Can anyone doubt that the Jewish tradition mandates universal access to healthcare? In a comprehensive and illuminating discussion, A.L. Mackler seems to have already said all that needs to be said. After aptly analyzing the principles of the traditional institutions and norms relating to tzedakah (social justice, or welfare), Mackler proceeded to apply these traditions to the context of healthcare, concluding that

Society has the responsibility to ensure that needed medical care is provided to those who would otherwise be unable to receive it... Medical care for potentially life-threatening conditions justifies extraordinary expenditures, and represents an urgent obligation of society. (p. 150)

As part of an effort to look at “what differences make a difference” for bioethicists interested in clinical decisionmaking, Erik Parens, the editor of this special section, asked us to look at social class. When we began our research for this paper, we were surprised to find that although bioethicists have written much on social class and such macrolevel issues as access to healthcare and the distribution of scarce resources, and have paid some attention to the effects of class on patient-provider relationships, bioethicists have written little specifically that looks at the implications of social class for medical decisions in individual cases.

The majority of adults in Britain cite the mass media as their main source of information about developments in science and technology. This alone makes it worth studying how the press covered the story of Dolly the cloned sheep. However, the media's reporting of Dolly revealed serious difficulties in the relationship of science to society. Although there were failures of journalistic accuracy and balance, these should not be allowed to obscure the deeper issues.

According to the present argument, worries that some individuals might make premature or unnecessary choices for themselves regarding euthanasia should further motivate and help shape our discussions about healthcare system reform. The reason for this is that in some cases individuals with chronic or terminal illnesses may have their lives made more unbearable than they otherwise might have been by the failure of the healthcare system to respond appropriately to their needs. Until these apparent inadequacies are remedied, there will remain doubt about whether such individuals have made a free and reasonable choice in favor of euthanasia, or whether such a choice was in effect forced upon them by the effects of unjust gaps in the provision of health services. Thus, it is inferred that there is a deep connection between discussions regarding liberalizing euthanasia in Canada and the ongoing move to reform our healthcare system. Further, it is claimed that explicit recognition of these links in the context of public debate will better inform our decisions in regard to both.

One of the arguments that is often put forward in the discussion of human cloning is that it is in itself wrong to create a copy of a human being.

When attempting to answer the question, “What difference does religion make?” in the context of clinical healthcare, one might be tempted to leap to either of two rather obvious, but seemingly contradictory conclusions. On the one hand, we might have a general impression of religion not making much of a distinctive and clear difference, at least in the actions and outcomes of most cases of clinical interaction. Those of us in the bioethics world of discourse are likely to think only of the less common cases of Christian Scientists, Jehovah's Witnesses, Orthodox Jews, or certain “fringe” religious groups who seem to the majority of the population to hold especially sectarian, if not “irrational,” beliefs about medical matters. The so-called mainstream religious groups do not get much attention because they largely don't cause much trouble (at least where their religion is concerned); they have learned to bracket their religious commitments from at least any professional settings (if they even understand how those commitments relate to healthcare at all); or they don't hold views entailing consequences any different from those of most nonbelieving, generally upright individuals. Furthermore, although religious believers may have some distinctive views, these views don't often noticeably manifest themselves in distinctive or significant “difference-making” ways.

The philosophical debate over the moral difference between killing and letting die has obvious relevance for the contemporary public debate over voluntary euthanasia. Winston Nesbitt claims to have shown that killing someone is, other things being equal, always worse than allowing someone to die. But this conclusion is illegitimate. While Nesbitt is correct when he suggests that killing is sometimes worse than letting die, this is not always the case. In this article, I argue that there are occasions when it is better to kill than to let die.

When addressing cultural and religious differences in the clinical setting we need to be realists. Despite our public homage to pluralism and good intentions, it is just not possible to overcome all the differences that might exist and achieve perfect understanding of others. Try as we may, we will never be able to see perfectly the world through another's eyes. Instead of reaching for such perfection, we should instead reach for an approximation of shared understanding that will promote discourse and civility when peoples of different races, genders, cultures, religions, and sexual preferences interact in the clinic.

A number of common and generally noncontroversial practices in the care of patients at the end of life lead to their deaths. For example, physicians honor a patient's refusal of medical intervention even when doing so leads to the patient's death. Similarly, with a patient's or surrogate's consent, physicians administer sedatives in order to relieve pain and distress at the end of life, even when it is known that doing so will cause the patient's death. In contemporary U.S. public policy, these practices are accepted as ethical and legal while physician-assisted suicide (PAS) is—for the most part—rejected in current U.S. law and public policy. Some think, however, that if one accepts practices that are known to lead to a patient's death, then one cannot reasonably reject a patient's request for a lethal dose of medication so that she may kill herself (PAS).

Among those who criticize the concept of ‘medical futility,’ a common refrain is that we really have no idea what futility means. For example, physicians seem to disagree on whether a treatment being futile means that it has a less than 5% chance of working or a 20% chance of working. If the concept is so unclear, then it seems a thin reed upon which to base a momentous ethical decision—namely, that the physician's judgment should be allowed to override the wishes of the competent patient or the patient's duly appointed surrogate.

