The issue of the protection of communities in clinical research first arose 10 years ago in studies conducted in technologically developing countries by scientists from technologically developed nations. The question was, which ethical standards ought to apply, those of the Western investigators or local standards?

Who is this young woman that seems to have chosen to die by default? She is in effect parentless at a labile and vulnerable age. An attempt at a different social environment has failed. She is depressed. Unknowns are her issues, feelings, and concerns and whether antidepressants have been tried, and if so, what their effect has been. Additional data not given is whether dialysis has been tried, and if not, why not? The known track record of adolescents doing poorly on dialysis would be a concern, but then so is the loss of a scarce resource.

A quick tour through an average U.S. hospital gives pause to anyone with even a rudimentary concern for environmental issues. To a careful observer, the typical U.S. hospital presents an array of challenges to the health of ecosystems. For example, hospitals consume vast quantities of natural resources. The most obvious of these are fossil fuels, which form the basic building blocks of the industrialized medical care industry. Aside from the worry that our healthcare systems are technologically and functionally dependent upon nonrenewable, relatively scarce, and politically volatile resources, our heavy reliance on fossil fuels has important ill effects, including unfavorable health outcomes for humans. For example, the combustion of fossil fuels is the driving force behind global warming, which will likely result in increasing heat-related mortality and morbidity and may contribute to the spread and resurgence of infectious diseases around the world. Also, the combustion of coal and oil releases pollutants such as sulfur oxides, nitrogen oxides, and ground-level ozone that contribute to various respiratory ailments. In addition to being energy intensive, the modern hospital uses a great deal of water, wood, paper, metals, minerals, plastics, chemicals, food, and land.

At the level of theoretical foundations, contemporary bioethics is to a large extent Balkanized. Without difficulty, one can find contributions from communitarians, consequentialists, and feminists, as well as those who advocate “the principle approach,” an “ethics of care,” and “narrative ethics.” The problem is not so much the wide diversity of views as the lack of agreement over the basics of medical ethics. For that reason alone, any attempt to find (or induce) some harmony among these many diverse voices is a welcome addition to the literature. Fragmentation and Consensus is such an attempt. Kuczewski argues that both communitarianism and casuistry can be understood as neo-Aristotelian approaches to ethics, and that once these views are “purged of non-Aristotelian elements” communitarianism and casuistry are found to be highly complementary. In the process of constructing his theory, Kuczewski also finds room for liberal political theory and narrative ethics. The resulting amalgam is interesting, and the project ambitious.

Professionals in transplantation medicine have a particularly difficult task that most other healthcare professionals in the United States do not have to face explicitly. That is, the transplanters control the use of scarce solid organs. Because they invariably have more than one patient who might benefit from a new kidney (or liver, heart, etc.), they cannot focus single-mindedly on their duty to each and every patient as if no other patient mattered. In the case at hand, the patient has had more than one “gift” of a life-sustaining organ. At some centers, one, perhaps two, previous organs would count as “enough.” After that, the patient has had her chances and it is time to move on to others. Moreover, some believe the patient in this case has contributed to the current problem by inadequate care of the gifts she has been given.

We were not surprised by the opinion piece written for the Cambridge Quarterly by George J. Agich, Ph.D., who chairs the Cleveland Clinic Foundation's bioethics department. Dr. Agich uses the article to attack those who criticized his institution's proposed non-heart-beating organ donor protocol. Because we reported on this controversy for 60 Minutes in April 1997, we wanted to set the record straight.

Physicians and nurses caring for terminally ill patients are expected to center their moral concerns almost exclusively on the needs and welfare of the dying patient and the patient's family. But what about the relationship of traditional medical ethics to the emerging new theories of environmental ethics, like deep ecology? As we glide into the twenty-first century, can anyone seriously doubt that the mounting global concerns of environmental ethics will eventually influence the ethics of medicine too?

In Part 1 of this essay, I raised the following question: How would our care of the dying patient change if environmentally inspired theories of ethics, like deep ecology, were imported into current Western norms of patient care?

It was a hot summer night, the kind where the air is so thick it seems to ooze into your lungs. I heard a knock on the door. “Come in,” I complained.

Frank Koughan and Walt Bogdanich's response to my article, “From Pittsburgh to Cleveland: NHBD Controversies and Bioethics,” reminds me of the Shakespearean line, “The lady protests too much, methinks.” My article was not about the specifics of the 60 Minutes April 13, 1997, story on NHBD at the Cleveland Clinic Foundation (CCF), even though the story formed the basis for the reflection. I did not attack the critics, though I do believe that bioethicists are accountable for their scholarly and public pronouncements. Although I do not see why the 60 Minutes' story should be treated with deference, my article was designed to raise questions for a primarily bioethics audience about the involvement of bioethicists in media coverage of bioethics topics. I am flattered that they took notice of my piece, but think their efforts to set the record straight only obfuscate matters further.

