”

In the language of secular bioethics, autonomy is always accorded first place in the hierarchy of values that has come to be referred to as the “Georgetown mantra” A dictionary definition of mantra is “a verbal spell, ritualistic incantation, or mystic formula used devotionally,” and the value placed upon autonomy is largely of this nature: uncritical and uncriticised. That there should be and are limits to autonomy is obvious, but these boundaries are undefined, little discussed, and mostly unexplored. To use another metaphor, our emphasis on autonomy is an index of how far the pendulum has swung in an understandable and partly justifiable reaction from, earlier paternalism; has this swing approached its proper limit, and should we be seeking a less extreme and more balanced assessment of autonomy as a bioethical value?

According to Frankena, “the moral point of view is what Alison Wilde and Heather Badcock did not have.” Most of us, however, are not such extreme examples. We are capable of the moral point of view, but we fail to take the necessary time or make the required efforts. We resist pulling ourselves from other distractions to focus on the plight of others and what we might do to ameliorate their suffering. Perhaps compassion is rooted in understanding what it is that connects us with others rather than what separates us, and rests on developing sufficient awareness, to internalize what our actions, or lack of them, mean in the lives of others.

Let us look at autonomy in a new way. Autonomy has a richly deserved place of honor in bioethlcs. It has led the set of principles that formed the basis of the discipline since the beginning. It is the leading principle In what is now regularly called “the Georgetown Mantra,” a phrase suggested by one of the first philosophers ever to be hired In a medical school, K. Danner Clouser. The phrase applies to the principled approach of autonomy, beneficence, nonmaleficence, and justice. This kind of bioethics was developed by scholars like Beauchamp and Childress, Veatch, and Engelhardt, during their association with Georgetown University.

The ethics of decision making for the critically ill elderly is an area of concern for all those involved in the decision-making process. The number of participants involved in decision making around end-of-life issues may be many: treatment and care decisions often bring together not only the patient and the physician, but the family, an extended medical care team, and impartial members of a hospital or institutional ethics committee. In addition, treatment and care decisions made at the end of life occur in a variety of settings, not just the acute care hospital. Elderly patients who are critically ill, or in the final days or weeks of life, are found in intensive care or medical units of hospitals, in hospital and nursing home based hospice programs, in long-term care settings such as skilled nursing facilities, or at home, where they are tended by family caregivers. Differences in patterns of decision making regarding the care and treatment of critically ill older adults can be found across these settings, and decisions often vary according to the roles of the participants.

This is a time of change in American healthcare. Market forces are restructuring local delivery systems around competing managed care networks. Many leading proposals for healthcare reform intend a reshaping of the national healthcare marketplace itself. Periods of change create an opportunity to reassess traditional values and practices. Such reassessments can be used to help insure that current innovations and proposed reforms preserve and strengthen the best in the traditions of medicine. A legitimate focus of concern in the medical and medical ethics community has been the effect of these delivery system changes on the physician-patient relationship. For example, will the future American healthcare system support and encourage compassion by physicians? Suppose it does not. Would something of significant moral value have been lost? More pointedly, would a system that undervalued or frustrated physician compassion be incompatible with the moral obligations of physicians? In order to address these questions, we examine the meaning of compassion and the role it should play in the physician-patient relationship. We argue that compassion is a duty of all physicians. Because this is so, we believe that changes in the healthcare system must be judged, in part, by how well they protect and encourage compassionate conduct by physicians.

In 1993, investigators from George Washington University (GWU) Medical Center separated the cells of 17 human embryos and produced 48 embryos, an average of three embryos for each original. The method, variously called twinning, cloning, embryo splitting, and blastomere separation, demonstrated that human embryos could be split to create genetically identical entities during conception. When publicized, however, the experiment brought to mind a different view of cloning repeated since the beginning of the new reproductive technologies. In the early 1970s, when research on in vitro fertilization (IVF) was in its infancy, commentators worried that cloning–defined as the duplication of persons–would be next, leading to a scenario of “boys genetically exactly like the father, girls like the mother, or individuals like some true or false hero of art, science, or sports, or like some demagogue or some saint.”

This article focuses on the elderly patient with a progressive and irreversible dementia, most often of the Alzheimer type. However dementia, the decline in mental function from a previous state, can occur in all ages. For example, if Alzheimer's disease (AD) is the dementia of the elderly, increasingly AIDS is the dementia of many who are relatively young. I will not present the major ethical issues relating to dementia care following the progression of disease from the mild to the severe stages, for I have done this elsewhere. Among the issues included are: presymptomatic testing, both psychological and genetic; responsible diag- nostic disclosure and use of support groups; restrictions on driving and other activities; preemptive assisted suicide; advance directives for research and treatment; quality of life in relation to the use of life-extending technologies; and euthanasia.

As the possibility of cloning humans emerges on the horizon people are worrying about the morality of using the new technology. They are anxious about the ethical borders that might be crossed when duplicate humans can be produced by separating the cells of a newly fertilized human egg or, in the more distant future, by creating a zygote from an existing person's genetic material. They are apprehensive about eugenics, concerned about creating humans as sources of spare parts for others, uneasy about producing humans without intending to allow them to live and develop, and uncomfortable about using duplicate humans as business ventures.

In situations where experience shows that a particular intervention will not benefit a patient, common sense seems to suggest that the intervention should not be used. Yet it is precisely in these situations that a peculiar ethic begins to operate, an ethic that Eddy calls “the criterion of potential benefit.” According to this ethic, “a treatment is appropriate if it might have some benefit.” Thus, the various maxims learned in medical school instruct physicians that “‘an error of commission is to be preferred to an error of omission,’ or ‘when in doubt, cut it out’ or ‘if but one patient is helped, then the treatment is worthwhile.’”

Traditional moral theories of rights and principles have dominated medical ethics discussions for decades. Appeals to utilitarian consequences, as well as the principles of respect for autonomy, beneficence, and justice, have provided the standard vocabulary and filled the literature of the field.

Recently on the bioethics scene, however, there has been some discussion of virtue, and, particularly within the nursing ethics literature, appeals are being made to the feminist ethics of care. This intimation of a shift in the wind may have to do with postmodern doubt, or it may be attributable to the claim that virtue theory and the ethics of care (which focus on the character or feelings of the agent, respectively) are more appropriate to private interaction; theories of rights and justice (which focus on the act rather than the agent) are best applied to the political domain of public policy.