Contributors.

Bioethics is a cautionary field. It warns society to be aware that the real danger lies not so much in ignorance but in the illusion of knowledge—and to be prepared for the unexpected. At the same time, bioethicists are an optimistic group in that we stake our professional lives on the belief that there is such a thing as progress. The point of our efforts is to help us to be wiser in our choices by expanding our views and avoiding overgeneralizations. Wisdom, however, is a long-term investment requiring far-reaching explorations.

Relativism is usually a derogatory word in philosophical bioethics in the West. If people make the mistake of trying to understand radically “different” points of view, an accusation of relativism is quickly forthcoming. But why should this be an accusation? My aim in this paper is to demonstrate that it should not.

On the beautifully clear and sun-filled morning of September 11, 2001, just before I went to vote in the New York City primary elections, news came over the car radio that a plane had crashed into the North Tower of the World Trade Center. As I drove toward Manhattan after casting my ballot, newscasters reported a second plane crashing into the South Tower. It became instantly clear to everyone that these were acts of terrorism. We were under attack. All around me the behavior of New York City drivers immediately converted from the standard aggressive mode to a remarkably accommodating style, and in a dramatically uncharacteristic way cars yielded to make way for the emergency vehicles that were suddenly racing down the highway. Only one car surged to follow in their wake.This paper is a revised and shortened version of my chapter, “Justice in Allocations for Terrorism, Biological Warfare, and Public Health” in Public Health Ethics, edited by Michael Boylan, Kluwer; 2004. Portions of this material were presented at the International Bioethics Retreat, Pavia, Italy, June 2003, and at the meetings of the Association for Politics and the Life Sciences, Philadelphia, September 2003.

In the regime of Anglo-American tort law, every person has a responsibility to comport him- or herself with “due care” in going about day-to-day activities so as not to imperil the health, safety, or general welfare of others. The gold standard for determining what constitutes due care in any particular situation is what a reasonable person, similarly situated, would do. Determinations of due care are necessarily fact specific. Nevertheless, the general objective is to strike an appropriate balance between an unrealistically high standard of caution and one that fails to take into account the known or foreseeable risks of any human endeavor. The same standard applies to individuals regardless of their age (so long as they have reached majority), gender, race, and level of education or economic status. The standard also applies to fictional “persons” such as corporations. The usual or prevailing custom and practice in an industry or occupation may provide relevant evidence of what constitutes “due care” in the activities common to it, but that evidence can be effectively overcome or rebutted by competent, credible evidence that the custom and practice either diverges from what it has been asserted to be or that the custom and practice is itself unsafe or otherwise poses an unreasonable risk of harm to others. Until quite recently, a singular exception to this general principle of tort law was made for the medical profession. We will consider this exception in the next section.

There are, broadly speaking, two kinds of knowledge—analytic and intuitive, explicit and tacit. Analytic knowledge is arrived at by logical deductive thinking, and is a sequential thought process in which each step can be explained and defended. Intuitive knowledge, in contrast, is frequently alogical or nonrational (though not illogical or irrational), and often involves nonconscious mental processes. Though intuitive ways of knowing are essential to both scientific research and scientific medicine, the culture of medicine celebrates only the analytic, evidentiary kind of knowledge, while eschewing intuition as being “nonscientific.” The popularity and prevalence of what is known as evidence-based medicine reflects this bias in favor of the analytic and the explicit. Though the evidence-based approach has contributed greatly to standardizing medical care, favoring treatments for which there is evidence of effectiveness, it has limitations. An overreliance on evidence-based medicine is problematic, because this approach leaves out important factors in the actual practice of clinical medicine such as diagnosis (pattern recognition, hunches), nonverbal cures provided by patients, and the way the doctor–patient relationship bears on patient management and compliance, and because it is not appropriate for dealing with medical conditions that do not lend themselves to study by controlled clinical trials.

Over the past decade, genetic tests have become available for a wide variety of disorders. As a result we are able to predict, with some degree of certainty, whether or not an individual will develop such diseases as breast cancer, Huntington's disease, polycystic kidney disease, and familial adenomatous polyposis. The ability to predict disease poses several unique ethical considerations for clinical decisionmaking regarding the provision of genetic testing. Patients must be able to comprehend the complexities of genetic testing and the potential meaning of the results. Patients must consider the emotional, social, and economic consequences of revelations regarding their risk status. Also, obtaining information on risk status may have implications for persons other than the individual seeking genetic testing.

