This issue of CQ was conceived in Salt Lake City, at the third annual meeting of the American Society of Bioethics and Humanities (ASBH). There, President-elect Laurie Zoloth delivered a stirring address, emphasizing the role of bioethics in responding to social deprivations and suggesting that ASBH “take a stand” on important issues where members share consensus. Not all the stirrings were pleasant. Debate erupted about the propriety of consensus statements, especially regarding possible deleterious effects on academic discourse, misappropriation of dues, and the proliferation of quasi-political factions. The roots of this controversy extend deeply into the collective psyche of contemporary bioethics.

Bioethics is not merely a theoretical discipline but a practice as well. Indeed, bioethics is a sort of moral trade. Bioethicists serve on ethics committees, give expert testimony to courts, provide guidance for healthcare policy, and receive payment for these services. The difficulty is that their role as experts able to guide clinical choice and public policy formation is brought into question by the diversity of moral understandings regarding central moral issues at the heart of the culture wars in healthcare. The disconfirmation of the expert role of bioethicists by their apparent actual role as partisans of particular moral schools and perspectives could be set aside, were there an avenue to moral consensus, a door to a common moral vision to guide this new profession of moral experts. This brief article addresses the hunger for consensus in bioethics, its impossibility with respect to the controversial issues that mark the field, and the inclination nevertheless to deny this manifest diversity by appeals to a consensus that could allow bioethicists to function as ethics experts able substantively to guide clinical choices and public policy.

Several months ago, I was walking down the hallway outside our medical school faculty offices and a colleague stopped me to ask a question. He phrased his query in the context of a “hypothetical” case that raised ethical issues for him, and he asked me to respond. I obligingly offered my opinion given the details he presented, ending my comments with the phrase, “at least, that is what I would say.” To this he kindly shot back, “OK, but what is the consensus of medical ethicists?” To be honest, this question caught me off guard. Though his particular dilemma was relatively well-trod territory for many bioethicists, I had done little research on the issue and could not immediately render a response to his latter query.

Contemporary bioethics is a peculiar creature. What was once a subdivision of moral theology and philosophy tended mainly within the confines of schools of arts and sciences or seminaries has now become a quasi-profession whose practitioners come from a wide variety of disciplines. Perhaps still more intriguing is that the “members” of this discipline routinely engage the public at the hospital bedside, in the institutional boardroom, and through public policy consultation. Bioethicists have actively embraced these roles as the natural outgrowth of their research and study. Contemporary bioethics is thus a “demi-discipline.” It is study and research but completes itself in public engagement.

Contemporary bioethics begins with the perception that medical values are a matter of public, rather than merely professional, interest. Such was the message of delegates in Helsinki and of the New Jersey court that decided for Quinlan. It is a theme that lurks within almost every major bioethical treatise since the first edition of Principles of Bioethics. This perception also undergirds the increasingly popular suggestion that moral authority in the patient-physician relationship resides neither in the medical profession, nor in the singular will of the patient, but in moral communities that link both parties with higher social orders.

The field of bioethics is by definition based on the presupposition that questioning, arguing, interruption, and response are the means by which we evaluate the truth claims of medicine and healthcare policy. The field began with the premise that another voice, one of at least critique, if not dissension, was just what was needed in any arena in which hegemonic expertise held sway. The field of the humanities is similarly based on the idea that both the literary and cultural canon—and the disputation and resistance to the canon—are acknowledged, taught, and honored. In situ in the clinic, on national boards, or in the literature, when a philosopher perceives a unanimity, she begins to be uneasy and begins to do the very thing she is trained for: to raise the questions of definition, method, data, motive, and goal.

It has been a pleasure to read these papers and to contemplate their importance for what I believe to be a useful and provocative prism though which to view the field of bioethics: the nature of moral consensus. In my own most extended contribution to this literature, Deciding Together, I did not attempt to prescribe so much as to understand the role of moral consensus in the practice of bioethics. At the end of the book, I expressed the hope that it might help trigger an examination of bioethics and moral consensus. Though a few others shared my interest at that time (in particular Tris Engelhardt, for whose early encouragement I remain deeply grateful), with this set of stimulating papers the conversation has finally begun in earnest.

