The last twenty-five years of published literature and curriculum development in bioethics suggest that the field enjoys a successful and stable marriage to philosophical ethical theory. However, the next twenty-five years could be very different. I believe the marriage is troubled. Divorce is conceivable and perhaps likely. The most philosophical parts of bioethics may retreat to philosophy departments, while bioethics continues on its current course toward a more interdisciplinary and practical field.

I make no presumption that bioethics is integrally linked to philosophical ethical theory. Indeed, I assume that the connection is contingent and fragile. Many individuals in law, theological ethics, political theory, the social and behavioral sciences, and the health professions carefully address mainstream issues of bioethics without finding ethical theory essential or breathtakingly attractive. This is not surprising. Moral philosophers have traditionally formulated theories of the right, the good, and the virtuous in the most general terms.

Clinical ethics, like the broader field of bioethics from which it emerged, is at a critical crossroads in its development, with conflicting paths ahead. It can either claim its distinctive place in the clinical arena, insisting unapologetically on certain minimal standards of professional training, practice and competence, addressing head on debates about various models of and methodological approaches to consultation, and establishing a shared vision of the purpose and meaning of the enterprise of clinical ethics itself. Or, it can devolve into a hobby that untrained, albeit interested, and generally well intentioned individuals can dabble in for fun or even profit, as they see fit, and without regard to the deep history and rich disciplinary roots of the field, the serious debates in the academic literature of bioethics, the foundational case histories and legal theories, or even any sense of professional accountability.

Empirical research in bioethics can be defined as the application of research methods in the social sciences (such as anthropology, epidemiology, psychology, and sociology) to the direct examination of issues in [bioethics]. As such, empirical work is a form of descriptive ethics, focused on describing a particular state of affairs that has some moral or ethical relevance. For example, empirical research can help to describe cultural beliefs about the appropriateness of providing health-related information, such as the diagnosis of a life-threatening illness, which informs deliberations about the extent to which it is morally important for clinicians to provide comprehensive information to patients in different cultural contexts. Similarly, empirical research can delineate popular attitudes and experiences related to contentious issues such as abortion, cloning, stem-cell research, and physician-assisted suicide to enlighten discussions and policy formulations regarding them.

Public health ethics in the future will be distinguished from public health ethics in the past by this new subfield being labeled as such, acknowledged, and called upon for service. Ethical dilemmas have been present throughout the history of public health. The question of whether to force Henning Jacobson to be immunized in 1905 in accordance with the 1902 Massachusetts smallpox vaccination law was one of ethics as well as law. How Thomas Parran, Surgeon General in 1936, chose to respond to a raging syphilis epidemic in the United States in the early part of the 2W century raised considerable moral debate in determining the appropriate public health response for a government? More recently, questions have arisen concerning the appropriate reach of government in controlling HIV banning smoking, or promoting healthy lifestyles. Debates over government infringement, morality, and justice recur throughout the history of public health.

First, to what level of quality can medical ethics a spire, if it ignores callous discrimination in medrcal practice against large populations of the innocent poor? Second, how effective can such theories be in addressing the critical issues of medical and clinical ethics if they are unable to contribute to the closing of the gap of sociomedical disparity?

As we look to the future in a world with porous borders and boundaries transgressed by technologies, an inevitable question is:Can there be a single, global bioethics? Intimately intertwined with this question is a second one: How might a global bioethics account for profound - and constantly transforming - sources of cultural difference? Can a uniform, global bioethics be relevant cross-culturally? These are not simple questions, rather, a multi-dimensional answer is required. It is important to distinguish between two meanings of bioethics: the academic discipline of bioethics as opposed to bioethics as a set of (increasingly globalized) practices governing clinical care and scientific research. There is growing evidence to support the notion of a shared global understanding of bioethics as a field of inquiry focused on the moral dimensions of science and biomedicine.

