To clone humans is deliberately to generate two or more individuals who share the same nuclear deoxyribonucleic acid (DNA). Using animals, researchers have performed two basic types of cloning that will eventually yield commercial benefits. Embryo twinning involves separating the individual cells of an embryo and allowing each to cleave for later transfer to a uterus. Cloning by nuclear transfer involves removing the nuclei from embryonic cells or fetal or adult somatic (body) cells and fusing those nuclei with enucleated donor egg cells. Although for the purposes of commercial biotechnology these techniques do not raise undue concern when attempted with animals, embryo twinning, embryo nuclear transfer, fetal somatic cell nuclear transfer, and adult somatic cell nuclear transfer all provoke intense ethical discussions when considered for human use.

Open any standard bioethics textbook, and therein can be found a host of subjects ranging from the abortion rights controversy to the morality of xenographic tissue transplantation. Just as there is a wide scope to the subject matter of bioethics, its practitioners come from a multitude of disciplines, including law, medicine, nursing, theology, philosophy, sociology, and anthropology. And yet, despite a rich variety of investigators and methods, bioethicists overlook numerous subjects that deserve to be addressed. In particular, they neglect issues of public health, preventive medicine, and social medicine. Although topics such as physician-assisted suicide, prenatal genetic testing, and the ethics of new reproductive technologies constitute the contemporary canon of bioethics and deserve sustained analysis, these subjects are not so significant that they should eclipse other issues. For example, gun control policies, the regulation of food additives. immunization programs, prenatal care, leave programs enabling employees to care for dying relatives, the provision of nutrition and medical care to the homeless, and the use of emergency rooms by the most impoverished citizens are all topics neglected by bioethicists.

In vitro fertilization (IVF) is now a well-established practice in the field of assisted reproduction. In 1995, over 41,000 IVF cycles were done in the United States, at a cost of more than $300 million. The overall success rate has risen to 22.8 deliveries per 100 egg-retrieval procedures (19.6 deliveries per initiated cycle). As the field has matured, the attention of policy-makers has shifted from questions about the ethical and legal status of human embryos to concerns about providing access and protecting consumers.

Three such concerns have emerged. One is the danger that IVF programs will disseminate misleading information about their success rates in order to attract patients. This problem, however, may be alleviated by the publication in late 1997 of the first of annual national and clinic specific reports, based on randomly audited data, by the Centers for Disease Control and Prevention, the American Society of Reproductive Medicine (ASRM), the Society for Assisted Reproductive Technology (SART), and RESOLVE, pursuant to the federal 1992 Fertility Clinic Success Rate and Laboratory Certification Act.

During the past two decades, several reports have documented substantial support from clinicians, policy-makers, and the general public for the use of advance directives, yet studies continue to find that only a minority of individuals (10 to 25 percent) have completed these legal documents. Advance directives are written instructions, such as living wills or durable powers of attorney for health care, which describe an individual's medical treatment wishes in the event that individual becomes incapacitated in the future. The completion and use of advance directives is one of several components of the broader activity of advance care planning, that is, the overall planning and communication of personal wishes concerning future medical care.

In December 1991, the federal Patient Self-Determination Act (PSDA) became effective. Promoted as a federal initiative to enhance an individual's control over medical treatment decision making and, therefore, patient autonomy and self-determination, PSDA placed several new requirements on health care organizations receiving Medicare or Medicaid payments.

The risk of tort liability for health maintenance organizations (HMOs) and other managed care plans has dramatically increased in recent years. This is due in part to the growing percentage of health care rendered through managed care plans. The cost-containment mechanisms commonly used by managed care plans, such as limiting access to services and/or choice of providers, creates a climate ripe for disputes that may end up in court. As dissatisfied patients and providers seek recourse in the courts, tort doctrines are extended and new legal theories emerge as needed. For example, the concepts of direct and vicarious tort liability developed in the hospital context have been extended by courts to encompass HMOs. vicarious liability claims, based on ostensible agency or respondeat superior doctrines, have been brought against HMOs and managed care plans for negligent treatment by physicians selected to provide care to members.

