Previous studies have documented the fallibility of attempts by surrogates and physicians to act in a substituted judgment capacity and predict end-of-life treatment decisions on behalf of patients. We previously reported that physicians misperceive their patients' preferences and substitute their own preferences for those of their patients with respect to four treatments: cardiopulmonary resuscitation (CPR) in the event of cardiac arrest, ventilator for an indefinite period of time, medical nutrition and hydration for an indefinite period of time, and hospitalization in the event of pneumonia.

In the mid to late 1980s a debate arose over the moral and legal authority of advance medical directives. At the center of this debate were two point-counterpoint law journal articles by Rebecca Dresser and Nancy Rhoden. What appeared to have the makings of an ongoing critical dialogue ended with the untimely death of Nancy Rhoden. Rebecca Dresser, however, has continued her challenge of advance directives in numerous publications, most recently in a critique of Ronald Dworkin's Life's Dominion. Like Rhoden, Dworkin has been a staunch advocate of advance directives as an exercise of what has come to be referred to as prospective or precedent autonomy. In this paper I will consider a number of the issues that Dresser has repeatedly raised about the infirmities of advance directives, and suggest that it is from an understanding of and appreciation for the narrative dimension of the life of a person that advanced directives draw one of their most powerful justifications.

Since its inception decades ago, technological intervention in human reproduction has been the subject of considerable attention and controversy. After identifying two focal points of debate, I focus in this paper upon an emerging body of literature responsive to a host of problematic issues that, scholars claim, reproductive technologies pose. Maintaining that critical assessment of this literature is necessary, I identify two areas of inquiry which deserve attention and, correspondingly, sketch directions which might guide further study.

The case in favor of gene therapy is quite simple. Gene therapy is likely to improve the health and well-being of some people that are among the worst off in society, namely patients with painful and life-threatening diseases. However, two types of objection have been raised.

For more than two decades euthanasia and assisted suicide have been openly debated in the Netherlands. This development started in 1973 when the Regional Court in Leeuwarden decided a case in which a physician had administered a deadly dose of morphine to her terminally ill mother on the mother's serious and persistent request. In this case the court concluded that the average Dutch physician no longer considered it his or her duty to prolong a patient's life under all circumstances. The court accepted that in specific cases a physician is allowed to prevent serious and irreversible suffering, even if the patient's life is short ened. This case was the first in which a legal opening for euthanasia or assisted suicide was created. In this specific case the physician was formally declared guilty, but the court gave her a suspended sentence of one week imprisonment. This decision started a debate on euthanasia and assisted suicide throughout all levels of Dutch society.

Voluntary active euthanasia (VAE) and physician-assisted suicide (PAS) remain technically illegal in the Netherlands, but the practices are openly tolerated provided that physicians adhere to carefully constructed guidelines. Harsh criticism of the Dutch practice by authors in the United States and Great Britain has made achieving a balanced understanding of its clinical, moral, and policy implications very difficult. Similar practice patterns probably exist in the United States, but they are conducted in secret because of a more uncertain legal and ethical climate. In this manuscript, we plan to compare end-of-life care in the United States and the Netherlands with regard to underlying values, justifications, and practices. We will explore the risks and benefits of each system for a real patient who was faced with a common end-of-life clinical dilemma, and close with challenges for public policies in both countries.

When God gave humankind dominion over the earth he may not have known exactly what we would be able to do with it. The technical capacities to which the production and reproduction of our everyday life have given rise have grown at an astonishing and, it seems, ever-increasing rate. The instruments that we use to do work on the world have become sharper and more refined, and the implications of human interventions in the nonhuman environment are much more far-reaching than could have been imagined even forty years ago. It has become something of a cliche to say that our technical abilities have outstripped the wisdom to know when, where, and how we should appropriately use them, but techniques such as genetic engineering invite the dusting-off of the cliche and the asking of the question implicit in it: We know we can splice genes, but should we splice them? We might of course come to the conclusion that we should only splice some of them some of the time, but even arriving at that conclusion presupposes that the ethical question has been asked and answered.