Hideo Kimura, a 46-year-old Japanese male patient in a Boston hospital, needs to undergo surgery to remove part of his lower intestine but resists signing the consent form and has little understanding of English. Discussing this with an interpreter, Hideo is puzzled, because he has already authorized his wife Sachiko to decide on his behalf. The interpreter points out to him that he has a right, a moral right, to give his informed consent to the surgery and that Hideo is quite competent to decide for himself. Nonetheless, Hideo cannot grasp the meanings of “informed consent” and “moral right.” Hideo agrees to sign the consent form only after he is told that this is official hospital policy.My thanks for insightful comments and critique by reviewers.

As healthcare institutions expand and vertically integrate, healthcare delivery is less constrained by geography, nationality, or even by institutional boundaries. As part of this trend, some aspects of the healthcare process are shifted from medical centers back into the home and communities. Telehealth applications intended for health promotion, social services, and other activities—for the healthy as well as for the ill—provide services outside clinical settings in homes, schools, libraries, and other governmental and community sites. Such developments include health information web sites, on-line support groups, automated telephone counseling, interactive health promotion programs, and electronic mail exchanges. Concomitant with these developments is the growth of consumer health informatics, in which individuals seeking medical care or information are able to find various health information resources that take advantage of new information technologies.

Many different factors influence our health prospects. The food we consume, the lifestyle we live (e.g., sedentary or active), our economic prospects, our love prospects, our gender, our age, and our education all influence our expected lifetime acquisition of what John Rawls calls the “natural primary goods” (e.g., health, vigor, imagination, and intelligence). Our well-being is also influenced by the natural endowments we inherit from our parents. All people have two copies of most genes, one from their mother and one from their father. Genes are the fundamental physical and functional unit of heredity; they “specify the proteins that form the units of which homoeostatic devices are composed.”Earlier versions of this paper were presented to the Department of Philosophy at the University of Waterloo, the James Martin Advanced Research Seminar at Oxford University, and the Department of Politics at Manchester University. I am grateful for the helpful feedback that I received on those occasions.

Informed consent is a perennial topic in bioethics. It has given the field a place in clinical practice and the law and is often the starting point for introductory instruction in medical ethics. One would think that nearly everything has been said and done on this well-worn topic.

Through a number of studies recently published in the psychology literature, T.D. Wilson, D.T. Gilbert, and others have demonstrated that our judgments about what our future mental states will be are contaminated by various distortions. Their studies distinguish a variety of different distortions, but they refer to them all with the generic term “affective forecasting.” The findings of their studies on normal volunteers are remarkably robust and, therefore, demonstrate that we are all vulnerable to the distortions of affective forecasting.We are grateful for the questions and useful comments we received from our audience when material from this paper was originally presented. The insightful remarks helped us to appreciate what we needed to explain further and to see how our ideas applied to additional domains of medicine: Rhodes R. Affective forecasting and the implications for medical practice. Presented at Medicine Grand Rounds, North General Hospital, New York, Apr 19, 2006. Rhodes R, Strain JJ. Affective forecasting and its implications for medical ethics. Presented at Oxford-Mount Sinai Consortium on Bioethics, St. Thomas's Hospital, King's College London, Apr 24, 2006. Rhodes R. Affective forecasting and its implications for medical ethics near the end of life. Presented at Responding to End-of-Life Decisions: Perspectives from Medicine, Law, and Ethics, International Academy of Law and Mental Health, University of Montreal, May 5, 2006 and at the David Thomasma International Bioethics Retreat, Pellegrue, France, Jun 15, 2006.

In the United States, healthcare providers, institutions, and society have failed to ensure the conditions necessary for racial and ethnic minority communities to be in good health. Many scholars and federal government officials consider racial and ethnic disparities in health to be an injustice and have called for national attention and strategies to eliminate them. Several of these strategies, including cultural competency, focus on addressing deficiencies within the health care system. Cultural competency is the ability of a healthcare provider to function effectively in the context of cultural differences with the clients they serve. Increasing cultural competency among healthcare providers has been shown to improve the quality of healthcare received by racial and ethnic minorities, which contributes to reducing health disparities. Achieving equity in the quality of healthcare received is a necessary strategy, but is insufficient for eliminating disparities in the health status of racial and ethnic minority populations. A growing body of literature reveals that health disparities are determined, not only by inequities in health care, but by social factors. The implication is that strategies that focus solely on healthcare perpetuate the misconception that health status is determined by access to or quality of healthcare. To eliminate racial and ethnic disparities in health status, the fundamental conditions for good health, which include but are not limited to healthcare equity, must be acknowledged and ensured for all people.Special thanks to the editors of this issue, John R. Stone and Erika A. Blacksher, as well Eugenia Eng, Shelley Golden, and Mondi Mason, for their helpful comments.