Over the last decade, more U.S. taxpayers money has been spent trying to anticipate and address the bioethical issues raised by advances in human genetics than any other set of issues in the field. Does this make sense? Not everyone in bioethics thinks so. Some think there are more important topics, like issues of health care justice, that will be neglected if the field continues to follow the money to dwell on the moral challenges of a relatively small community of research scientists. Others decry genetic exceptionalism as inappropriately singling out this scientific enterprise for criticism and regulation, when the same issues are faced even more acutely in other parts of the biomedical world. Human genetics is not accelerating as fast as pharmacology, for example, or as easy to abuse as virology, or as philosophically challenging as neurology.

Bioethics is clearly a field in transition, if not confusion. Bioethics began as a scholarly, reflective, academic enterprise. Increasingly, however, some in bioethics are not as interested in producing scholarship as they are in practicing bioethics by providing services to institutions and clients.

Bioethics also began as an interdisciplinary line of inquiry, with its major contributors all trained in some established discipline. We were and for the most part still are a field composed of theologians, philosophers, lawyers, physicians, nurses, and social scientists who work in bioethics. Today, however, some young people actually aspire to be bioethicists. Increasingly, they have the option of being trained directly in bioethics, without any other disciplinary background.

We are not the first field to find itself engaged in these kinds of transitions. In this short piece, I consider very briefly how two fields--health psychology and epidemiology- have approached similar branch points.

The relationship between sociology and bioethics has been an uneasy one. It has been described as contentious and adversarial, and at least some of the sociologists who have ventured into the territory of medical ethics report back on unfriendly natives. This bioethical ill will toward sociology is not without cause. Sociologists have been quite critical of what they call (with not-so-subtle pejorative overtones) the bioethical project.

Two decades ago - when bioethics was just getting up on its organizational feet - Renée Fox and Judith Swazey leveled the charge of cultural myopia against bioethics, noting that this myopia generally manifests itself in the form of systematic inattention to the social and cultural sources and implications of its own thought. They go on to say ifbioethics is an indicator of the general state of American ideas, values, and beliefs, of our collective self knowledge, and our understanding of other societies and cultures - then there is every reason to be worried about who we are, what we have become, and where we are going

Debate over the relationship of law and bioethics is growing - what the relationship has been and what it should be in the future. While George Annas has praised law and rights-talk for creating modern bioethics, Carl Schneider has instead blamed law for hijacking bioethics and stunting moral reflection. Indeed, as modern bioethics approaches the 40-year mark, historians of bioethics are presenting divergent accounts. In one account, typified by Albert Jonsen, bioethics largely grew out of philosophy and theology, not law. In another account, law has deeply shaped bioethics from the start, forging its central commitment to the rights of patients and research subjects and the fields imposition of broad fiduciary responsibilities on health care professionals and researchers.

In addition to debating how to properly describe laws historical relationship to bioethics, commentators have argued over whether laws influence in bioethics is now good or bad.

In August 2001,just after President Bush announced his stem cell funding policy and the creation of a new Presidents Council on Bioethics PCB), the new chair of the PCB, Leon Kass, set out his philosophy for constructing public bioethics bodies: There are several ways of running commissions, he said. One is to stack it with your people, make them homogenous, and force a consensus. Another is to make them heterogeneous, so that you can only come to the lowest common denominator. We re not going to adopt either . We are going to allow the debate to be developed and heard.

Now, three years, sixteen meetings, and five reports later, there are nagging questions about whether this council indeed has allowed the debate to be developed and heard. And the charge of politicizing public bioethics to a degree heretofore unknown and stifling the voices of dissenting members comes not from the political left but from President Bushs own appointees, including one scientist who was dismissed from further service.

Back injuries have a bad reputation. The workman looks upon them with apprehension, the insurance company with doubt, the medical examiner with suspicion, the lawyer with uncertainty. The medical examiner is faced with the difficulty of estimating the true value of the subjective symptoms in the comparative absence of physical signs. His suspicion is born of the frequent disparity between these two.

