For years there was no focus within the U.S. federal government for alternatives to animal toxicity testing. Questions coming to regulatory agencies fell upon individuals to address in the best way they could. Given this void, the ad hoc Interagency Regulatory Alternatives Group was founded by staff in a number of federal agencies in the late 1980s to coalesce efforts in the field. The group sponsored two international workshops on eye irritation, the first making proposals for change in the current test method in rabbits, the second reviewing available data on in vitro alternatives. The result has been that the Organization for Economic Cooperation and Development (OECD) is considering revision of the in vivo eye irritation test guideline to incorporate a number of the workshop deliberations. However, movement of the in vitro eye irritation alternatives has been disappointing; attempts to determine their practical testing significance have thus far been unrewarding.

On the first page of this very timely paper the author quotes Linda Gordon: “Birth control has always been primarily an issue of politics, not of technology.” This statement provides a theme for response to Jing-Bao Nie's arguments. In reading this paper, I found myself reminded of two of George Orwell's insights: (1) When governments use euphemisms they are usually up to no good: “Such phraseology is needed if one wants to name things without calling up mental pictures of them” [e.g., the use of “remedial measure” for abortion]. “A mass of Latin words falls upon the facts like soft snow, blurring the outlines and covering up the details.” (2) Sexuality and the sexual act (I would add here reproduction—having children) can be a powerful tool of subversion and rebellion. One's sexuality (and reproductive ability) can be the last line of defense against repression or authority.

Fox, McGee, and Caplan's “Paradigms for Clinical Ethics Consultation Practice”, in the Summer 1998 issue of CQ, evoked memories and an image.

These CQ Sources were compiled by Bette Anton.

I would like to present the details of an actual case from my own experience over which I, along with the family, have agonized. I think this case brings into focus some of the unique issues in perinatal medicine where multiple patients, some real and some potential, can enter into a single decision. I hope that through this presentation others may gain insight into the complexities of applied ethics in perinatal medicine.

Twenty years ago, Australian biomedical researchers took the first steps along a pathway toward common ground with opponents of the use of animals in science. Leaders of Australian medical research at that time saw the necessity of established science facing the ethical and political challenges that a revived antivivisectionist movement was mounting in the late 1970s and the 1980s.

Appropriate concerns about cost and unequal access to healthcare have resulted in the creation of powerful managed networks seeking to share the risks of high healthcare costs among plans, providers, and patients. Much to their credit, these managed networks have slowed the rise in healthcare spending by as much as 44% in markets with high HMO penetration. However, whether these savings will materially improve access and quality remains to be seen.

In an interesting response to an article I published in CQ that questions the ability of advance directives to reflect autonomy, Christopher Tollefsen raises a number of issues that deserve greater attention. Tollefsen offers several examples to illustrate how the critique of advance directives I offer would also threaten other choices that most people would consider autonomous. Importantly, I largely agree that the examples Tollefsen offers should be captured as autonomous. Where I disagree, however, is whether these examples reflect the particular type of second order decision strategy that I categorize advance directives as, and so whether the critique of advance directives I offer, if accepted, would commit us to an unreasonably narrow conception of autonomy.

Carson Strong has argued that if human cloning were safe it should be available to some infertile couples as a matter of ethics and law. He holds that cloning by somatic cell nuclear transfer (SCNT) should be available as a reproductive option for infertile couples who could not otherwise have a child genetically related to one member of the couple. In this analysis, Strong overlooks an important category of people to whom his argument might apply, couples he has not failed to consider elsewhere. In this discussion, however, Strong refers exclusively to opposite sex couples facing obstacles such as surgically removed ovaries and the inability to produce sperm. In fact, however, there are many adult couples who, while fertile in and of themselves, are not fertile as couples. This group includes not only opposite sex couples but coupled same sex partners as well. I believe the defenses Strong offers regarding the use of SCNT by opposite sex infertile couples would extend to same sex couples for two reasons. First, some same sex couples might face the inability to have a genetically related child, and second, Strong's arguments ultimately ground a general defense of SCNT independent of the question of a couple's fertility.

CQ Sources is compiled and edited by David A. Buehler, 50 Elliot Street, Dartmouth, MA 02720 USA. Please send any additions, corrections or suggestions directly to him at this address or online to 〈[email protected].〉

Decisions concerning use of gene therapy will probably not be made within the privacy of what was once a dyadic doctor–patient relationship. More likely, some overarching guidelines will emerge directing or limiting the practice. Debate and position-taking over the myriad scientific, social, ethical, legal, and political implications of research into and manipulation of the human genome has intensified since the U.S. government officially launched the Human Genome Project in 1988 by appropriating funds to the Department of Energy and the National Institutes of Health (NIH) for genome research. The discourse this costly research endeavor has generated in the scientific and bioethics literature and even in the popular press outlines a host of issues likely to evoke attempts at line drawing and policymaking. Many of these issues lend themselves easily to the shorthand of dualistic opposition: somatic cell therapy (insertion of genes into patients' nonreproductive cells or tissue to accomplish the work of defective or missing genes) versus germ line therapy or engineering (manipulation of a patient's reproductive [germ] cells and the undifferentiated cells of early embryos); correction of defects and disease only versus enhancement of conditions not considered defects or diseases; intervening on the basis of phenotype only (physically expressed genetic traits or symptoms) versus intervening on the basis of genotype also (the biochemical composition of an individual's genome).

