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.

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.

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.

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.

An icy wind blows through your cotton shirt while you sit outside the hospital door, waiting for your wife to bring up the car. The warm August day, when you entered the emergency room, has transformed into a gray November one. Your mind returns to Dr. Snipe.

Money plays a powerful role in modern medicine, both in terms of how health services are organized and delivered and increasingly in how physicians understand themselves and their work. The phrase “the hegemony of money” is intended to capture that power.

Justifying his proposal for “health savings accounts,” which would allow individuals to set aside tax-free dollars against future healthcare needs, President Bush has said that “Health savings accounts all aim at empowering people to make decisions for themselves.” Who could disagree with such a sentiment? Although bioethicists may be among those who express skepticism that personal health savings accounts will be part of the needed “fix” of our healthcare financing system, self determination has long been part of their mantra. Indeed, the field of bioethics played an important role in advancing this idea in the medical world when physician paternalism was regnant. Has its popularity caused it to become so vapid as to be ripe for misuse?

I briefly discuss three components of the media that play a role in the commercialization of medicine: advertising, television dramas, and journalism.

There is a palpable malaise in American medicine as clinical practice veers off its moorings, swept along by a new commercialism that is displacing medical professionalism and its attendant moral obligations. Although the sociology of this phenomenon is complex and multifactorial, I argue that this move toward medical commercialism was accelerated by the abortive efforts of the Clinton Administration's Health Security Act. Through an analysis of performative speech I show that, although the Clinton plan drew on many strands of speech about healthcare, it favored the discourse of health policy and health economics over that of clinical practice and professionalism. Though the Clinton plan failed, this new vocabulary of health economics has led us to imagine a new descriptive framework, which has commodified healthcare and commercialized the clinic.I am grateful to Drs. William Andereck and Al Jonsen and the California Pacific Medical Center's Program in Medicine and Human Values for the invitation to participate in their deliberations on “Commercialism in Medicine,” my fellow colloquialists for their helpful comments, Dr. Pablo Rodriguez del Pozo for his insights, and Dr. Jonsen, in particular, for his astute editorial advice and guidance.

The question of the influence of commercialism in medicine is often put in terms of how the money factor influences the actions and the judgments of the individual physician—just as in the culture at large there is and has always been the question of sacrificing personal moral values for financial gain. But it is necessary now, perhaps especially for physicians and others who are presumably operating in the “market-free zone,” to put the question in an even more intimate way. The question becomes to what extent does the pressure of financial gain influence perception itself in the clinical setting. To what extent do the pressures of commercialism block or interfere with perceptions of fact and truth in establishing diagnosis, in projecting methods and strategies of treatment, and in assessing the medical, psychological, and moral needs of the individual patient? To this extent, it is not so much a question of physicians making intentional, self-serving decisions. It is a question of physicians unconsciously making such decisions based on perceptions and processes of judgment subconsciously or semiconsciously governed by the monetary considerations that have permeated nearly every corner and pocket of the contemporary culture.

These last words are titled “Conclusion,” but they should be “Inception.” Professor Jacob Needleman encourages a vigorous conversation about commercialism in medicine. An honest conversation, he maintains, will spur understanding, indignation, and reformation. We do sincerely hope that such a conversation begins and is carried on to meaningful change. However, as the essays in this collection show, that conversation must take place in many different places and about many different things. All of our authors acknowledge that the problem of commercialism is extremely complex. It cannot be understood as a simple fact or a single feature of modern healthcare. Thus, the conversation that discusses it must be varied and diverse.

These CQ Sources were compiled by Bette Anton.

In my paper “Parental Love and the Ethics of Sex Selection,” published in the previous issue of the Cambridge Quarterly of Healthcare Ethics, I set out to determine whether a plausible argument could be constructed in support of a common intuition about the ethics of sex selection. The intuition in question is that sex selection for nonmedical reasons is incompatible with a proper parental love: that is, with the sort of love that a parent ought to have for her child or, equivalently, with the sort of love that someone accurately describable as a good parent will have for her child. I concluded that there is a prima facie compelling argument that fits the bill, though I did little more than introduce and set that argument out. In the current paper, my aim will be to subject it to closer scrutiny, by considering a number of possible objections to it. I will start by asking why the argument should be thought to apply only to sex selection for nonmedical reasons and not to cases in which selection is employed in order to prevent the birth of children with serious sex-linked genetic conditions.Thanks are due to Doris Schroeder for enlightening discussions of the issues raised in this paper. I also extend my thanks to Rachel Cooper, Sean Crawford, Neil Manson, and Alison Stone for comments and objections made during and after a paper that I gave on this topic at Lancaster University.

