Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the event of pneumonia.

You wrote an editorial in JAMA giving a 30-year retrospective on bioethics. If you look ahead to the next 30 years, what are the issues you see facing bioethics in the future?

Hospital ethics committees have become widespread over the last 25 years, stimulated by the Quinlan decision of the New Jersey Supreme Court, the report of a President's Commission, and most recently by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), which now man dates that each hospital seeking accreditation have a functioning process for the consideration of ethical issues in patient care. Laws and regulations in several states require that hospitals establish ethics committees, and some states stipulate that certain types of cases and disputes be taken to such committees. At least one state grants legal immunity to those who implement recommendations of an ethics committee.

The practice of nonphysician ethicist-consultants giving ethics advice concerning the appropriate medical treatment of patients in hospitals is a relatively recent development. Although only a minority of hospitals make substantial use of any formal ethics consulting service, the number is growing and apparently will continue to do so. Indeed, at least among urban teaching hospitals, some sort of ethics consulting service is increasingly commonplace.

In recent years, bioethics has increasingly become an international area of inquiry with major contributions being made not only in North America but also in Europe and in the Pacific Rim countries. This general observation is particularly true for research ethics. Little attention has been paid, however, to this internationalization of bioethics in general and research ethics in particular, and there are few studies comparing what has emerged in the different countries.

An anencephalic infant, who came to be known as Baby K, was born at Fairfax Hospial in Falls Church, Virginia, on October 13, 1992. From, the moment of birth and repeatedly thereafter, the baby's mother insisted that aggressive measures be pursued, including cardiopulmonary resuscitation and ventilator support, to keep the baby alive as long as possible. The physicians complied. However, following the baby's second admission for respiratory failure, the hospital sought declaratory relief from the court permitting it to forgo emergency life support on the grounds that “a requirement to provide respiratory assistance would exceed the prevailing standard of medical care,” and that “because any treatment of their condition is futile, the prevailing standard of medical care for infants with anencephaly is to provide warmth, nutrition, and hydration.” The United States Court of Appeals for the Fourth Circuit ruled in favor of the baby's mother, citing the federal Emergency Medical Treatment and Active Labor Act (popularly known as the “anti-dumping” act), which contained no “standard of care” exception to the requirement to provide “treatment necessary to prevent the material deterioration of the individual's condition.” An appeal to the United States Supreme Court was rejected. The baby died some two and one-half years later of cardiac arrest during her sixth visit to the emergency department of Fairfax Hospital for respiratory failure.

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.

Since its inception decades ago, technological intervention in human reproduction has been the subject of considerable attention and controversy. After identifying two focal points of debate, I focus in this paper upon an emerging body of literature responsive to a host of problematic issues that, scholars claim, reproductive technologies pose. Maintaining that critical assessment of this literature is necessary, I identify two areas of inquiry which deserve attention and, correspondingly, sketch directions which might guide further study.

Equipoise is an essential condition to justify a clinical trial. The term, describes a state of uncertainty: the data suggest but do not prove a drug's safety and efficacy The only way to resolve this uncertainty is further study In many cases, a clinical trial seems to be the most efficient way to prove safety and efficacy Equipoise is therefore not an esoteric philosophic construct applied to research ethics. Rather, since it is vital for the justification of clinical trials, it is part of how society regulates medical progress. Where there is equipoise, drug design and development proceeds according to Food and Drug Administration (FDA) and Health and Human Services (HHS) regulations. When that equipoise ends, a drug is either not approved or becomes standard care.

A scientist at Edinburgh University announced in 1994 that he had removed ovaries from, mouse fetuses and transplanted them, to adult mice. The ovaries released eggs, and conceptions occurred. Although this was not the first such attempt with mice, the study attracted attention because the researcher suggested, that fetal to adult ovarian transplants were a theoretical possibility for humans. If aborted, fetuses were used, as egg sources in assisted conception, a new entity would arise: the never-born genetic mother. Using eggs from aborted fetuses for conception would lead to quixotic and novel family ties. Its use would echo surrogate gestational motherhood, in which a child has both a genetic mother who contributed her egg and a gestational mother who contributed her uterus for gestation and childbirth. With fetal egg use, however, the child's genetic mother would be a never-born fetus without sentience or known, physiology.

Recent ethics literature suggests that issues involved in non-heart-beating (NHB) organ procurement are both highly charged and rather urgent. Some fear that NHB is a public relations disaster waiting to happen or that it will create a backlash against organ donation. The purpose of the study described below was to assess ethics committees' current level of involvement in and readiness for addressing the difficult issues that NHB organ retrieval raises—either proactively through policy development or concurrently through ethics consultation.