Four years ago The Hastings Center initiated a “pluralism project.” That project gave the Center staff a chance to explore one swath of the theoretical literature concerning how members of democratic regimes ought to think about and respond to the differences among themselves. Much of that literature, produced by philosophers like Charles Taylor, Martha Nussbaum, and John Kekes, is wonderfully articulate about difference in general. But it is nearly silent about how particular categories of difference actually make a difference in the lives of particular individuals negotiating particular institutions.

Critics from a variety of camps have argued that bioethics has suffered an indifference to “difference.” Cases have been described as thin and the selves inhabiting them hollow. This criticism has been driven at least in part by a reworked conception of the self. The rational and autonomous self that once dominated bioethics discourse has been replaced with a more “textured” self, a self embedded in stories, relationships, families, communities, cultures, and other “thick” particularity—such as race, ethnicity, gender, sexual orientation, religion, and experience generally. The import of such a self is not simply descriptive accuracy; these contextual details—these differences—matter. They matter because they figure importantly into our ethical analyses of cases, affecting, for example, how we interact with and treat patients. And with this shift has come increasing attention to the processes of moral inquiry that enable inquirers to gather all of this moral information and find their way from complex cases to context-sensitive responses.

Modern feminism has been preoccupied with difference. An early and continuing struggle has been to acknowledge differences between men and women without having those differences used against women. That struggle has been extended to recognizing differences among women. By the end of the 1980s, women were calling for a “politics of difference” in which “redefining our differences, learning from them, becomes the central task.” Although cautioning words were raised by some, feminists in general moved to trying not only to recognize but to celebrate difference.

Cultural difference has been largely ignored within bioethics, particularly within the end-of-life discourses and practices that have developed over the past two decades in the U.S. healthcare system. Yet how should culture—specifically cultural differences as reflected among groups defined as ethnically or racially different—be taken into account?

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.

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.

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.

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.”

In responding to our paper “Germ-Line Therapy to Cure Mitochondrial Disease: Protocol and Ethics of In Vitro Ovum Nuclear Transplantation” (CQ Vol 4., No. 3), Matthew D. Bacchetta and Gerd Richter include several misinterpretations and misrepresentations of our IVONT protocol and structure for ethical debate. We actively invited scrutiny of our IVONT protocol; however, for us to seriously respond to criticisms of our publication, we suggest respectfully that those who critique the article critique the protocol that we proposed. First and foremost, we certainly do not have a “misunderstanding of cellular biology” regarding mitochondrial genetics.

We appreciated the important commentary provided by Michelle Oberman on our paper, “Discontinuing Life Support in an Infant of a Drug-Addicted Mother: Whose Decision Is It?” (CQ Vol. 6, No. 1). For the most part we agree with Oberman's analysis of the issues, but there are seven points of variance, either of conception, emphasis, or accuracy. We wish to clarify these and welcome the chance her commentary provided to offer aspects of the social situation surrounding the case we presented.

Genetic counselors are on the front lines of the genetic revolution, presented with tests of varying predictive values and reliability, unfair testing distribution mechanisms, tests for conditions where no treatment exists, and companies that oversell the usefulness of their tests to physicians and nurses. Many scholars, both genetic testing task forces as well as the newly formed National Bioethics Advisory Commission, have all noted that genetic counseling programs and services are critical for adequate genetic testing. At the same time, in our own work at the University of Pennsylvania we have encountered many requests for new materials for training genetic counselors in ethics and providing ethics resources for genetic counseling. One of us has noted elsewhere that it is crucial that resources from the Human Genome Project, the Centers for Disease Control, and other public agencies be devoted to providing better resources for genetic counselors facing difficult ethical issues. Although the American Board of Genetic Counseling requires that training programs include some formal coursework in ethics, many wonder whether enough is being done to prepare genetic counselors for an ever-tougher job, and in particular there has been much concern expressed about whether “nondirectiveness” is an outmoded ideal that hampers this profession as it attempts to grow and identify the value of its practice. On the basis of many comments to us by genetic counselors and on the basis of our review of the current literature, we hypothesized that accredited genetic counseling training programs are poised at the turn of the century to begin planning a new approach to teaching the philosophy of genetic counseling, one that integrates philosophical, theoretical, and ethical training throughout the curriculum in genetic counseling.

On August 1, 1996, due to the expiration of the five-year preservation limit provided by British law for unclaimed and legally unusable frozen embryos, 3,300 embryos were thawed and discarded. In Italy the news of this impending event triggered many reactions among scholars as well as the general population. In Massa, a little town in Tuscany, a most unusual response arose. Two hundred women banded together and asked to carry out a prenatal adoption. Their purpose in making this request was to avoid what they believed to be mass infanticide. Many of the women were married and already had children. They belonged to a local Catholic association. Nonetheless, their reaction was their own response to numerous appeals to respect life by the Catholic Church worldwide and by Italian Catholic thinkers especially.

Interdisciplinary hospital ethics committees have been the most common response to the mandates for ethical review procedures set forth by the Joint Commission for the Accreditation of Health Care Organizations (JCAHO, 1995 Standards), the American Hospital Association, and within institutions themselves. A 1989 national survey reported that 60% of hospitals had ethics committees. However, little is still known about the current state of these committees in hospitals, their composition, what functions are performed, or what issues are discussed.

Anyone with so much as a passing familiarity with bioethics knows how significantly and persistently (at least since mid-century) the law has insinuated itself into healthcare and the process of bioethical decisionmaking. Viewed from the insular perspective of traditional medical practice and medical ethics, it is not surprising that the “legalization” of the patient–physician relationship and clinical judgment has been characterized by some as pernicious. What is much more surprising, however, is when a book by a professor of law evinces the same jaundiced view of the role of law in this area. Nonetheless, the “limits” that Professor Dworkin considers to be inherent in the capacity of the law to resolve bioethical issues are significant, and hence in his opinion the role of the law should be severely circumscribed. This gloomy portrait of the “havoc” wreaked by law upon the landscape of medical practice, painted by a lawyer, stands in stark contrast to an earlier and much more sympathetic account offered by Columbia University historian and medical humanities professor David J. Rothman in his 1991 book Strangers at the Bedside, the informative subtitle of which is A History of How Law and Bioethics Transformed Medical Decision Making.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.