Contributors.

Paradoxically, the unifying characteristic of our annual Open Forum issues is the absence of any particular thematic topic, a common thread of concern that is examined and discussed from multiple perspectives. What the papers do share, however, is a challenge and invitation to readers to take up the arguments presented here and advance the discussions with their own debates.

I would like to share some reflections on how bioethics fosters dialogue between the sciences and humanities by talking a bit about my work as a physician-ethicist collaborating with neuroscientists studying severe brain injury and mechanisms of recovery. If I am successful in this Pilgrim's Progress, I hope I will convince you that the injured brain can teach us much about ourselves. It is not something I was prepared to believe as a medical student, when I was more certain of things than I am now.

Discussions of appeals to conscience by healthcare professionals typically focus on situations in which they object to providing a legal and professionally permitted service, such as abortion, sterilization, prescribing or dispensing emergency contraception, and organ retrieval pursuant to donation after cardiac death. “Negative claims of conscience” will designate such appeals to conscience. When healthcare professionals advance a negative claim of conscience, they do so to secure an exemption from ethical, professional, institutional, and/or legal obligations or requirements to provide a healthcare service.

In a provocative 1991 paper, Alvin Moss and Mark Siegler argued that it may be fair to give individuals with alcohol-related end-stage liver disease (ARESLD) lower priority for a liver transplant than those who develop end-stage liver disease (ESLD) from other factors. Like other organs, there is a substantial gap between the available livers for transplantation and the number of people who need liver transplants. Yet, unlike those with end-stage renal disease, who can survive for some time on dialysis before receiving a kidney transplant, those with liver failure will die without a liver transplant.

Polemicists and disciplinary puritans commonly make a sharp distinction between the normative, “prescriptive,” philosophical work of bioethicists and the empirical, “descriptive” work of anthropologists and sociologists studying medicine, healthcare, and illness. Though few contemporary medical anthropologists and sociologists of health and illness subscribe to positivism, the legacy of positivist thought persists in some areas of the social sciences. It is still quite common for social scientists to insist that their work does not contain explicit normative analysis, offers no practical recommendations for social reform or policy making, and simply interprets social worlds.

Okay, Professor Turner is not Rodney King. He is not responding to bioethicists and social scientists running amuck, setting automobiles aflame, and pelting each other with rocks and broken bottles. He does not come right out and ask, “Why can't we all just get along?” But in its academic way, Turner's essay is an effort to negotiate a truce in the interdisciplinary squabbles that plague bioethics, a plea to move bioethics beyond the “misleading” and “unhelpful” “demarcation of disciplinary goals” that leads to “dichotomous thinking” and “polemical accusations.”

Even the most scientifically reductionist view of the individual reveals that we are complex systems nested within complex systems. These interactions within and among systems are based and depend on numerous variables of our (internal and external) environment(s). If we define ethics as a system of moral decision making, then it becomes clear that these decisions ultimately affect the situation(s) of managing our activities and relationships with others in our environment (in essence, our being in the world). Given that ecology literally means “a study or system of wisdom and reasoning about the interrelation of organisms in their environment or place of inhabitance,” Owen Flanagan's description of ethics as “human ecology” takes on considerable relevance and importance.

In the United States, health disparities have been framed by categories of race. Racial health disparities have been documented for cardiovascular disease, cancer, diabetes, HIV/AIDS, and numerous other diseases and measures of health status. Although such disparities can be read as symptoms of disparities in healthcare access, pervasive social and economic inequities, and discrimination, some have suggested that the disparities might be due, at least in part, to biological differences based on race. Or, to be more precise, if race itself has no determined biological meaning, race may nonetheless be a proxy that collects a group of individuals who share certain physiological or genotypic features that affect health.

“Health and Human Rights,” edited by Doris Schroeder, welcomes contributions on all areas outlined below. Submitted papers are peer-reviewed (short discussion papers will be reviewed by at least one, full papers by at least two reviewers). To submit a paper or to discuss suitable topics, please e-mail Doris Schroeder at [email protected].

In December 2007 it was revealed that the British government is considering the exclusion of certain groups of migrants—those considered to be present “illegally”—from primary health care provided by the National Health Service (NHS). At present, practitioners have discretion to accept any individual for NHS treatment regardless of their status. A joint Home Office and Department of Health review is examining this access for foreign nationals, and the likely outcome is the restriction of access to irregular migrants, which would, according to the Institute of Public Policy Research, affect around 390,000 people. In 2004 such groups were excluded from NHS secondary care, most controversially from treatment for HIV, and so the present proposal would bar them from all but emergency health treatment.

In an earlier piece in these pages,1 I described the health effects of the still massive problem of global poverty: The poor worldwide face greater environmental hazards than the rest of us, from contaminated water, filth, pollution, worms, and insects. They are exposed to greater dangers from people around them, through traffic, crime, communicable diseases, sexual violence, and potential exploitation by the more affluent. They lack means to protect themselves and their families against such hazards, through clean water, nutritious food, satisfactory hygiene, necessary rest, adequate clothing, and safe shelter. They lack the means to enforce their legal rights or to press for political reform.

“Dissecting Bioethics,” edited by Tuija Takala and Matti Häyry, welcomes contributions on the conceptual and theoretical dimensions of bioethics. The section is dedicated to the idea that words defined by bioethicists and others should not be allowed to imprison people's actual concerns, emotions, and thoughts. Papers that expose the many meanings of a concept, describe the different readings of a moral doctrine, or provide an alternative angle to seemingly self-evident issues are therefore particularly appreciated. The themes covered in the section so far include dignity, naturalness, public interest, community, disability, autonomy, parity of reasoning, symbolic appeals, and toleration. All submitted papers are peer reviewed. To submit a paper or to discuss a suitable topic, contact Tuija Takala at [email protected].

As a result of workplace clean air regulations and strict guidelines imposed by the Joint Commission on Accreditation of Healthcare Organizations in 1993, most hospitals in the United States are now virtually smoke free. Although evidence suggests that these restrictions both cause smoking employees to consume fewer cigarettes per day and induce some employees to quit smoking entirely, the policies have also driven many healthcare providers—including physicians—onto the public sidewalks for their cigarette breaks. Patients entering many hospitals pass white-coated medical students and residents puffing away at the curbside.

This section is meant to be a mutual effort. If you find an article you think should be abstracted in this section, do not be bashful—submit it for consideration to feature editor Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will give you an opportunity to respond in the letters section. Your input is desired and anticipated.