The case in favor of gene therapy is quite simple. Gene therapy is likely to improve the health and well-being of some people that are among the worst off in society, namely patients with painful and life-threatening diseases. However, two types of objection have been raised.

Starting bioethics in Russia we were motivated with the idea of the democratization of our society on a basic micro-social level. The country was swift enough to take several important steps in this direction on the macro-social level, i.e., to adopt a new constitution with guarantees of human rights and rights of ownership of private property, to elect the parliament and the president. But these modernizations in the Russian political facade did not sufficiently change the internal structure of the society–the net of everyday relationships in the home, at work, at school, in hospitals and other places. One of the most brilliant philosophers of the Russian “silver age,” L.S. Frank, wrote in the beginning of the century that a tyrannical state (at his time the czarist state) grows out of tyrannical interpersonal relationships. Political revolution not grounded in a social evolution on the basic level of satisfying “simple” human economic, physical, and psychological needs could reproduce only the same totalitarian pattern under a new ideological label. Events resulting from the Bolshevik revolution in 1917 proved the wisdom of his statement. Russia could suffer the same fate today.

Over the past two decades ethics committees have proliferated in healthcare institutions across the country. Catalysts for this growth include the endorsement of ethics committees by the New Jersey Supreme Court in the Quinlan case, by the President's Commission for the Study of Ethical Problems in Medicine and Biomedical Research (“President's Commission”) in its report entitled Deciding to Forgo Life Sustaining Medical Treatment, by the U.S. Department of Health and Human Services in its 1985 “Baby Doe” regulations, by numerous other courts in treatment decisionmaking opinions issued after Quinlan, and more recently by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).

Medical practitioners have traditionally seen themselves as part of an international community with shared and unifying scientific and ethical goals in the treatment of disease, the promotion of health, and the protection of life. This shared mission is underpinned by explicit acceptance of traditional concepts of medical morality, and by an implied link between individual human rights and the ethics of medical practice long enshrined in a range of World Medical Association (WMA) and other medical codes. These have been powerful instruments exhorting individual practitioners to promote health and to defend universal principles in order to protect their patients and the physician-patient relationship even in the face of authoritarian state coercion and imposed national ideologies and policies. There has been widespread support for this approach and this should be intensified.

Treatment of sick children of Jehovah's Witness and Christian Scientist families at times presents significant dilemmas to American medicine and ethics, for modern healthcare professionals rely heavily on active treatment, and withholding of some treatments is a central religious tenet for Witnesses and Scientists. In important instances, physicians, nurses, ethicists, and courts may wish to set aside traditional religious beliefs and values when medical values support treatment to which adherents of these sects at times object.

For more than two decades euthanasia and assisted suicide have been openly debated in the Netherlands. This development started in 1973 when the Regional Court in Leeuwarden decided a case in which a physician had administered a deadly dose of morphine to her terminally ill mother on the mother's serious and persistent request. In this case the court concluded that the average Dutch physician no longer considered it his or her duty to prolong a patient's life under all circumstances. The court accepted that in specific cases a physician is allowed to prevent serious and irreversible suffering, even if the patient's life is short ened. This case was the first in which a legal opening for euthanasia or assisted suicide was created. In this specific case the physician was formally declared guilty, but the court gave her a suspended sentence of one week imprisonment. This decision started a debate on euthanasia and assisted suicide throughout all levels of Dutch society.

Part of the debate on cost containment in healthcare systems may be characterized as applied political philosophy One might say that the current debate between competing theories of justice that started with Rawls' A Theory of Justice in 1971 has acquired a small sister debate in healthcare philosophy Major participants in the debate on social justice have become an important source of inspiration for bioethicists interested in a just distribution of healthcare resources. Thus Rawls' A Theory of Justice has been remodeled for healthcare philosophy by Norman Daniels. Nozick's libertarian manifesto Anarchy, State, and Utopia has been used for bioethical purposes by H.T. Engelhardt. The books of Daniel Callahan evidently belong to a family of communitarian theories, though Callahan cannot be said to follow one or another communitarian thinker (be it Christopher Lasch, Alisdair Maclntyre, or Amitai Etzioni) in particular. In the next two sections of this article I will give a very brief sketch of the debate on social justice in political philosophy and then discuss the sister debate on social justice in healthcare.

It is not the outpatient setting, per se, that is presenting new challenges and opportunities to ethics consultants and ethics committees. Rather, it is the underlying reason for shifting more and more patient care from the inpatient to the outpatient setting-namely, calculations of cost-effectiveness.

At the end of the most violent century in human history, it is good to take stock of our commitments to human and other life forms, as well as to examine the rights and the duties that might flow from their biological makeup. Professor Thomasma and Professor Loewy have held a long-standing dialogue on whether there are moral differences between animals and humans. This dialogue was occasioned by a presentation Thomasma made some years ago at Loewy's invitation at the University of Illinois, Peoria, Medical Center. During that presentation, Thomasma argued that human beings are sufficiently distinct from other animals genetically and otherwise to justify a moral difference in rights and obligations. In effect, he argued that there are species-specific rights. This essay will pick up the threads of that dialogue.

