Bette Anton, M.L.S., is Head Librarian for the Pamela & Kenneth Fong Optometry & Health Sciences Library of the University of California, Berkeley. This library serves the UC Berkeley School of Optometry and the UC Berkeley–UC San Francisco Joint Medical Program.

Contributors.

Contributors.

Akira Akabayashi, M.D., Ph.D., is Professor in the Department of Biomedical Ethics at the School of Health Science and Nursing, University of Tokyo Graduate School of Medicine, Tokyo, Japan, and Chair of the Advisory Committee for Conflicts of Interest, Faculty of Medicine, University of Tokyo.

In fall 2002, Paul Ellwood's Jackson Hole Group proposed “Heroic Pathways”—a healthcare reform concept that includes (1) a voluntary system of portable, personal electronic medical records owned by patients and (2) a health information pathway that is managed by patients and clinicians. This proposal, like so much of the innovative thinking in healthcare policy, is premised on the conviction that informed patients will drive healthcare changes in the near future.

Although keeping up with developments in any field is a challenge, because of bioethics' interdisciplinary nature and growing international community, it is especially important to keep the larger landscape in view, beyond one's own specialty and nationality.

Bioethics is a cautionary field. It warns society to be aware that the real danger lies not so much in ignorance but in the illusion of knowledge—and to be prepared for the unexpected. At the same time, bioethicists are an optimistic group in that we stake our professional lives on the belief that there is such a thing as progress. The point of our efforts is to help us to be wiser in our choices by expanding our views and avoiding overgeneralizations. Wisdom, however, is a long-term investment requiring far-reaching explorations.

Although the precise birth date may be ambiguous, by anyone's count the field of bioethics has emerged from infancy and childhood and is now a young adult—a stage in time when making decisions for future directions is imperative. In this “Quo Vadis?” Special Section, we've invited bioethicists from various disciplines and stages in their careers to share their thoughts, not on where we are now, but where should we be going? Is reorienting ourselves in order? How would they chart the future of bioethics and what needs to be done to implement their visions?

Should patients request antibiotics from their physicians for common upper respiratory infections?I am grateful to Drs. Richard Bukata and Jerome Hoffman and the staff of Primary Care Medical Abstracts for retrieving and analyzing some of the references used in this paper.

Relativism is usually a derogatory word in philosophical bioethics in the West. If people make the mistake of trying to understand radically “different” points of view, an accusation of relativism is quickly forthcoming. But why should this be an accusation? My aim in this paper is to demonstrate that it should not.

The Islamic Republic of Pakistan has a population of more than 145 million people, about 95% of whom are Muslims (approximately 20% Shi'i and the rest Sunni). Although it has a few large cities such as Karachi, almost 65% of the country is still rural, with a per capita income of $408 per year. The overall literacy rate is estimated to be 41.5% but is much lower for women in many of the provinces. Pakistan has a complex culture with many ethnic groups and socioeconomic strata, but overall the society is characterized by hierarchical systems in both private and public domains. The population is religious and family centered with the “family” understood as extending beyond the nuclear; it is not uncommon to have three generations residing under one roof or within close proximity to each other and pooling their resources.

In 1986, philosopher-bioethicist Samuel Gorovitz published an essay entitled “Baiting Bioethics,” in which he reported on various criticisms of bioethics that were “in print, or voiced in and around … the field” at that time, and set forth his assessment of their legitimacy. He gave detailed attention to what he judged to be the particularly fierce and “irresponsible attacks” on “the moral integrity” and soundness of bioethics contained in two papers: “Getting Ethics” by philosopher William Bennett and “Medical Morality Is Not Bioethics,” coauthored by us. Gorovitz attributed some of the criticisms that bioethics was eliciting to the fact that this new, rapidly rising, and increasingly visible field had brought “scholars and practitioners together who otherwise would have little exposure to one another's disciplines. Their interactions are mutually enriching at times,” he declared, “but mutually baffling and even infuriating at other times.” In this latter regard, he suggested that “perhaps” Fox and Swazey's characterization of bioethics in the article he dissected “reflects a general revulsion at endeavors they see as inadequately like the social sciences or insufficiently respectful of them.” He went on to say that despite his objections to our “complaints” about bioethics—especially to our claim that “autonomy [had] been an unduly emphasized value” in the field—he had “a lingering sense” that there might be “a grain of truth” in them. Gorovitz ended his essay with an affirmation about the “benefit” that bioethics can derive from “responsible” and even from “irresponsible” criticism. “The unexamined discipline invites the philosopher's critical scrutiny no less than the unexamined life,” he aphoristically concluded.Research for this paper was conducted, in part, during the Acadia Institute's Project on Bioethics in American Society, for which Dr. Swazey was the PI and Dr. Fox the CO-PI. The project was supported by grants from the Greenwall Foundation, the National Library of Medicine (RO1 LM 06893), and the National Science Foundation's Program on Societal Dimensions of Engineering, Science, and Technology (SBR-9710570). The views in this paper are the authors'.

