Consider the thought experiment offered at the conference that generated this collection of essays: in this fantasy, face transplants are safe and effective. A young woman is the victim of a devastating accident. A face transplant will enable her to live a completely normal life. But, say she is African American, or Asian. Would it be ethically permissible to allow her to take the face of a Caucasian woman? Or, say you have a child with a muscle wasting disorder. Would it be permissible to alter his muscle repair system so that he not only does not have the genetic variation that causes the disease, but he has the capacity for enhanced muscular strength, beyond that of his peers, such that he could become a big league pitcher?

In his introduction to this symposium, “Religions and Cultures of East and West: Perspectives on Bioethics,” Dr. Robert Sade defined its purpose as follows: “The objective of [our] discussions…is to explore the limits of enhancement technologies in light of what makes us essentially human, in the view of world-wide cultures and religions.”

These issues would seem to be at the cutting edge of any informed deliberation concerning the merits of “human enhancement” technologies. For instance, the issue of how “what makes us essentially human” affects our reflection on issues of technological “life enhancement” is raised in a 2007 book by Harvard professor Michael J. Sandel, The Case Against Perfection: Ethics in the Age of Genetic Engineering.

Current discussions of so-called “enhancement” technologies immediately involve matters of definition, because the distinctions between enhancement and therapy invite ambiguity. Therapy is generally defined as the prevention or cure of disease, or as the restoration or approximation of return to normal physiological function. Enhancement is defined as the alteration of individual (or group) characteristics, traits, and abilities (both health- and non-health-related) beyond a measurable baseline of normal function. Both notions rely on shared understandings of disease and illness, which depend in turn on the ways that we conceptualize and operationalize judgments of normalcy. Both notions have therefore generated significant controversy among philosophers of medicine, with the result that blanket distinctions between therapy and enhancement appear unlikely to convince everyone.

Not much work has been done on Hindu bioethics other than by a select few scholars and medical doctors. Professor Cromwell Crawford, author of Dilemmas of Life and Death: Hindu Ethics in a North American Context and Hindu Ethics for the Twenty-first Century, for example, is well known in the field of Hindu bioethics. Others scholars include Dr. Uma Mysorekar, who is a gynecologist as well as the president of the board of trustees of the Ganesha Temple of Flushing New York. She has published several short pieces on Hindu bioethics, and has even been interviewed by PBS for their “Religion and Ethics” program. Dr. H. L. Trivedi, director of the Institute of Kidney Diseases and Research Center at the Civil Hospital Campus in Ahmedabad, India, is also prominent. His pithy paragraph in Transplant Proceedings on Hinduism and organ transplantation is cited with enormous frequency on the Internet and elsewhere. These thinkers, however, are unequivocally wrong in their position that Hinduism supports organ transplantation, and, more importantly, that it offers any coherent or systematic bioethics whatsoever.

Physically and intellectually, man is not the same as a million years ago. This “improvement” in humans has occurred over a period of time and not as a result of any outside biotechnical intervention. So, the question is what is the need now? The fine line between what can be done technically and what should be done morally is the reason for biomedical ethics. What is the nature of man, and what is his relationship with his creator and his environment? Whose interest (man, God, and environment) are we as scientists and physicians to guard? What are the rights of the unborn, and who protects those rights? While seeking medical treatment for infertility and reconstructive surgery for a malformation or genetic manipulation for a genetic disease might perhaps be appropriate and recommended, is it also appropriate to create a super healthy, super human with genetic manipulation? If so, then are we embarking on the path of ethnic cleansing of humans of lesser ability, and is it appropriate to discriminate? In this paper, such questions and concerns are discussed from an Islamic perspective.

In what follows, I draw on things I have found in Japanese discussions of bioethics in order to clarify some aspects of the ethics of biotechnological enhancement. In doing so it will, I hope, become evident that what we might call a “religious” component is in Japan somewhat differently construed than in the contexts with which we are more likely to be familiar in North America. And in the end an attempt will be made here to show that the materials considered give us all – not just the Japanese – reasons for going forward with biological enhancement technologies only on condition that extreme caution be exercised. The fast-moving, oncoming traffic in this domain ought to be forced, these materials suggest, to come up to a caution-demanding signal – not a green light but one that is unambiguously amber. Caution and perhaps even a full stop appear to be in order.

The question of why women, in consultation with their physicians, should choose hormone therapy (HT) in response to menopause represents a renewed controversy at the beginning of the new century. Conflicting messages regarding the health risks and benefits of HT have been conveyed in the mainstream media, especially information in the media regarding the results of large-scale studies of the health impact of hormone therapy. Women who have been on one or another of the hormone replacement regimes have been forced to reconsider continuing on HT. Doctors who suggest these hormones to their patients are somewhat confused, as are perimenopausal women who are considering HT. Pharmaceutical companies that produce these compounds are worried, and public health officials are on the defensive.

Media coverage of HT research has been extensive. In particular, two large-scale studies, one here in the U.S. (the Women's Health Initiative, or WHI) and the other in Great Britain, have recently cast a negative light on the use of hormone therapy, after years of routine prescription of HT for menopausal women.

The standards for medical education in the United States now go above and beyond traditional basic science and clinical subjects. Bioethics, health law, and health economics are recognized as important parts of translating physicians’ technical competence in medicine into effective research, administration, and medical care for patients. The Liaison Committee on Medical Education (LCME), which establishes certification requirements for medical schools, requires all medical schools to include bioethics in their curricula. Furthermore, issues such as the growth of genetic testing, end-of-life decision making for a burgeoning elderly population, confidentiality in the era of electronic medical records, and allocation of scarce medical resources make bioethics training clearly necessary for physicians. Although 16 percent of the United States GDP is devoted to health care, the LCME does not currently mandate training in health law or health economics. Furthermore, as the Schiavo case and HIPAA remind us, legal directives influence medical practice in areas such as billing, confidentiality, and end-of-life care.