As the structure of healthcare delivery undergoes a breathtaking transformation, many ethics committees are wondering how and if they will be affected. Although the impact has not yet been widely felt, hospital-based ethics committees cannot avoid the pressures and upheaval caused by the reorganization of healthcare. This article will briefly review some of the factors contributing to the transformation of medicine, and suggest a number of ways in which ethics committees can respond proactively.

Voluntary active euthanasia (VAE) and physician-assisted suicide (PAS) remain technically illegal in the Netherlands, but the practices are openly tolerated provided that physicians adhere to carefully constructed guidelines. Harsh criticism of the Dutch practice by authors in the United States and Great Britain has made achieving a balanced understanding of its clinical, moral, and policy implications very difficult. Similar practice patterns probably exist in the United States, but they are conducted in secret because of a more uncertain legal and ethical climate. In this manuscript, we plan to compare end-of-life care in the United States and the Netherlands with regard to underlying values, justifications, and practices. We will explore the risks and benefits of each system for a real patient who was faced with a common end-of-life clinical dilemma, and close with challenges for public policies in both countries.

“Ethical dilemmas…are rarely simple and stark but are, instead, multifaceted, complex, and gut wrenching for parents and care givers alike.” This is never more the case than when one must treat vulnerable babies who are not, nor ever can be competent to offer us some guidance about that treatment. The ethical problems are heightened when the parents, or the single mother, are incompetent to make decisions themselves, for example, because of drug addiction. In such cases, when the baby is premature and suffering the effects of the drugs the mother has taken, and the mother herself is either no longer available for consultation or so damaged by her own addiction that she is not a reliable decisionmaker, the usual trend In the United States is to initiate treatment and continue until it is virtually certain that the infant will die.

Community discourse about the moral status of animals is critical to the future of bioethics and, indeed, to the future of modern society. Thomasma and Loewy are to be commended for sharing thoughts and trying to attain some common ground. I am grateful to them for fostering discussion and allowing me to respond. I cannot endorse the negative tone of the end of their conversation, however. They end with serious concerns about the possibility of any agreement between themselves. Even though I perceive some moral differences between them, I do not believe that they are moral strangers. In this commentary I review the ways in which I agree and disagree with Thomasma and Loewy and conclude with some thoughts about the kind of broad ethical thinking we need to do to address our moral relationship to nonhuman, living creatures.

When God gave humankind dominion over the earth he may not have known exactly what we would be able to do with it. The technical capacities to which the production and reproduction of our everyday life have given rise have grown at an astonishing and, it seems, ever-increasing rate. The instruments that we use to do work on the world have become sharper and more refined, and the implications of human interventions in the nonhuman environment are much more far-reaching than could have been imagined even forty years ago. It has become something of a cliche to say that our technical abilities have outstripped the wisdom to know when, where, and how we should appropriately use them, but techniques such as genetic engineering invite the dusting-off of the cliche and the asking of the question implicit in it: We know we can splice genes, but should we splice them? We might of course come to the conclusion that we should only splice some of them some of the time, but even arriving at that conclusion presupposes that the ethical question has been asked and answered.

Numerous studies have shown almost uniformly positive opinions among patients and physicians regarding the concept of advance directives (either a healthcare proxy or living will). Several of these studies have also shown that the actual use of advance directives is significantly lower than this enthusiasm would suggest, but they have not explained the apparent discordance. Nor have researchers explained why members of minority groups are much less likely to complete advance directives than are white patients. In this study, we used a focus group methodology to examine the ways in which diverse populations of patients view the medical, philosophical, and practical issues surrounding advance directives. We were motivated by the significantly lower prevalence of advance directives among African-American and Hispanic patients at one urban teaching hospital (18% for Caucasians, 4% for African-Americans, and 2% for Hispanics). Our premise was that African-American and Hispanic populations, who have had higher rates of morbidity and mortality across numerous disease categories, and historically have had limited access to care and opportunities to discuss health concerns, may be more suspicious about the right of autonomy that an advance directive is designed to ensure.

‘Treatment’ from which the patient cannot benefit is sometimes administered to a patient so that the comfort of the patient's family or caregivers may be increased. Is this permissible? To answer that question we will explore the interests of the permanently unconscious patient and the potential for such a patient's interests to conflict with those of her family and healthcare providers. We will conclude that in the likely absence of a specific advance directive from the patient providing for such circumstances, treatment for the benefit of the family may be given so long as it is not abusive. However, treatment solely for the comfort of caregivers may not be given without consent of the patient's surrogate decisionmakers.