Contributors.

American Journal of Bioethics, Bioethics, Cambridge Quarterly of Healthcare Ethics, Journal of Medical Ethics, Kennedy Institute of Ethics Journal, Nursing Ethics, Theoretical Medicine and Bioethics.

Contributors.

Contributors.

In proportion to other serious illnesses, diseases of the brain and mind represent the greatest—and still increasing—public health burden that Western societies are facing. Consequently, scientists, governments, advocacy groups, and public health authorities are committed to research to tackle the causes and consequences of neurological and psychiatric diseases and to find cures for them. As neuroscience research progresses, ethicists and neuroscientists face numerous ethical challenges to the integration of frontier application of research—neurotechnology—with the delivery of high-quality healthcare. In this special neuroethics issue, we have invited distinguished scholars with diverse disciplinary backgrounds to present their reflections and research on the ethical dimensions of this crucial integration.

Resolving competing claims in bioethics dilemmas is never easy. On the assumption that vigorous debate is the most effective ground for reaching reasonable decisions, this annual Open Forum issue is devoted to timely controversies in a number of areas: governmental regulations and reproductive rights, determining fair compensation for gamete donation, balancing responsibilities in the doctor–patient relationship, violating rules to benefit patients, persistent problems in end-of-life care, and professional standards of conduct and bioethics consultation, as well as insights into the shifting landscape of oversight in clinical research and directions for the future.

The essays in this Special Section are about the ethics of Commercialism in Medicine. They are written, for the most part, by bioethicists, with the support of several prominent physicians and a health policy lawyer. This journal is, of course, devoted to ethics. Thus, our intent is to subject the question of commercialism in medicine to ethical scrutiny. Much has been written about commercialism in healthcare but very little about the ethics of commercialism in healthcare. One of our authors, Dr. Jerome Kassirer, has encouraged a national dialogue about these issues. We hope to start that dialogue in the bioethical community and, through that community, into the nation.Special thanks to J. Westly McGaughey for his editorial assistance in preparing this collection of papers.

It is well known that we are beholden to Norbert Weiner for coining the modern use of the term “cybernetics” to denote a field of study in technological control mechanisms. In recognition of the fact that the blurring between technology and life is becoming increasing apparent, perhaps the title of this Special Section should have been “The Cyborgs among Us.” Using a definition of “cyborg” (i.e., “cybernetic organism”) as persons in which the organic and the technical have fused, more than 10% of the American population already qualify, for example, people with artificial organs, limbs, joints, or electronic pacemakers, drug implant systems, or implanted corneal lenses. Of course, such a definition is quite broad and purposefully provocative, but it remains insightful. Technology is already “under our skin” (both figuratively and literally) and the future only promises more interface at the micro-, nano-, and cellular levels.

Sex selection technologies have become increasingly prevalent and accessible. We can find them advertised widely across the Internet and discussed in the popular media—an entry for “sex selection services” on Google generated 859,000 sites in April 2004. The available services fall into three main types: (1) preconception sperm sorting followed either by intrauterine insemination of selected sperm (IUI) or by in vitro fertilization (IVF); (2) preimplantation genetic diagnosis (PGD), by which embryos created by IVF are tested and only those of the desired sex are transferred to the woman's uterus; and (3) prenatal testing of fetuses through ultrasound or chromosomal analysis, followed by selective abortion of fetuses detected to be of the undesired sex.Victoria Seavilleklein's research was supported by the following grants: Izaak Walton Killam Memorial Scholarship, Social Sciences and Humanities Council Doctoral Fellowship, and CIHR Training Program in Ethics of Health Research and Policy. Earlier versions of this paper were read to the Philosophy Department at Dalhousie University and to the participants of the CIHR Training Program in Ethics of Health Research and Policy. We are grateful for the helpful feedback we received on both occasions. We also appreciate the comments made by Micah Hester and two anonymous reviewers.

As our knowledge of the functional and pharmacological architecture of the nervous system increases, we are getting better at treating cognitive and affective disorders. Along with the ability to modify cognitive and affective systems in disease, we are also learning how to modify these systems in health. “Cosmetic neurology,” the practice of intervening to improve cognition and affect in healthy individuals, raises several ethical concerns. However, its advent seems inevitable. In this paper I examine this claim of inevitability by reviewing the evolution of another medical practice, cosmetic surgery. Cosmetic surgery also enhances healthy people and, despite many critics, it is practiced widely. Can we expect the same of cosmetic neurology? The claim of inevitability poses a challenge for both physicians and bioethicists. How will physicians reconsider their professional role? Will bioethicists influence the shape of cosmetic neurology? But first, how did cosmetic surgery become common?I thank Lisa Santer, Barry Schwartz, and Martha Farah for their thoughtful comments on earlier drafts of this paper.

Healthcare depends increasingly on advanced medical technology. In addition, other forms of technology contribute to determine how our lives are influenced by disease and disability. The extent to which persons with impaired bodily functions are forced to live their lives differently than other people depends to a large part on a variety of technologies, from wheelchairs to computer interfaces, from hearing aids to garage doors. This wide-ranging influence of technology has important ethical aspects, but has seldom been discussed in bioethics, the ethics of technology, or other branches of applied ethics.

Commercialism first became a major problem for medicine in the decade of the 1970s, when huge quantities of new money began to flow into the healthcare system, as a result of Medicaid and Medicare, and the rapid expansion of private, employer-based insurance. Of course, physicians benefited, but most of this new money went to insurance plans and medical care delivery institutions, like hospitals, nursing homes, diagnostic services, and ambulatory care facilities of many kinds. Many of these were newly established for-profit businesses. A vast number of satellite enterprises sprang up to serve the growing needs of the new businesses by providing services like marketing and advertising, brokering, consulting, information technology, financial services, case and disease management, billing and collecting, and so forth.

