George Annas serves a critical function as an incisive commentator on the interactions between law and medicine and law and public health. Along with Alex Capron, Dena Davis, Rebecca Dresser, and Larry Gostin—to pinpoint a few—Professor Annas analyses legal aspects of a spectrum of medicolegal issues both in a forum and in a manner that makes them accessible and understandable to a broad community of healthcare providers. His latest book, Some Choice, continues that valuable tradition. The bulk of the volume (17 out of 22 chapters) is drawn from essays originally published as the “Legal Issues in Medicine” feature of the New England Journal of Medicine. The topics include such staples of patients' rights debate as the boundaries of informed consent, authorization of medical experiments, and physician-assisted suicide. A treat is the inclusion of less frequently covered issues, such as access to health information concerning presidential candidates and constitutional bounds of limits on cigarette advertising.

As a way of contributing to bioethics' understanding of itself, and, more particularly, to invigorate conversation about how we can best educate future colleagues, we present here a sketch of the quarter-century-old graduate concentration in medical ethics housed in the Department of Philosophy at the University of Tennessee, Knoxville. Our hope is to incite other programs to share their histories, strategies, problems, and aspirations, so as to help the field as a whole get a clearer sense of how we are putting together our future, and of how we might best go about this important job.

A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a Central American country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system.

Was this just another incendiary sound bite, headline news banner attacking the airwaves? Getting it wrong? Overstating some small technicality for the sake of getting attention? No, to all of the above: the most incendiary aspect of the blurb was that it was accurate. And it did get attention.

In this case, when the ethics committee is asked “What is our duty to this patient?” the questions that should be addressed are “What is whose duty to the patient, and whose duty has primacy?”

Even if the term bioethics is used all over the world, its meanings are multiple and different, especially between American and European countries, depending on local cultural and medical contexts. These differences concern the issues discussed or the institutional form bioethics takes. In France, bioethics was used from the end of the 1970s and focused on research ethics and issues at the beginning of life. At the national level, a permanent commission, the “national consultative ethics committee on life sciences and health” (Comité Consultatif National d'Ethique, CCNE) was created by President François Mitterrand in 1983. Its recommendations dealt essentially with procreative medicine and biomedical research ethics.

Classical American pragmatists, such as William James, John Dewey, and C. S. Peirce, have had little influence on the development of bioethics. Glenn McGee and the other authors whose essays make up this book believe that this is a mistake. They maintain that the work of these pragmatists constitutes an original and effective method for understanding and resolving bioethical dilemmas. Their collective goal is to convince the rest of us that they are right.

Ruth Macklin's new book, Against Relativism, says in its subtitle that it intends to address cultural diversity and the search for ethical universals in medicine. This it does very well. Every chapter includes some discussion of cultural relativism, cultural anthropology, or postmodernism, and her analyses are acute and scathing. Macklin is unabashed in her defense of the principles of medical ethics, and she gives a strong argument that principles are essential elements of any ethical system that is to successfully survive the skeptical doubts of relativism.

In his professional life, Richard Posner is addressed as “Your Honor,” inasmuch as he is Chief Judge of the U.S. Court of Appeals for the Seventh Circuit. He is also a senior lecturer at the University of Chicago Law School. Finally, he is a prolific author of books and articles in scholarly journals in which he expounds at length and with copious footnotes his particular views of jurisprudence and public policy. One of his frequent intellectual adversaries, legal philosopher Ronald Dworkin, wryly described Judge Posner as “the lazy judge who writes a book before breakfast, decides several cases before noon, teaches all afternoon at the Chicago Law School, and performs brain surgery after dinner.”

This is a case that speaks directly to the issue of an organization's mission. As private insurance and government reimbursement decline, the economic pressures facing healthcare systems both public and private continue to increase. For many institutions it is no longer a question of prospering but surviving. As this case accurately describes, survival is dependent on continually reducing costs and maximizing reimbursement. These strategies often include reducing the number of nonpaying or charity cases while attempting to remain faithful to the mission of the organization, whether this be a religious or civic mission. The ethics committee, although it may be an appropriate forum for discussions to begin concerning this patient, is not the appropriate decisionmaking body regarding whether this gentleman receives the treatment he needs. That task should fall to whichever group defines or articulates the mission and values for the organization, normally the hospital's administration in concert with the board of directors or trustees.

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.

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.

Ram Dass is one of America's most renowned spiritual teachers. Born Richard Alpert, he received his Ph.D. in psychology from Stanford University and taught there and at Harvard University before going to India and receiving the name Ram Dass (“Servant of God”) from his guru. He has long been involved in many charitable service organizations, particularly those devoted to providing healthcare for underserved populations. Among his many books are Be Here Now (currently in its fortieth printing), How Can I Help, and Compassion in Action; his newest book is Still Here: Embracing Aging, Changing, and Dying (Putnam, 2000).

Ethics raises questions about what kind of society we ought to be, questions that are at the heart of this case. Increasingly, inequalities in healthcare fueled by lack of access, inadequate insurance coverage, and rising costs are creating dilemmas in the proper distribution of healthcare resources. Questions of distributing scarce and valuable resources are fundamentally questions of justice. The classic definition of justice is the duty to give to each person what they deserve and can legitimately claim so that justice is understood as a moral obligation to help persons exercise their rights. Distributive justice, i.e., what distribution of resources is fair, equitable, and appropriate, thus turns on the concept of rights. One of the key questions in this case is whether and to what extent this patient has a right to treatment for his heart disease. In the classic understanding of justice, he must assert and we as a society must agree that he has a right to treatment for his heart condition before we are morally obligated to provide this care. Are there limits to this patient's right to healthcare? If so, what are they? The differing principles of distributive justice use different criteria to rank or weight decisions regarding the proper and just distribution of healthcare services. In this case, at least two competing but ethically valid principles can be identified: the humanitarian principle and the libertarian principle.

To ask whether and to what extent there is an obligation to treat illegal immigrants implies—just in the asking—that any duty to treat an illegal resident is different from or lesser than the duty to treat a citizen. What could be the reason for thinking that morality affords fewer benefits or rights to illegal residents?

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.

The ethics committee was in agreement that the patient should be operated on, given his emergent status. Initially, he was too medically unstable, and for three weeks was in an intensive care unit until his condition stabilized to the point that he could tolerate the surgery. He became sufficiently stable to permit surgery and both of his heart valves were replaced. He did very well after surgery. His pitting edema and jaundice reversed, and he was discharged after a week to the care of a relative. He received follow-up care in the hospital's cardiac clinic and was provided needed medications. He stated his intent to return to his home country once he recovered from the surgery.

The Central and East European Association of Bioethics, CEEAB, was founded in the Hungarian city of Pecs, on 6 February 1999, at a meeting of scholars from Croatia, Hungry, Lithuania, Slovakia, and Russia. The meeting was supported by the Soros Foundation and the Albert Schweitzer Institute for the Humanities.

In a new and important book entitled The Managed Care Blues and How to Cure Them, a lifetime consumer advocate and a surgeon who witnessed the excesses and unaccountable errors of his colleagues under fee for service explain with deft hands the promise of managed care, its problems, and solutions to them. Walter Zelman and Robert Berenson show empathy for the consumer backlash, provider resentment, and the patients' rights movement that has spawned a thousand bills to prevent possibly unethical actions. Yet they believe these efforts to regulate managed care are misdirected and will prevent it from realizing its potential.

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.