A woman presents to her physician with a newly diagnosed condition that in her considered and informed judgment requires an elective surgical procedure. The physician, after speaking with her, agrees that this is an acceptable option. The procedure in question is in fact one of the commonest surgeries performed on American women. The physician is also aware that although the procedure is deemed elective in this and in most cases, research has shown that the consequences of not providing the procedure when it is requested can be severe in terms of both physical and emotional sequelae—in fact, the woman's death can be a worst-case result when the procedure is denied. However, this senior physician is also aware that the procedure is controversial, and that ever fewer of his (now mostly younger) colleagues perform it, either because they are not appropriately trained, not so inclined, or fearful of becoming the target of vocal and even violent opponents of the procedure. In fact, he knew of seven American physician colleagues who had been slain in the past five years for providing this procedure, and of 16 more attempted slayings. Seeking an appropriate referral for this patient, the physician learns that she will have to travel hundreds of miles, involving considerable additional expense and delay—which itself can add to the complexity and risk of the procedure. Presented with this option, the patient expresses dismay but also her resigned commitment to follow through with this referral, and leaves the office in tears.

Michael Stingl's sensitive paper links two debates now dominating contemporary Western societies: the debate on euthanasia and the debate on healthcare reform. The link is important for both practical and theoretical reasons. Given the rise of national expenditures for healthcare, most governments have a strong interest in cost containment. In various countries we see reduced accessibility to healthcare services and facilities, albeit for different reasons. Sometimes healthcare is largely a matter of private insurance, as in the United States; sometimes shifts are made toward rising financial copayments for the use of particular services, as seems to be the case in Canada and in many European countries; sometimes accessibility is reduced by waiting lists, characteristic of systems with socialized medicine such as in Britain and the Netherlands.

Germ-line therapy has long been regarded with great caution both by scientists and by ethicists. Even those who do not reject germ-line therapy in principle have tended to reject it in practice as carrying unacceptable risks in our current state of knowledge. For this reason, a recent paper by Rubenstein, Thomasma, Shon, and Zinaman is unusual in putting forward a serious proposal for the use of germ-line therapy in the foreseeable future.

Kant postulates in The Metaphysics of Morals that we share a moral duty to sympathize actively in the suffering of another and to cultivate the virtue of compassion. More recently, Howard Brody has claimed that a good physician must maintain in her imagination “that separate vantage point from which the experience of the sufferer can be reinterpreted and reconnected to the broader context of culture and society.” What does it mean to take suffering seriously in the context of abortion? It means that a physician must listen to three rival versions of suffering: that of a woman who has inquired about an abortion, that of her fetus, and that of the community in which the woman lives. The professional duty that Brody ascribes specifically to physicians compounds the moral duty we all share to lessen suffering. Physicians differ importantly from nonphysicians, for suffering is their business.

Technical, ethical, and social questions of germ-line gene interventions have been widely discussed in the literature. The majority of these discussions focus on planned interventions executed on the nuclear DNA (nDNA). However, human cells also contain another set of genes that is the mitochondrial DNA (mtDNA). As the characteristics of the mtDNA grossly differ from those of nDNA, so do the social, ethical, psychological, and safety considerations of possible interventions on this part of the genetic substance.

A recent issue of Cambridge Quarterly of Healthcare Ethics provides a fascinating look into the uncertainties surrounding the subject of human cloning. As Nelkin and Lindee point out, for example, the popular assumption is that this technology will lead to individual immortality. “Again and again media stories predict that cloning will allow the resurrection of the dead … life everlasting for the deserving.” This is not an attitude reserved to popular imagination, however. As John Harris noted in his contribution, for example, even the World Health Organization (WHO) “considers the use of cloning for the replication of human individuals to be ethically unacceptable.”

These CQ Sources were compiled by Bette Anton.

The patient was a 19-year-old female who was transferred to this children's hospital from a community hospital in a neighboring state. She is well known to the hospital staff because she had a kidney transplanted and retransplanted several times there. Her first transplant as at age 8 and she was retransplanted most recently approximately 3 years ago. She immediately rejected her second kidney and received a third. She is currently admitted because she is again rejecting her kidney, probably due to not taking her medication. The ethics consultant was called because the attending physician wanted to know if it was ethical to retransplant a “noncompliant” patient.

The article by Jessica Pierce and Christina Kerby, “The Global Ethics of Latex Gloves: Reflections on Natural Resource Use in Healthcare,” raises some important but seldom asked questions about the use of natural resources in healthcare. They take for their example latex gloves, which are in wide everyday use, especially since the establishment of principles of universal precautions in infection control as a reaction to the spread of HIV. They trace the production of latex gloves back through rubber processing to their origins in Malaysian rubber plantations and elsewhere. They then ask, but do not answer, some hard questions about the ethics of our relationship as patients to the impact of the materials we use on communities and the environment. To draw out their theme more starkly, consider the rumor widespread in South America that some babies purportedly adopted by Northerners are sold and cut up for their organs. Suppose this story were true; suppose your donated organ were obtained in this way. You would probably be so revolted by the immorality of its acquisition that you would refuse to accept it. But now take a morally more ambiguous case, as Pierce and Kerby intend. Suppose that the process of obtaining latex gloves is part of the gradual erosion of the Malaysian environment, and that workers in latex factories are poorly paid. Now, should or would you refuse to use latex gloves? Should or would you even be more selective in their use? The practice of universal precautions presumes a virtually unlimited supply of gloves; yet to react to resource scarcity with selective precautions hazards discrimination. Is there any way philosophically to balance the local justice issue of discrimination in comparison to injustice on a global scale and to future generations?