Healthcare systems in Singapore, Hong Kong, and mainland China are strikingly distinct from those in the West. Economically speaking, each of the aforementioned Eastern systems relies in great measure on private expenditures supplemented by savings accounts. Western nations, on the other hand, typically exhibit government funding and wariness about healthcare savings accounts. This essay argues that these and other differences between Pacific Rim healthcare systems and Western systems should be assessed in light of background Confucian commitments operating in the former. In the Confucian context, bioethics and healthcare policy have a unique content, texture, and set of implications that often affront Western assumptions about the appropriate individual autonomy of patients and the appropriate character of social safety nets for healthcare.

The potential public and individual health consequences of unequal access to digital technologies have been recognized in the United States for at least a decade. Unequal access to the Internet and related technologies has been characterized as a “digital divide”; naturalistic trends toward broader access across the population and targeted intervention to increase access are described as progress toward “digital inclusion.” The problem of the digital divide has been characterized as one of healthcare justice. The idea that everyone should have access to the telecommunications grid—telephone and computer—is a central tenet of the U.S. universal service policy. With the diffusion of broadband technologies, the issue of digital access includes not only access to the Internet but also access to new levels of service, such as broadband, to support a wide range of emerging applications.

Informed consent has passed through three stages. The first paternalistic stage lasted for many centuries: The doctor's diagnosis and healing arts were kept secret, and informing patients was regarded as professionally and ethically wrong. Second came the legal stage, when the right of patients to make informed decisions concerning their own treatment was imposed by the courts and reluctantly tolerated by medical professionals. The third informed consent stage emerged more recently: the general therapy stage. The therapeutic benefits of informed consent have been well established, and informed consent is widely recognized as an important element in sound medical practice. When patients are effectively informed and can exert knowledgeable control over their own treatment decisions and therapy processes, that enhances recovery, strengthens the immune system, promotes better pain tolerance, prevents depression, and encourages patient cooperation and fortitude in treatment, rehabilitation, and preventative procedures. As the medical community has absorbed greater knowledge of this research, informed consent has been recognized as both ethically essential and therapeutically sound: the hallmark of the current general therapy stage of informed consent.

We report here on recent developments in Israel on the issue of sex selection for nonmedical reasons by preimplantation genetic diagnosis (PGD). Sex selection for medical reasons (such as in cases of sex-linked genetic diseases) is generally viewed as uncontroversial and legal in European and American law. Its use for nonmedical reasons (like “balancing” the gender ratio in a family) is generally illegal in European countries. In the United States, it is not illegal, although in the opinion of the Ethics Committee of the American Society for Reproductive Medicine (ASRM), it is problematic. This position is undergoing reconsideration, albeit in a limited way.

Many cultural competency efforts in healthcare stress the importance of cultural diversity and difference. This emphasis is necessary and well justified. It has helped sensitize healthcare systems to the differences among people and their health-related attitudes, preferences, and behaviors. However, the emphasis on diversity and difference has, unfortunately, also detracted from serious consideration of the things that cultures have in common and the possibility that socioeconomic differences are today far more important than cultural ones in determining healthcare outcomes.We thank the Comprehensive Cancer Center at Case Western Reserve University and University Hospitals of Cleveland, Ohio, for supporting the research on which this paper is based. We are also grateful to the wonderful people of Masidaal, our project coordinator, Debbie van Stade, and our large team of research assistants for making the research possible.

As we move toward the creation of a networked health information environment, the potential of privacy intrusions increases, with potentially devastating impact on quality and access to healthcare. This paper describes the risks we face and proposes a framework to minimize those risks. In particular, it proposes nine principles to protect privacy in an information age.

In this article we highlight the main points of the development of bioethics and ethics committees in France. We argue that the French cultural context of medicine and its current political transformations favor new models of hospital ethics committee and we provide an example of such a model developed at Paris's Institut Curie, the oldest French cancer treatment and research centre.

The privacy and security rules of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 emphasize taking steps for protecting protected health information from unauthorized access and modification. Nonetheless, even organizations highly skilled in data security that comply with regulations and all good practices will suffer and must respond to breaches. This paper reports on a case study in responding to an important breach of the confidentiality and integrity of identifiable patient information of the Kaiser Internet Patient Portal known as “Kaiser Permanente Online” (KP Online). From the perspective of theories about highly reliable organizations, effective health information security programs must respond resiliently to as well as prospectively anticipate security breaches.