I work at a large urban medical center. Our hospital has over 1,200 beds and was built in 1805 to take care of the poor. Our patients are still poor, but now so are the hospital and the doctors. Russian doctors are paid about one-third of what truck drivers are paid. The government historically allocates no more than 3% of the budget to medicine because this is not a means of production, like manufacturing.

This case is not about whether retransplant candidates should receive organs over first-time candidates, or whether risks of transplant failure from psychological or social factors are relevant to allocating organs. Rather, it concerns only this patient's qualifications to wait for a kidney transplant. Should the patient's prior transplants, noncompliance, and poor social network exclude her even from the waiting list? Do attending physicians inappropriately favor their patients over all others in need of transplants just by listing them? The answers turn on the difference between identifying a transplant need and allocating an organ.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.

This tragic case raises two important ethical issues. One is the obvious problem of just allocation of scarce transplant organs. The other is the less obvious problem of the healthcare team's feelings of commitment to their patient. Together they present an unusual conflict for bioethics.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.

Muraskas et al. and Hefferman and Heilig present the painfully elusive ethical questions regarding decisionmaking in the care of the extremely low birth weight (ELBW) infants in the intensive care nursery. At what gestation or size do we resuscitate? Can we stop resuscitation after we have started? How much money is too much to spend? Is the distress of the parents of the ELBW infant, the anguish of their caregivers, and the moral and ethical uncertainty of the approach to these infants too much to pay? Who speaks for the neonate: the parent, nurse, attorney, or physician? Ideally these questions should have been answered 30 years ago when modern neonatology embarked on a journey from where it could not return. A new breed of physician, called “neonatologist,” seduced by the high-tech lure and the promise of saving lives previously unsavable pioneered a lucrative and life-saving technological revolution in the care of premature newborns. This rapid advancement in neonatology occurred a few years after the death of a premature infant named Patrick Kennedy in 1963. While the country mourned, medical scientists vowed that this would not happen again. First continuous positive airway pressure, then mechanical ventilation, changed medical care of premature newborns forever. It began an era of euphoria and excitement. Neonatologists raced to push to the edge of newborn viability. What was the youngest salvageable gestational age? What was the smallest that could be saved? Yes, we dreamed, and still do dream of artificial placentas. Ethical questions took a back seat in the search for the edge because the waters were uncharted and the tough questions could not be answered without experience. What was to be the cost in dollars and in anguish to save the Patrick Kennedys of the world? Triumphs led to grave concerns as we approached the edge. However, no advancement in neonatology has ever changed the ultimate questions.

The transplant coordinator scheduled a meeting that included numerous members of the multidisciplinary team, among them the transplant surgeon, a social worker, a psychologist, and an ethics consultant. The ethics consultant outlined the ethical issues and made a recommendation. The consultant argued that the question whether the patient should again be listed as a transplant candidate really came down to the kind of environment that could be provided during aftercare. That is, if a rather structured living environment—one more structured and supportive than the previous independent living facility—could be found for the patient, then retransplantation might be warranted. But without such an environment, the patient would again probably fail to adhere to the medical and psychological treatment regimen necessary for a successful life as a transplant recipient. The psychologist, who had been working closely with the ethics consultant, concurred in this opinion.

In a recent issue of Cambridge Quarterly of Healthcare Ethics, Howard Brody and Lawrence Schneiderman offer contrasting opinions about how to apply the concept of “futility” in medicine. Brody holds that “futility cases” are those in which it is reasonably certain that a given intervention “will not work” when applied for the purpose of attaining a specific clinical goal. To determine which actions are futile, Brody prescribes a division of labor. Patients (or patient surrogates) are charged with choosing the goals of treatment while physicians are charged with determining whether specific treatments will be effective in achieving these goals. Though physicians do not choose specific goals, Brody thinks they have a prerogative to decide whether they can, in good conscience, aid in the achievement of specific patient goals. Let us use “positive validation” to denote choosing between alternative goals and “negative validation” to denote choices about whether one will assist in the pursuit of particular goals. Brody's position is essentially that patients are positive validators and that physicians are negative validators. Brody concludes that treatments that are effective in achieving patients' goals are not futile—even when physicians' personal or professional moral commitments prevent them from offering these treatments for the given purpose. “Futility” applies only where interventions won't “promote a goal that both agree is desirable.”

As in other countries, medical ethics in Mexico has rescued the world of philosophical ethics from oblivion. The needs of clinical medicine gave birth to Mexican bioethics. After the growth of scientific and technologic subjects in medical schools, the humanities, such as medical history, deontology, and medical philosophy, were replaced by such core subjects as radiology, pharmacology, and microbiology. Since the 1950s, graduates from Mexican medical schools have not been exposed to any courses in the medical humanities.

The patient was born at 29 weeks gestation. There was a prenatal diagnosis that the child's small intestine had developed outside of the abdominal cavity. The length of gestation had made the initial prognosis good. But after birth, surgery to place the intestine back into the abdominal cavity found that the baby actually had very little small intestine and a diagnosis of “dead gut syndrome” was made. The amount of small intestine was not compatible with survival. The transplant service saw the baby twice and each time said the baby's profile did not meet the transplant protocol.