Paradoxically, the unifying characteristic of our annual Open Forum issues is the absence of any particular thematic topic, a common thread of concern that is examined and discussed from multiple perspectives. What the papers do share, however, is a challenge and invitation to readers to take up the arguments presented here and advance the discussions with their own debates.
In the spirit of our Open Forum issue, Joseph J. Fins in “Lessons from the Injured Brain: A Bioethicist in the Vineyards of Neuroscience” describes ground-breaking work being done to expand understanding of the biological and ethical differences in differing states of severe brain injury. Fins shares his personal reflections and experiences as a physician–ethicist in collaboration with neuroscientists as they seek to chart the terra incognita of the mysterious world of patients described as “minimally conscious.”
In “Negative and Positive Claims of Conscience,” Mark R. Wicclair challenges a state of affairs that protects negative claims of conscience by exempting healthcare professionals from penalties for refusing to provide or participate in providing goods or services when it is contrary to their moral or religious beliefs, but fails to extend similar protection to positive, or conscience-based claims, for an obligation to provide professionally permitted medical goods or services when doing so is prohibited by the law or other institutions. Wicclair recognizes that, in both cases, the moral integrity of the healthcare professional is at stake and, although claims of conscience might have different moral weights that must be balanced against competing claims, it is both logically consistent and morally imperative to recognize both types of claims of conscience.
What moral claim, if any, do persons with alcohol-related end-stage liver disease (ARESLD) have on such absolutely scarce resources such as transplantable organs? This is the thorny question addressed by Walter Glannon in his paper, “Responsibility and Priority in Liver Transplantation.” Rejecting the stronger claim that ARESLD patients should be excluded from transplant consideration, he argues for giving them lower priority with a reduced place on the transplant wait list. The aim of his paper is to give principled reasons as to why some people may have a weaker claim than others to a scarce life-saving resource and to demonstrate how the facts of particular circumstances can justify treating people unequally.
Thanks to Leigh Turner in “Bioethics and Social Studies of Medicine: Overlapping Concerns,” a full spotlight is focused on the distrust, misunderstandings, and, yes, ignorance that often characterizes one discipline's view of the other. As Turner points out, dichotomous thinking and polemical accusation falsely suggest that there is a profound gap between bioethics and social studies of medicine and tidy distinctions are unfounded and unhelpful. Moving past an emphasis on the differences that distinguish academic disciplines, Turner says we can recognize the extent to which bioethicists seek to understand particular social worlds while social scientists draw upon moral terms and categories in their interpretations of particular social settings.
Taking a cue from Robert Frost's line that “Good fences make good neighbors,” Raymond De Vries responds to Turner in “Why Can't We All Just Get Along” by suggesting that too much togetherness may not be a good thing. Provocatively, he declares that he is “persuaded that the interdiscipline of bioethics will be more productive if social science and bioethics do not get along.” His argument is centered on the observation that bioethics is well served by interdisciplinary tension and if social scientists and bioethicists get along too well, the field of bioethics will suffer. Although sharing a common goal, the topics and the disciplines composing bioethics are disparate, and therein lies their strength.
A meta-ethics of pain medicine is the subject of “Culture, Subjectivity, and the Ethics of Patient-Centered Pain Care,” in which James Giordano, Joan C. Engebretson, and Roland Benedikter call for an approach to the pragmatic and moral issues in pain care that is grounded in the realities defined by persons in culture. Persons cannot be extracted from culture, and even if pain is interpreted solely as a neurophysiologic event, the effects of culture cannot be ignored. For pain medicine to treat and heal the person made vulnerable by pain, physicians must go beyond thinking of pain only as object but also to understand how the event of pain is subjectively experienced by the “culturally nested patient.”
In “Race-Based Medicine and Justice as Recognition: Exploring the Phenomenon of BiDil,” authors Joon-Ho Yu, Sara Goering, and Stephanie M. Fullerton offer an analysis of how the FDA's approval of the drug BiDil for treatment of heart failure in African Americans marked the public entry of the pharmaceutical industry into the arena of race-targeted drugs. Although the authors take seriously the potential risks of rebiologizing the concept of race, they also recognize the desire of some in the African American community to take that risk as a stop toward achieving justice. The pharmaceutical industry's increasing interest in drug development and marketing that is racially targeted carries both positive and potentially negative consequences and deserves further attention and debate.
As these Open Forums show, doing bioethics is not just an internal monologue but potentially a powerful instrument to expose intellectual error, offer new approaches, and possibly change policies. At its best, bioethics is an implied conversation between author and reader, an invitation to be more tenacious in our analyses, and a call to join in making things better.