Last year I published a short article urging bioethicists to carefully examine the question of what ought to constitute the canonical issues topics and questions driving research and teaching in bioethics. Why some subjects dominate the field whereas other topics are regarded as matters for scholars in other disciplines is a question that has intrigued me for nearly a decade. How are the boundaries of bioethics established? What factors influence research agendas and the creation of bioethics curricula? How do funding agencies, editors, and leading scholars shape the field of bioethics? These questions are increasingly receiving scrutiny from Charles Bosk, Raymond De Vries, and other researchers as they explore the sociology of bioethics and the “construction” of the “ethical enterprise.”

The philosophy of Josiah Royce (1855–1916) has recently begun to regain attention; Griffin Trotter, in particular, has utilized Royce in questions concerning medical ethics. This resurgence in attention is for good reason—Royce's philosophies of loyalty and community provide both a descriptively accurate picture of the self and a prescriptively solid ethical system. Royce recognized, as do all pragmatic philosophers, that persons only exist socially, and this sociality will necessarily influence the individual ethically, but also epistemologically. What we know, how we act, how we think we ought to act are not individual questions, but rather questions that arise for individuals only in the context of a larger community.

This article examines bioethics in Tanzania, particularly in relation to the HIV/AIDS epidemic for the following reasons: First, not only is HIV/AIDS the most alarming health problem in most parts of Africa, but the complexity of issues involved in medical and research ethics (codes of conduct and standard guidelines, conflicting rights and responsibilities, and issues of distributive justice) clearly illustrates the various levels of problems that bioethics—more precisely, both professional medical ethics and research ethics—faces in a poor, developing country. The article defends uniformity in the general, international bioethical guidelines but calls for wider discussion in their applicability in different economic and social conditions by claiming that in the present debates the issues of distributive justice, culture, and individual professional judgment have been tangled together in a manner that tends to justify double standards in practice. To avoid this confusion there is a need to find a more coherent approach to bioethics that brings together the normative requirements set by international guidelines, national policy planning, social ethics, and professional medical ethics.I thank particularly Dr. Louis Mlingi, Tanzanian Occupational Health Service, and Dr. Pekka Nokso-Koivisto, Tanzanian Occupational Health Service and the Nordic Clinic, for their insightful views and for sharing their personal experiences in the issues of medical ethics in Tanzania in relation to their participation in our development ethics project funded by the Finnish Academy of Science 2000–2003. Some of the empirical examples are collected from our medical and healthcare ethics training in Lindi, Southern Tanzania with the Finnish funded Professional and Civic Ethics Project (CPEP), 2003. In addition I am grateful to professor Zul Premji, Muhimbili University College of Health Sciences, Dar es Salaam, for his advise on research ethics in Tanzania.

On the beautifully clear and sun-filled morning of September 11, 2001, just before I went to vote in the New York City primary elections, news came over the car radio that a plane had crashed into the North Tower of the World Trade Center. As I drove toward Manhattan after casting my ballot, newscasters reported a second plane crashing into the South Tower. It became instantly clear to everyone that these were acts of terrorism. We were under attack. All around me the behavior of New York City drivers immediately converted from the standard aggressive mode to a remarkably accommodating style, and in a dramatically uncharacteristic way cars yielded to make way for the emergency vehicles that were suddenly racing down the highway. Only one car surged to follow in their wake.This paper is a revised and shortened version of my chapter, “Justice in Allocations for Terrorism, Biological Warfare, and Public Health” in Public Health Ethics, edited by Michael Boylan, Kluwer; 2004. Portions of this material were presented at the International Bioethics Retreat, Pavia, Italy, June 2003, and at the meetings of the Association for Politics and the Life Sciences, Philadelphia, September 2003.