The notion of “cultural competency” in healthcare has gained currency in recent years. Health professionals are expected to be sensitive to the cultural backgrounds and language of their patients. Courses on cultural competency are now routinely offered to physicians, nurses, and others working in health fields. Although the rhetoric of cultural competency has been applied to clinical contexts, little attention has been given to its applicability in health research generally or, more specifically, in international health research. In this paper, I briefly explore the relevance and limitations of cultural competency for informed consent to international health research, particularly in the context of low-resource settings.This paper is based upon material included in Ethical Issues in Research Design and Informed Consent to Biomedical and Social Research in Resource Poor Settings, a monograph by Patricia Marshall (2007) commissioned by the World Health Organization, Ethics, Trade, Human Rights, and Health Law, and Special Topics in Social, Economic, and Behavioral Research Series of Programme for Research and Training in Tropical Diseases. Work on this manuscript was supported by funding from the NIH/National Human Genome Research Institute (PI: Patricia Marshall, 2 R01 HG002207-04), the Center for Genetic Research Ethics and Law, Case Western Reserve University (PI: Eric Jeungst, NIH/National Human Genome Research Institute, P50-HG-03390), and the Case/UHC Center for AIDS Research (CFAR), (PI: Michael Lederman, NIH AI36219). I am grateful to John Stone and Erika Blacksher for their helpful remarks on an earlier version of this manuscript.

The current main source of transplantable organs is from heart-beating donors. These are patients who have suffered a catastrophic brain injury, been ventilated, declared dead by neurological criteria, and had their vital functions maintained mechanically until the point of transplantation. But the demand for organs far outstrips the supply, and these patients are not the only potential donors. The idea behind non-heart-beating transplantation is to expand the donor pool by including in it patients who are in hopeless conditions but who are not dying because of brain injury and hence will not suffer the neurological death necessary to become heart-beating donors. As long as we continue to hold the so-called dead donor rule, according to which dying donors cannot have their organs taken before they are dead, this requires that death be able to be declared by alternative criteria, specifically by cardiopulmonary criteria. The challenge is to find such criteria that will identify a state that the public will readily recognize as death and that will facilitate non-heart-beating transplantation.I am grateful to Don Brown for encouragement, advice, and stimulating discussion and to Michael Feld for reminding me just how resilient a theory utilitarianism is.

From computerized medical records to databases of pharmacological interactions and automated provisional EKG readings, the emergence of information technology has significantly altered the practice of medicine. Information technology has been widely used to enhance diagnosis and treatment and to improve communication between providers. The advent of the Internet also brings far-reaching implications for patient–physician communication, challenging physicians, patients, and policymakers to consider its impact on the delivery of medical care and the therapeutic relationship. A new set of practices by patients and physicians is unfolding in cyberspace, ranging from the use of e-mail to communicate between physicians and patients in an existing relationship to one-to-one consultations with an anonymous physician and ongoing online treatment, such as psychotherapy. These practices are emerging in both the for-profit and not-for-profit spheres.

To promote so-called cultural competence in work of direct-care providers and other health professionals among diverse peoples, cross-cultural training (CCT) is now widely advised. However, in ethically assessing aims and content of CCT, and surrounding issues and concerns, what should guide us? And if we can elaborate satisfactory moral touchstones, what do they imply for healthcare professionals, overarching structures, and bioethicists? Building on prior work, this paper tries to help answer these questions.Work in this paper is indebted to discussions with Annette Dula, Insoo Hyun, Muhjah Shakir, Melanie Tervalon, and colleagues at Tuskegee University and the Tuskegee University National Center for Bioethics in Research and Healthcare. Erika Blacksher, Leonard Ortmann, and Madison Powers provided useful comments about earlier drafts. This work was supported by CDC Cooperative Agreement Number P76/CCP424229-2.

In a provocative 1974 article entitled “Harvesting the Dead,” Willard Gaylin explored potential uses of “neomorts,” or what are currently referred to as “heart-beating cadavers”—that is, humans determined to be dead by neurological criteria and whose cardiopulmonary function is medically maintained by ventilators, vasopressors, and so forth. Medical research was one of the potential uses Gaylin identified. He pointed out that tests of drugs and medical procedures that would have unacceptable health risks if performed on living human subjects could be performed on neomorts without any health risks. According to Gaylin, the potential benefits of such research could be enormous, including not subjecting patients to ineffective or harmful medical procedures and eliminating delays in providing effective therapies to dying patients.

There are not many international consensuses in the governance of biomedicine. One that exists concerns a general reluctance toward a commercialization of organ procurement. However, with reference to the problem of “organ scarcity,” there is an increasingly louder call in ethical and legal discourse to “give urgent consideration to any option that may make up the shortfall,” and to establish a debate on financial incentives “without any taboos.” Other ethicists and jurists criticize this development, and warn of injustice, exploitation of the poor, and a commodification of the human body.