The panic occasioned by the birth of Dolly sent international and national bodies and their representatives scurrying for principles with which to allay imagined public anxiety. It is instructive to note that principles are things of which such people and bodies so often seem to be bereft. The search for appropriate principles turned out to be difficult since so many aspects of the Dolly case were unprecedented. In the end, some fascinating examples of more or less plausible candidates for the status of moral principles were identified; central to many of them is the idea of human dignity and how it might be affected by human mitotic reproduction.

People with disabilities use more medical care and see health professionals more often than do those of the same age, ethnic group, or economic class who do not have impairments. An indisputable medical goal is “preventing, ameliorating, or curing disease and its associated effects of suffering and disability, and thereby restoring, or preventing the loss of, normal function or of life.”

On Sunday morning, 23 February 1997, the world awoke to a technological advance that shook the foundations of biology and philosophy. On that day, we were introduced to Dolly, a 6-month-old lamb that had been cloned directly from a single cell taken from the breast tissue of an adult donor. Perhaps more astonished by this accomplishment than any of their neighbors were the scientists who actually worked in the field of mammalian genetics and embryology. Outside the lab where the cloning had actually taken place, most of us thought it could never happen. Oh, we would say that perhaps at some point in the distant future, cloning might become feasible through the use of sophisticated biotechnologies far beyond those available to us now. But what many of us really believed, deep in our hearts, was that this was one biological feat we could never master. New life—in the special sense of a conscious being—must have its origins in an embryo formed through the merger of gametes from a mother and father. It was impossible, we thought, for a cell from an adult mammal to become reprogrammed, to start all over again, to generate another entire animal or person in the image of the one born earlier.

Not everyone finds a “salvific meaning” in suffering. Indeed, even those who do subscribe to this interpretation recognize the responsibility of each individual to show not only sensitivity and compassion but render assistance to those in distress. Pharmacologic hypnosis, morphine intoxication, and terminal sedation provide their own type of medical “salvation” to the terminally ill patient suffering unremitting pain. More and more states are enacting legislation that recognizes this need of the dying to receive relief through regulated administration of controlled substances. Wider legislative recognition of this need would go far toward allowing physicians, in the exercise of their reasonable medical judgment, to administer a range of narcotics and barbiturates to the terminally ill without fear of legal sanctions. Sadly, social attitudes and governmental concerns about the spread of drug addiction provide an undeniable policy nexus that impedes unduly a rational approach or exception for the treatment of pain experienced by the dying.

Howard Brody expresses concern that citing the “two cases that put futility on the map,” namely Helga Wanglie and Baby K, may be providing ammunition to the opponents of the concept of medical futility. He in fact joins well-known opponents of the concept of medical futility in arguing that it is one thing for the physician to say whether a particular intervention will promote an identified goal, quite another to say whether a goal is worth pursuing. In the latter instance, physicians are laying themselves open “to the criticism of taking on basic value judgments that are more appropriately left to patients and their surrogates.” Brody states that in both the Wanglie and Baby K cases, the “basic value judgments” had to do with the worthiness of maintaining unconscious life via medical technology. He classifies this as “a question of professional integrity—but not a question of futility,” adding that “more than semantics hinges on this distinction.” The “more than semantics” factor is a pragmatic, even political one. Failure to make this distinction renders physicians “that much more suspect and less trustworthy in the public debate.”

In Márquez's Of Love and Other Demons Abrenuncio the physician and the Marquis discuss the outbreak of rabies that is the centerpiece of the book, since the Marquis' daughter has been bitten by a rabid dog. Abrenuncio notes that the poor “had the courage to poison the food of their rabid kin in order to spare them of a ghastly death... People believe that we physicians do not know that such things occur... That is not true, but we lack the moral authority to endorse them. What we do instead is... commend them to St. Hubert and tie them to a pillar in order to prolong and intensify their suffering.”

Although there are important moral arguments against cloning human beings, it has been suggested that there might be exceptional cases in which cloning humans would be ethically permissible. One type of supposed exceptional case involves infertile couples who want to have children by cloning. This paper explores whether cloning would be ethically permissible in infertility cases and the separate question of whether we should have a policy allowing cloning in such cases. One caveat should be stated at the beginning, however. After the cloning of a sheep in Scotland, scientists pointed out that using the same technique to clone humans would, at present, involve substantial risks of producing children with birth defects. This concern over safety gives compelling support to the view that it would be wrong to attempt human cloning now. Thus, we do not reach the debate about exceptional cases unless the issue of safety can be set aside. I ask the reader to consider the possibility that in the future humans could be cloned without a significantly elevated risk of birth defects from the cloning process itself. The remainder of this paper assumes, for sake of argument, that cloning technology has advanced to that point. Given this assumption, would cloning in the infertility cases be ethically permissible, and should it be legally permitted?

Everybody recognizes that most of the problems in medical ethics arise, these days, from innovations in medical technology. We would not have had to lay down laws or ethical guidelines about assisted reproduction had it not been for the new technology of in vitro fertilization, which produced the first IVF baby in 1978. We would not be currently anxious about the ethics of possible human cloning, had it not been for the production in Edinburgh of Dolly, the lamb whose birth resulted from the removal of a mammary gland cell from an adult sheep. So the question is whether there is some research into developing technology that is too dangerous, that will lead to consequences too dramatic for humanity, for the research itself to be permitted. Should there be control over what technological innovation should be permitted?