In the regime of Anglo-American tort law, every person has a responsibility to comport him- or herself with “due care” in going about day-to-day activities so as not to imperil the health, safety, or general welfare of others. The gold standard for determining what constitutes due care in any particular situation is what a reasonable person, similarly situated, would do. Determinations of due care are necessarily fact specific. Nevertheless, the general objective is to strike an appropriate balance between an unrealistically high standard of caution and one that fails to take into account the known or foreseeable risks of any human endeavor. The same standard applies to individuals regardless of their age (so long as they have reached majority), gender, race, and level of education or economic status. The standard also applies to fictional “persons” such as corporations. The usual or prevailing custom and practice in an industry or occupation may provide relevant evidence of what constitutes “due care” in the activities common to it, but that evidence can be effectively overcome or rebutted by competent, credible evidence that the custom and practice either diverges from what it has been asserted to be or that the custom and practice is itself unsafe or otherwise poses an unreasonable risk of harm to others. Until quite recently, a singular exception to this general principle of tort law was made for the medical profession. We will consider this exception in the next section.

The importance of preserving trust in physicians and in medical institutions has received widespread attention in recent years. Primarily, this is due to the threats to trust posed by managed care, but there is a general and growing recognition that trust deserves more attention than it traditionally has received in all aspects of medical ethics, law, and public policy. Trust has both intrinsic and instrumental value. Trust is intrinsically important because it is a core characteristic that affects the emotional and interpersonal aspects of the physician/patient relationship. As an instrumental value, trust is widely believed to be essential for effective therapeutic encounters. It has been hypothesized or shown to affect a host of important behaviors and attitudes relating to care, including seeking care, disclosing private information, complying with treatment, and being satisfied with care. Moreover, trust may be a mediator of measurable clinical outcomes and a key factor in the mind–body interactions that underlie placebo/nocebo effects and the effectiveness of alternative medicine. It is no surprise, then, that preserving, justifying, and enhancing trust is the fundamental goal of much of medical ethics, and is a prominent objective in healthcare law and public policy. Discussions of trust and related concepts were commonplace in professionally based medical ethics prior to the 1970s.This research was supported in part by the Robert Wood Johnson Foundation, under its Patient-Provider Relationship Initiative. Several colleagues contributed to the development of these ideas, including Elizabeth Dugan, Ph.D., Douglas Levine, Ph.D., Beiyao Zheng, Ph.D., Raj Balkrishnan, Ph.D., and Charles Rawlings, M.D. This article is based in part on a prior article and book chapter.Hall MA. The ethics and empirics of trust. In: Englehardt TH, Bondeson W, eds. The Ethics of Managed Care: Professional Integrity and Patient Rights. Amsterdam: Kluwer;2003:109–26.Hall MA. Law, medicine and trust. Stanford Law Review 2002;55:463–527.

Readers of the Cambridge Quarterly of Healthcare Ethics need hardly be told that each year a huge amount of very valuable work in bioethics is carried out in the academic's study and the university seminar room and appears in the pages of specialist, restricted-readership journals. However, if it is to be as effective, relevant, and influential as it deserves to be, there arguably comes a point when this work needs to leave the confines of the academy and engage the wider public. This perhaps happens less often than it should.

In a recent issue of The Lancet, the historian Roger Cooter predicted that the field of bioethics will soon die of self-inflicted wounds. “Conspiring against it,” he wrote, “is exposure of the funding of some of its US centres by pharmaceutical companies; exclusion of alternative perspectives from the social sciences; retention of narrow analytical notions of ethics in the face of popular expression and academic respect for the place of emotions; divisions within the discipline (including one over its origins and meaning); and collusion with, and appropriation by, clinical medicine.” Cooter's prognosis? “Hardly wet behind the ears, bioethics seems destined for a short lifespan.”