Several recent articles raise an issue long unaddressed in the medical literature: physician compliance with patient or family requests for futile or ineffectice therapy. Although they agree philosophically that such treatment ought not be given, most physicians have followed the course described by Stanley Fiel, in which a young patient dying of cystic fibrosis was accepted “for evaluation” by a transplant center even though he has already passed the threshold of viability as a candidate for a heart-lung transplant. Dr. Fiel reported this action was taken not in the hope of doing the transplant but so that the family could assure themselves they had done “everything possible.” The patient, after a long and stressful cross-country flight, arrived at the hospital in respiratory failure. He died soon thereafter far from home and familiar surroundings.

The ethics of clinical research may be viewed from three different perspectives: the process of acquiring new knowledge, the moral use of the knowledge acquired, and the ethics of the investigator seeking this knowledge.

Erhics committees and ethics consultants are becoming more involved in helping individuals make decisions and in advising institutions and legislatures about drafting policy. The role of these committees and consultants has been acknowledged in law, and their function is generally considered salutory and helpful. Ethics consultants and committees, furthermore, play a critical role in educating students and members of the hospital community and the public at large. More over, many ethicists engage in scholarky activities to expand the boundaries of our understanding and, in turn, facilitate our capacity for helping. The role of the ethicist and of the ethics committee is thus manifold. Ethics committees and ethics consultants somehow “in competition” is a mistaken notion: when ethics committees, ethics consultants, and the community work smoothly together, much good can be accomplished.

I find myself in a strange position writing a commentary to an article on ethics committees because in Germany, ethics committees in the American sense do not exist. What we call Ethikkommission are present in every German faculty of medicine and would be called institutional review boards (IRB) in the United States; committees that review research projects of faculty members with respect to ethical standards. So i most consult my imagination rather than my experience about what really happens in Americal ethics committees. There are only two things. I perhaps can fall back on to simultaneously inspire and bridle my imagination. I have been sitting for 5 years on the IRB of our faculty and have been giving ethics seminars and case discussions to students for more than 10 years. Ethics is an optional subject in Germany and attracts the more sensitive and thoughtful students. Perhaps the intellectual process generating itself in those groups in some ways similar to that occurring in ethics committees. As for the rest, I hope to profit from the so-called unprejudiced perspective of the foreigner. I agree with a great deal of Loewy's descriptions and even with suffering as a principle, but I have some doubt whether that occurring in ethics committees. As for the rest, I hope with a reat deal of Loewy's descriptions and even with suffering as a principle, but I have some doubt whether that principle has the highest possible generality.

In recent years, the theoretical work of Gilligan in women's psychological development has led to the development of the concept of moral orientation or moral voice in contrast to the concept of moral reasoning or moral judgment developed by Kohlberg. These concepts have been of particular interest in gender studies, especially as applied to adolescence. These concepts of moral orientation and moral reasoning are being increasingly employed in healthcare ethics studies in a wide variety of settings. The recent work has included studies of physicians, nurses, dentists, veterinarians, social workers, teachers of medical ethics, and hospital ethics committees. However, the study of moral development in healthcare providers has been hampered because collecting the necessary data from healthcare workers has been labor intensive and extremely time consuming. More efficient methods are needed.

In the last issue of Cambridge Quarterly, I summarized several sessions on bioethics held at conferences sponsored by organizations that are not usually thought of as being in the mainstream of bioethics. In particular, I mentioned the American Public Health Associtation and the American Anthropological Association as examples of organizations with broad interdisciplinary memberships that have developed specialized interests in the relationships between their respective fields (Public health and anthropology) and healthcare ethics. The article pointed out that there are other voices outside the field of bioethics that make valuable contributions to the shape, function, and direction the field takes.

Historically, patients have deferred to physicians′ judgments about appropriate medical care, thereby limiting patient participation in treatment decisions. In this model of medical decision making, physicians typically decided upon the treatment plan. Communication with patients focused on securing their cooperation in accepting a treatment decision that essentially had already been made.

The patient was a woman in her 30s who, until the rapid progression of an ultimately fatal neurologic disease, had been a very successful professional, enjoying athletics and an active social life. In the 6 months of swift deterioration, she had gone from being extremely vibrant and energetic to being totally unable to care for her personal needs. There had been no loss of intellectual capacity. Her sister later recounted to Dr. J., the emergency department physician, that she had found the patient unconscious and unresponsive at home and had immediately called the patient's neurologist in a neighboring city. He directed her to call the paramedics.

During Operation Desert Shield and Operation Desert Storm, USNS Mercy (T-AH 19) was one of two American hospital ships deployed to the Persian Gulf. She arrived in the Gulf on 15 September 1990, following a 12,000-mile transit from her homeport of Oakland, California, and remained on station until 18 March 1991, when she passed through the Straits of Hormuz on her return voyage home. During the height of her deployment, Mercy was staffed with nearly 1,200 men and women, including physicians, nurses, dentists, representatives of affiliated health-care disciplines (including physical therapy, pharmacy, clinical psychology, social work, dietetics, and environmental health), hospital corpsmen, dental technicians, healthcare administrators, chaplains, and various nonmedical support personnel. The staff included a mix of active duty military providers and recalled reservists.

Most of us find the surgeon's surprise at this patient' request understandable, and it is hard to imagine any surgeon acceding to this patient's demand. On the other hand (the one left), the patient is right—the surgeon is denying his technical skill because his values are different from those of the patient, whose values the surgeon does not respect. The autonomy of the patient is being limited by the values of the doctor whose own interests, other than his interest in practicing medicine according to his own ethical values, would remain unaffected by his decision to provide the service.