These CQ Sources were compiled by Bette Anton.

John Portmann attributes the current shortage of organs for transplantation to the dual effects of bioethics' reverence for autonomy and a general anxiety in the public about cutting bodies. Contrary to Portmann, I argue that attributing even partial blame to autonomy for organ shortages wrongly locates the problem. Indeed, there is reason to believe that waiting lists would be considerably shortened by respecting people's autonomy. I also question Portmann's explanation of the general aversion to organ donation in terms of a deep-seated anxiety about cutting bodies.

T. L. Zutlevics has written a thoughtful response to my piece on the anxiety borne of cutting bodies. I am grateful for this opportunity to turn back to the pressing problem of organ shortages.

Jean E. Chambers and Timothy F. Murphy responded to my article “Cloning and Infertility” and extended the debate over human cloning in interesting ways. I had argued that none of the objections to cloning by somatic cell nuclear transfer are successful in the context of infertile couples who use cloning to have genetically related children, assuming the issue of safety is overcome by scientific advances.

For many commentators in bioethics and the law, safety is the fulcrum for evaluating the ethics of human reproductive cloning. Carson Strong has argued that if cloning were effective and safe it should be available to married couples who have tried to have children through various assisted reproductive technologies (ARTs) but been unable to do so. On his view, cloning should be available only as reproductive last resort. I challenged that limited use by trying to show that the arguments Strong adduces in favor of reproductive somatic nuclear transfer (SNT) for married couples extend to same-sex couples as well, who face a different kind of infertility. I also went on to argue that his justifications would in fact extend the legitimate use of SNT to any couples regardless of whether they had fertility difficulties or not.

In 1992, the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) passed a mandate that all its approved hospitals put in place a means for addressing ethical concerns.Although the particular process the hospital uses to address such concerns—ethics consultant, ethics forum, ethics committee—may vary, the hospital or healthcare ethics committee (HEC) is used most often. In a companion study to that reported here, we found that in 1998 over 90% of U.S. hospitals had ethics committees, compared to just 1% in 1983, and that many have some and a few have sweeping clinical powers in hospitals.

Admittedly, productivity is valued in American society. For jobs that involve manufacturing, each minute of production is calculated in formats of cost and profit. Management sets goals for individual and team performance that foster competition and an ever-fervent culture of output. Industry and academia have gone to great lengths to develop tools that measure productivity as a variable, and certainly, in the manufacturing setting, productivity is a value because it promotes competition (thus more output) and efficiency (less waste). But is it ethically appropriate for productivity-based values and goals to cross over to healthcare allocation? Can other constructions of productivity be valued in terms of healthcare allocation or is the American work ethic (benefiting people in the prime of their productive years) an ethically appropriate route?

Chris Shaw is the Chair of Biotechnology and Head of the Pharmaceutical Biotechnology Research Group at the University of Ulster in Northern Ireland. His concern for the unequal distribution of benefits has prompted him to take a leading role in developing partnership models for scientists doing research in underdeveloped countries.

Imagine a genetic counselor working with a young couple pregnant with their first child. The explosion of genetic knowledge and technology in recent years is complicating this professional relationship as a host of new choices brings a few clients with atypical needs. This couple is deaf. They seek not to avoid a child with their disability but rather to assure that the child too will be deaf—a child to share their culture and perspectives on the world. If prenatal diagnosis indicates that the prospective child would be hearing, they intend to terminate the pregnancy and try again. So, how should the counselor respond to this request for services? Does a traditional deference to parental autonomy in reproductive matters require that we respect such decisions by informed couples? More broadly, what are the concepts by which society will guide policy in this new and sensitive domain?

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 igve you an opportunity to respond in the letters section. Your input is desired and anticipated.