There is something embarrassing about money. Everybody is seeking it but at the same time they are reluctant to talk about their bank balances and stock holdings. As a society we have so much of it that we can install 7000 saffron curtains all over Central Park, send tourists into outer space, and analyze the gas on the surface of Titan, yet we fail to spend it on millions of poverty-stricken people who die of disease or starvation each year. We do open our pocketbooks sometimes, but only when television images of massive destruction overwhelm our sensibilities. Money often dominates our consciousness and bombards us in the headlines: Our national debt is 7.7 trillion dollars and it's increasing by more than 2 billion dollars a day; corporate executives of Enron walk away with millions while their employees lose their jobs and their pensions; and we had an endless fascination with Martha Stewart, who is worth millions, but went to jail trying to save a few thousand.

The human mind strives to maintain equilibrium between memory and oblivion and rejects irrelevant or disruptive memories. However, extensive amounts of stress hormones released at the time of a traumatic event can give rise to such powerful memory formation that traumatic memories cannot be rejected and do not vanish or diminish with time: Post-traumatic stress disorder may then develop. Recent scientific studies suggest that beta-blockers stopping the action of these stress hormones may reduce the emotional impact of disturbing memories or prevent their consolidation. Using such an intervention could, in principle, help people who suffer from post-traumatic stress disorder, but the idea of doing so is controversial. I shall here discuss memory manipulation in this perspective.

In August 2005, the United Kingdom's Human Fertilisation & Embryology Authority (HFEA) launched a public consultation, seeking views on the use of preimplantation genetic diagnosis (PGD) for the detection of cancer genes. The issue was considered by the Authority to be a possible source of particular controversy because it involved extending the range of conditions for which PGD can be licensed in a potentially important way: As well as testing for genes that would definitely cause disease traits, such as cystic fibrosis and muscular dystrophy, this would involve genes that would only possibly manifest themselves phenotypically. In other words, there is a very real chance that such an application of PGD would result in the destruction of perfectly healthy embryos.

Mechanical devices implanted in the body present implications for broad themes in religious thought and experience, including the nature and destiny of the human person, the significance of a person's embodied experience, including the experiences of pain and suffering, the person's relationship to ultimate reality, the divine or the sacred, and the vocation of medicine. Community-constituting convictions and narratives inform the method and content of reasoning about such conceptual questions as whether a moral line should be drawn between therapeutic or enhancement interventions and/or between somatic and neural/cognitive interventions. By attending to these broader community-forming concepts, it is possible to identify three general orienting themes in religious perspectives on incorporated mechanical devices, which we shall designate as perspectives of “appropriation,” “ambivalence,” and “resistance.”

After decades of specialization within the sciences, the development and application of implantable microchips and biosensors are now being made possible by a growing convergence among seemingly disparate scientific disciplines including, among others, biology, informatics, chemistry, and engineering. This convergence of diverse scientific disciplines is the basis for the creation of new technologies that will have significant medical potential. As of today, implantable microchips and biosensors are being used as mental prostheses to compensate for a loss of normal function, to remotely monitor patients' vital signs, to control the delivery of medications, and to communicate with geographically distant healthcare professionals and the outside environment.

In Canada, laws and policies consistently reject the commodification of human organs and tissues, and Canadian practice is consistent with international standards in this regard. Until the Assisted Human Reproduction (AHR) Act of 2004, gamete donation in Canada was an exception: Canadians could pay and be paid open market rates for gametes (sperm and egg) for use in in vitro fertilization (IVF). As sections of the AHR Act forbidding payment for gametes (Section 6) and permitting only reimbursement of receipted expenses (Section 12) gradually came into effect in 2005, Canada did away with this anomaly. Medical practice and legal prohibitions in assisted human reproduction are now consistent with other areas of medicine where tissues and organs are taken from one person to benefit others: Altruistic donation, rather than selling and buying, will be the norm.The authors thank Françoise Baylis, Jocelyn Downie, and members of the Novel Tech Ethics Research Team at Dalhousie University for their assistance with and feedback on earlier drafts of this paper. We also thank Tim Krahn for assistance in formatting this paper.

Neuroimaging has provided insight into numerous neurological disorders in children, such as epilepsy and cerebral palsy. Many clinicians and investigators believe that neuroimaging holds great promise, especially in the areas of behavioral and cognitive disorders. However, concerns about the risks of various neuroimaging modalities and the potential for misinterpretation of imaging results are mounting. Imaging evaluations also raise questions about stigmatization, allocation of resources, and confidentiality. Children are particularly vulnerable in this milieu and require special attention with regards to safety guidelines and modality adaptations. This article examines pediatric neuroimaging practice through an ethics lens. Most authors in the field of neuroethics focus on the future concerns of neuroimaging. In contrast, our paper examines ethical matters surrounding current clinical applications in the pediatric population. We first provide a brief overview of the neuroimaging technologies most commonly used in a pediatric clinical context and then discuss a variety of ethical issues arising from the use of these technologies.

Is medical commerce a recent phenomenon? Does it distort the patient–physician relationship? Are investor-owned firms the main source of medical commercialism? I contend that medicine has generally been commerce in the United States, that medical commerce is a problem when it creates or worsens physicians' conflicts of interest, and that these conflicts thrive in nonprofit organizations as well as in investor-owned firms. I provide a historical sketch to show that physician entrepreneurialism, rather than commerce generally, is the main source of physicians' conflicts of interest.Thanks are due to Jerome P. Kassirer, Albert R. Jonsen, and Joseph Fins for helpful comments on a draft. The history and themes herein are further developed in a book I am now writing, titled Medical Profession, Market and State in France, the United States and Japan.