Controversies associated with the use of Tylenol (acetaminophen) are not new to Johnson & Johnson. Reported cases of poisoning in 1982 and 1986 raised serious concerns about both the life of the analgesic and the well-being of consumers. In 1994, the results of two clinical studies raised product safety concerns about acetaminophen-based over-the-counter (OTC) analgesics, suggesting development of hepatotoxicity, and an increased risk of end-stage renal disease (ESRD). The alarm created by the studies is not of the same magnitude as the 1980s poisonings and the circumstances differed in that the findings did not only apply to acetaminophen-based analgesics; nonetheless, the implications of the latter are equally significant. Still operating by the same company credo, how Johnson & Johnson has handled the link between acetaminophen and hepatotoxicity and ESRD is of interest (especially when contrasted with its response to the 1980s poisonings); in particular, management's efforts to reassure both consumers and company shareholders.

When infertility clinics offer money-back guarantees, they prefer to give them more delicate names such as “shared risk,” “warranty,” or “outcome” programs. We should not allow such daintiness to distract us from the bottom line of these programs which are all about the bottom line.

John Robertson and Theodore Schneyer defend such programs as special forms of insurance, what they call “risk-of-failure insurance.” They argue, in “Professional Self-Regulation and Shared-Risk Programs for In Vitro Fertilization,” that the criticisms of in vitro fertilization (IVF) shared-risk programs by the American Medical Association (AMA) and others are off the mark. It would be sufficient, Robertson and Schneyer contend, to develop guidelines for informed consent or protocols that discourage risky clinical procedures. They acknowledge that shared risk plans “present problems if not offered with full disclosure and attention to patient interests,” but they insist that “there is no reason why they cannot be implemented in an ethically sound way.”

Having a serious illness like breast cancer is a calamity for individuals and families. Along with the pain, discomfort, and dislocation comes the issue of how to pay the medical expenses for the care and treatment of the disease. If the seriously ill person has inadequate or no insurance, these problems are aggravated.

Stories abound about seriously ill people losing private health insurance following diagnosis with a catastrophic disease, remaining in jobs just to maintain health insurance, or facing financial hardship because of gaps in coverage. Yet surprisingly little research has focused on the problems that people with serious illness face with health coverage and, in particular, how concerns about access to health insurance coverage shape their lives.

Further, despite profoundly moving anecdotes of cancer victims and other seriously ill people about their problems with health insurance and despite recent federal and state efforts to reform the private health insurance market in ways discussed below, neither the federal government, states, nor the private sector has crafted comprehensive strategies to enhance health coverage for the seriously ill.

Increasingly, the world seems to shrink due to our ever-expanding technological and communication capacities. Correspondingly, our awareness of other cultures increases. This is especially true in the field of bioethics because the technological progress of medicine throughout the world is causing dramatic and challenging intersections with traditionally held values. Think of the use of pregnancy monitoring technologies like ultrasound to abort fetuses of the “wrong” sex in India (where a female's dowry can be a tremendous burden to the family), the sale of human organs in and between countries, or the disjunction between the haves and the have-nots in South America when it comes to bone marrow transplants, while thousands of other children die for want of fundamental goods and services like clean water, basic inoculations, and food itself.

It is often claimed that managed care organizations (MCOs) involve physicians in conflicts of interest by creating financial incentives for physicians to refrain from ordering treatments or making referrals. Such incentives, the argument goes, force the physician to balance the patient's health interests against the MCO's interests and the physician's own financial interest. I assume, for the sake of argument, that such arrangements at least provide reason to believe that physicians in MCOs are involved in conflicts of interest. Two approaches have evolved for dealing with these conflicts. On one approach, MCOs disclose the financial arrangements under which their physicians work so that patients can consent to the managed care plan and thereby to the plan's limitations. The chief proponent of this approach is Mark Hall, whose recent book Making Medical Spending Decisions applies prior consent to a variety of decisions regarding medical financing and allocation. The other approach is simply to forbid conflicts of interest through regulations.

In February 1997, the Committee on Bioethics of the American Academy of Pediatrics (AAP) updated its position on religious exemptions to medical care. In its earlier statement, the committee noted that forty-four states have religious exemptions to the child abuse and neglect statutes, and they argued for the repeal of these exemptions. The committee did not indude in its statement a position on religious exemptions to childhood immunization requirements that exist in forty-eight states, although this issue was discussed in committee meetings. In its revised statement, the committee concluded that “The AAP does not support the stringent application of medical neglect laws when children do not receive recommended immunizations.” In this paper, we consider whether failure to immunize one's child is a form of medical neglect and, if so, whether states should repeal their religious exemptions to the immunization statutes. We argue that failure to vaccinate a child properly is medical neglect.