As everybody knows, advances in medicine and medical technology have brought enormous benefits to, and created vexing choices for, us all – choices that can, and occasionally do, test the very limits of thinking itself. As everyone also knows, we live in the age of consultants, i.e., of professional experts who are ready, willing, and able to give us advice on any and every conceivable question. One such consultant is the medical ethics consultant, or the medical ethicist who consults.

Medical ethics consultants involve themselves in just about every aspect of health care decision making. They help legislators and judges determine law, hospitals formulate policies, medical schools develop curricula, etc. In addition to educating physicians, nurses, and lawyers, amongst others, including medical, nursing, and law students, they participate in clinical decision making at the bedside.

The Physician Orders for Life-Sustaining Treatment (POLST) Paradigm is designed to improve end-of-life care by converting patients’ treatment preferences into medical orders that are transferable throughout the health care system. It was initially developed in Oregon, but is now implemented in multiple states with many others considering its use. Accordingly, an observational study was conducted in order to identify potential legal barriers to the implementation of a POLST Paradigm. Information was obtained from experts at state emergency medical services and long-term care organizations/agencies in combination with a review of relevant state law. Legal analysis of survey responses and existing laws identified several potential state legal barriers to a POLST Paradigm implementation. The most potentially problematic barriers are detailed statutory specifications for out-of-hospital DNR (do not resuscitate) protocols (n = 9 states). Other potential barriers include limitations on the authority to consent to forgo life-sustaining treatments (n = 23 states), medical preconditions (n = 15), and witnessing requirements (n = 12) for out-of-hospital DNR protocols.

Molecular genetic testing has increasingly been incorporated into clinical medicine, and this trend is likely to accelerate in the future. The introduction of genetic testing into medical practice is beginning to collide head on with patents that claim ownership of correlations between human genetic variants and predisposition to disease, response to therapeutic drugs, and susceptibility to pharmacologic side effects. Patent holders or licensees of genes, genetic variants, and their genotype-phenotype correlations are already using the threat of litigation to monopolize genetic tests for important well-known syndromes like Duchenne Muscular Dystrophy and inherited breast and ovarian cancer, in addition to a host of less commonly discussed conditions.

Patients belonging to ethnic, racial, and religious minorities have been all but excluded from the legal academy’s ongoing conversation about informed consent. Perhaps this is just as well, since the conversation appears to have concluded that the doctrine has failed to serve as a meaningful regulation of clinical relationships. Informed consent does not operate in practice the way it was intended in theory. More than a decade ago, Peter Schuck noted the “informed consent gap” that distinguishes the “proper” law of informed consent “on the books” from the actual consent law in action, and called for a more contextualized approach to informed consent. Susan Wolf later called for a systemic approach to informed consent in order to accommodate multiple decision points in the managed care setting. Some reformers have sought enhancements to expand the doctrine.

It has been pending in Congress for twelve years, despite the support of the last two presidential Administrations and the National Institutes of Health. It has been the subject of extensive affirmative lobbying by academic medical centers, pharmaceutical and biotech companies, genetic disease advocacy groups, and civil rights organizations. It has overcome vehement objections by employers and insurers. Its final passage, however, has been thwarted by a few Congressional leaders, who have prevented enactment despite overwhelming bipartisan support in both houses of Congress.

Based on this legislative history, one could not help but assume that the Genetic Information Nondiscrimination Act (GINA) is a revolutionary piece of legislation that, if finally enacted, would provide extensive, effective, and comprehensive protection against genetic discrimination in health insurance and employment Unfortunately, such an assessment would be incorrect. Indeed, GINA may be a case of too much ado about too little.

I come from a medical family. My father and uncle were physicians, and my father also chaired a department at a West Coast medical school for over 30 years. I am sure I got my interest in teaching from him. My brother is a physician and is currently the safety and quality officer of a Canadian province. My mother operated the last non-automated medical laboratory in my state. I have always understood what sacrifices are made by health care professionals, and I think I have managed to learn a bit about their motivations as well.

I was in private practice for ten years with litigation firms, and the last five years of that time I worked for a firm that specialized in professional liability defense and health law.

In May of 2006, the Abigail Alliance for Better Access to Development Drugs (Abigail) appeared to have won a victory when a divided panel of the Court of Appeals for the District of Columbia Circuit (D.C. Circuit) ruled that “terminally ill, mentally competent adult patients” had a constitutionally protected right to access investigational medications. This victory was short lived, however. On August 7, 2007, the D.C. Circuit sitting en banc reversed this earlier decision, marking a setback in Abigail's campaign for removal of the regulatory barriers that currently prevent terminally ill patients from gaining early access to investigational drugs (i.e., experimental drugs). This loss represents a big blow for Abigail's cause, because there is no guarantee that they will have another day in court, and attaining their goal through other branches of the government remains uncertain.

The New Jersey Supreme Court has continually avoided making moral judgments about the value of life and emphasized that such decision making should be the province of the potential parents. Recently, in Acuna v. Turkish, the court elaborated on the limitations of the decision-making right of the potential parents, and its decision demonstrated that New Jersey courts were only willing to require physicians to disclose all relevant medical information, and not moral statements that had not been agreed upon by the state's medical community, people, or legislature. Acuna might be read as a departure from the trend displayed by New Jersey courts in “wrongful birth” and “wrongful life” actions toward empowering potential parents to decide if they want to bring the pregnancy to term. However, the decision actually fits squarely within this trend in that the reluctance to expand the information to which potential parents are entitled from their physicians can be directly tied to the reluctance of the New Jersey Supreme Court to weigh in on the value of life in wrongful birth and wrongful life suits.