Despite the fact that ethics consultations are an accepted practice in most healthcare organizations, many clinical ethicists continue to feel marginalized by their institutions. They are often not paid for their time, their programs often have no budget, and institutional leaders are frequently unaware of their activities. One consequence has been their search for concrete ways to evaluate their work in order to prove the importance of their activities to their institutions through demonstrating their efficiency and effectiveness.

The issue of prenatal testing and selective abortion has never received open public appraisal. This is somewhat regrettable. The interest in this area, however, is rapidly growing. In part this is a result of concerns about the rate of development in genetic knowledge and questions as to its application. For instance, there will be a huge increase in the scope of conditions or features for which we will be able to screen, some of which could hardly be described as significant. Further, for some time now, people with disabilities have had concerns about the practice of prenatal testing and selective abortion. This article looks at the relationship between reproductive autonomy, prenatal testing and associated practices, and the interests of people with disabilities. It asks whether such practices negatively affect the interests of such individuals, and if so, how. This is an important question for the formulation of public policy in this area. Although some groups have studied this issue in detail, policy bodies do not necessarily fully engage with their analyses. This may be a reflection of public confusion about this issue. To some degree, fear of causing offense may also inhibit both expression of public opinion and, in turn, policy analysis. This is unfortunate and needs to be acknowledged.I am grateful to participants of the Mt. Sinai School of Medicine—King's College London—Oxford Consortium on Bioethics, 2003, for comments on an earlier draft of this paper and particularly to Professor Jonathan Glover and Dr. Bobbie Farsides for conversations relating to it.

A demographic revolution is taking place in Europe and worldwide. According to World Health Organization (WHO) estimates, the number of people aged 60 and over is growing faster than any other age group. This change in the population structure affects disease patterns and is deemed to cause an increase in the demands on healthcare systems. This raises concerns about the ethics of healthcare delivery (among others). What criteria should direct healthcare distribution? Is it right to meet the demands of an ageing population, to the detriment of the younger strata of population?This paper has been written thanks to the support of the European Union, which has sponsored my project on ageism with a Postdoctoral Marie Curie Fellowship. More details on this project are available at the website http://les.man.ac.uk/simona/. I thank Prof. John Harris for our discussions on the topic and for his comments on this paper.

The question of whether or not either elderly people or those whose life expectancy is short have commensurately reduced claims on their fellows, have, in short, fewer or less powerful rights than others, is of vital importance but is one that has seldom been adequately examined. Despite ringing proclamations of justice and equality for all, the fact is that most societies discriminate between citizens on the basis both of age and life expectancy.

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics.

The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated.

The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration.

All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at tuija.takala@helsinki.fi.

Transplantation is now the best therapy for eligible patients with end-stage organ disease. For patients with failed kidneys, successful renal transplantation improves the quality and increases the quantity of their lives. For people with other types of organ failure, transplantation offers the only hope for long-term survival.This study was supported by a grant from the Upstate New York chapter of the National Kidney Foundation.

Every day in the United States 17 people die waiting for an organ transplant. The waiting list for organs, which now contains the names of 82,000 people, has more than tripled in the last 10 years. The U.S. policy on who can donate an organ is based both on previous consent of the potential donor and on the consent of the donor's family. This foundation greatly limits the number of potential donors. Spain is the world's leader in providing organs to its population, and the underlying principle of their policy on donors in presumed consent. That is, those people who have not expressly opposed donating their organs are considered eligible for donation. This policy, along with a plan of public education and a strong infrastructure for organ procurement, is what has enhanced their donor rates. Spain is not alone: other countries have seen the benefits of presumed consent and the limits of opt-in systems. The United States must put to use the experiences of these countries to stem the tide of organ shortage and give new life to those desperately awaiting organs.I would like to thank Dr. Philip Lee, Geoffrey Heller, and Dr. Linda Hogle for their invaluable advice on this article.

Whether one loves, hates, or is indifferent to statistics, it is impossible to avoid the fact that scientific medicine is founded on statistical thinking. Statistics does much more than help us determine if a drug or treatment procedure is efficacious. It provides a rational framework for studying a stunningly broad array of medical questions. Will an annual mammogram measurably decrease a 40-year-old woman's risk of early death? What is the best public health response to minimize morbidity and mortality from an intentional release of Bacillus anthracis? How can we rationally allocate limited medical and financial resources to deal with public health risks into the future? All of these questions, and most associated with public health and even curative health care, ultimately require quantitative evaluation. Dig down to the epistemological heart of medicine, and there you will find statistics and mathematics smiling, some might say glaring, back at you.

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 feature editor 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.