This CQ department is dedicated to bringing noted bioethicists together in order to debate some of the most perplexing contemporary bioethics issues. You are encouraged to contact “The Great Debates” department editor, D. Micah Hester ([email protected]), UAMS/Humanities, 4301 W. Markham St., #646, Little Rock, AR 72205, with any suggestions for debate topics and interlocutors you would like to see published herein.

Disability rights advocates sometimes claim that prenatal tests to select against disabilities discriminate against people with disabilities. The “expressivist argument” that supports this position has been challenged on grounds of the difference between fetuses and born persons. In this essay, I explain why the expressivist argument is valid despite the questionableness of its conclusion, and why the distinction between fetuses and born persons fails to provide an adequate counterargument to the expressivist conclusion. I also consider a compelling argument for prenatal testing to select against disabilities and propose a reformulation of this argument that, I think, supports prenatal testing for disabilities while avoiding discrimination against people born with disabilities.

In my previous thinking about the considerations that go under the heading of the “expressivist argument,” I have been fascinated chiefly by two of its features: its (implicit) semantic commitments and its independence from disputes about the moral standing of fetuses. Abortions prompted by prenatal testing are undertaken because of indications that the fetus has physical features that would be configured as disabilities in the social world into which it would otherwise emerge. The expressivist argument's allegation, as I have understood it, is that abortions so motivated convey semantic content—“send a message”—to people who are currently living with disabilities that is somehow insulting, hateful, dismissive, or disparaging. It is thus uncontroversial moral subjects who are wronged, not—or, at least, not necessarily—the aborted fetuses. So far as this argument goes, a person might hold strongly pro-choice views about abortion generally and still object to “selective” abortions.

It is gratifying that thoughtful philosophers and bioethicists like Mahowald and Nelson are continuing to address the objections to prenatal testing that have been made by disability scholars and advocates. But it is frustrating to see those objections presented in ways that reflect the doubts of those who reject them more than the intentions of those who make them, in ways that make those objections appear censorious toward pregnant women and prospective parents or naïve about nonverbal expression. We recognize that disability critics share the responsibility for these misunderstandings, that their objections to prenatal disability testing have not always been made as clearly or consistently as they might have been. We therefore welcome this opportunity for clarification and rebuttal. Briefly, we will argue against Mahowald that it is not apparent how prospective parents could have a duty to potential offspring requiring them to prevent the birth of any child expected to have a life worth living. And we will remind Nelson that our primary concern is with the perpetuation of stigma; that even if any reason for abortion can be framed in terms of a trait of the fetus to be aborted, only certain reasons for abortion are based on the rejection of future children because of stigmatized traits.

In the portion of their reply directed to me, Professor Asch and Dr. Wasserman helpfully develop the synecdoche argument by highlighting its connections to stigma. I understand them to distinguish the situation of a woman making a decision concerning her pregnancy informed by prenatal testing from a woman making a similar decision informed by considerations of, for example, poverty, like so: In testing contexts, it will characteristically be the case that the woman's decision will be distorted by the stigma associated with impairment: She will consider only the fact that, should her pregnancy come to term, the child would be impaired; she will not be able to attend in a satisfactory manner to a fuller range of possible features, both good and bad, that may characterize the child's life and her experience of being the child's parent. The woman considering whether to terminate her pregnancy due to, say, poverty will, in contrast, typically be able to deliberate in ways more responsive to a broader range of relevant matters, as the possible child's poverty will not be the only thing she is in a position to take into account about her or his life and their life together. Further, even where poverty or some other factor influencing decisions about terminating or continuing pregnancy are stigmatizing, they are not as thoroughly stigmatizing as are impairment-related conditions, due to prevalent confusions about the immutability of traits seen as biological rather than social.

We are gratified by Nelson's response to our commentary. It shows, for the first time, an appreciation of the distinctive character of our criticism of individual decisions to test and terminate for fetal impairment. Although we still find much to disagree with in Nelson's characterization and critique of our views, he has given us a welcome opportunity to clarify and develop them.