This prophetic statement made almost 100 years ago highlights an ongoing problem - how people who are incapacitated by painful conditions such as chronic low back pain can be evaluated consistently and equitably for purposes of disability compensation. We confronted this vexing problem when we participated in writing the chapter devoted to impairment associated with pain (Chapter 18) of the American Medical Association s Guides to the Evaluation of Permanent Impairment, 5th edition AMA Guides 5th Our purposes in this essay are to clarify several important conceptual issues associated with the assessment of pain among disability applicants, and to articulate reasons why pain should be considered in impairment and disability ratings.

Criminal law and the proceedings surrounding it work, at least in theory, much like an author works when writing a play or a novel. Both the lawyer and the writer follow traditional formulae that allow them to create and express a vision of reality. When done well, the reality created is virtually seamless. This, however, is the point at which law and literary works diverge. Although we embrace creativity in literary endeavors, we would prefer that the foundation of our legal system be something more substantial. Unfortunately, where US. criminal HIV exposure statutes are concerned, there appears to be little if any concrete connection between proscribed behaviors and what we know about HIV transmission risk. Twenty-four states in the U.S. make it a criminal offense for a person who has HIV to expose another to the virus through consensual sexual activities. The relationship between the activities prohibited by these laws and actual risk of virus transmission is tenuous at best.

Most medical experiments are reviewed by groups known as Institutional Review Boards (IRBs); according to every standard account of medical research ethics, an IRB should not approve an experiment unless it has an acceptable combination of risks and benefits. This requirement is often stated in different terms. Some codes say that an experiments benefits to individuals and society must outweigh its risks. Others say that the experiment must have a favorable risk-benefit ratio. The Code of Federal Regulations says that risks must be reasonable in relation to the expected benefits.

However, even though everyone agrees that an experiment must have an acceptable combination of risks and benefits, almost nothing has been said about what it would mean to weigh risks against benefits, compute risk-benefit ratios, or figure out if an experiments risks are reasonable.

The issue of death due to medical errors is not new. We have all heard horror stories about patients dying in the hospital because of a drug mix-up or a surgery patient having the wrong limb amputated. Most people believed these stories were the exception to the rule until November 1999, when the Institute of Medicine (IOM) issued a report entitled To Err Is Human: Building A Safer Health System. This report focused on medical errors and patient safety in U.S. hospitals. The report indicated that as many as 44,000 to 98,000 people die each year in hospitals as a result of medical errors. These numbers suggest that more Americans are killed in U.S.hospitals every 6 months than died in the entire Vietnam War, and some have compared the alleged rate to fully loaded jumbo jets crashing every other day. This report was not without its critics.

Institutional ethics committees remain largely absent from the literature on error reduction and patient safety. This paper attempts to fill the gap. Healthcare professionals are on the front lines in the defense against medical error, but the changes that are needed to reduce medical errors and enhance patient safety are cultural and systemic in nature. As noted in the Hastings Centers recent report, Promoting Patient Safety, the occurrence of medical error involves a complex web of multiple factors. Human misstep is certainly one such factor, but not the only one. In this paper, I build on the Hasting Centers report on patient safety (HCR) in arguing that institutional ethics committees ought to play an integral role in the transformation of a culture of blame to a culture of safety in healthcare delivery.

An increasing number of community physicians are involved in clinical research.Indeed, 60 of industry-funded research is now spent on community based trials. This surge in community based clinical trials has increased the number of clinical trials applications submitted to the drug regulatory agencies by pharmaceutical sponsors. Many have argued that the commercial interests connected to the conduct and outcome of these trials also increases the potential for conflicts of interest for participating physicians. The context in which these trials take place increases the potential for a host of practices that infringe on ethical, legal and clinical obligations of physicians For example, financial recruitment incentives may lead to violations of the inclusion criteria and the consent process. It may result in inappropriate recruitment of patient participants and a blurring of the ethically significant distinctions between treatment and research. In some cases, it may be hard to distinguish research from the marketing of new products and attempts to influencing prescribing patterns.