Culture and ethics are inextricably bound to each other. Culture provides the moral presuppositions and ethics the formal normative framework for our moral choices. Every ethical system, therefore, is ultimately a synthesis of intuitive and rational assertions, the proportions of each varying from culture to culture. There is also in every culture an admixture of the ethnocentric and the universal that is indissolubly bound to a particular geography, history, language, and ethic strain and is common to all humans as humans.

Mrs. J. is a 76-year-old woman who had been in good health. When she was brought to the hospital 10 days after being involved in an automobile accident, she was found to have severe brain injury and, despite vigorous treatment, has neverregained consciousness. The consulting neurologist feels that she has no chance to recover completely and the “best case scenario” is that she may regain some consciousness without ever being able to take care of herself or probably without ever being able to interact with her environment in a meaningful fashion. She and her husband have been very close and had just celebrated their 50th wedding anniversary when the accident occurred. After long deliberation, her husband states that his wife had often said that “she would never want to live like this” and that she had always had a fear of being a burden to anyone. He wants active treatment stopped and asks that she only be kept comfortable and allowed to die. Their daughter agrees with this decision, although their son who lives in a distant state, feels that all treatment should continue and that she “certainly wouldn’t be a burden.” Among other considerations brought up by the husband is the fact that there are no financial arrangements to take care of long-term care in a nursing home.

Hospital ethics, familiar enough in practice but surprisingly neglected in the literature, deals with the ethical problems that arise distinctively or typically in hospitals. More precisely, it consists of the ethical principles that shouldgovern 1) the conduct of healthcare professionals and other staff in their capacities as members of the hospital as an institution, and 2) the conduct of the hospital itself as an institution. It is a species of institutional ethics, which focuses on the ethical problems created or significantly shaped by the institutional setting in which they occur.

Ethics consults at a university medical center share many qualitites with those in other settings. What makes them different, if at all, is a difference of degree, not kind. All consult services share the tasks of exploring cases for possible recommendation, contributing to the development of institutional and public policy, and educating colleagues and patients about medical ethics dimensions. Nonetheless, the university setting, devoted as it is to teaching, research, and public service, brings a slightly different focus to these tasks and adds other, peripheral ones.

An increasing number of HIV-infected patients require surgical care. Many surgeons, regardless of their venue of practice, would prefer not to treat HIV-infected patients.1 The reasons for this attitude differ from individual to individual but include the fear of contracting an incurable fatal illness, a desire to avoid interaction with homosexuals and intravenous drug users, and fears that occupationally acquired HIV infection would result in restriction of clinical privileges and loss of income.2,3 At the same time, many individuals, institutions, and professional organizations have affirmed the obligation of all healthcare workers, including surgeons, to care for patients without regard to their HIV status.4-6 This article explores the nature of this obligation from the perspective of a clinical surgeon working in an inner city hospital.

Heathcare spending, which was almost 13% of the gross national product last year, is estimated to jump to 14% in 1992. For the first time, hosital expenditures are projected to exceed $300 biilion, representing over 38% of the nation's total healthcare bill. In an effort to reduce federal and state budget deficits and to stimulate institutional cost containment, Medicare and Medicaid officials are becoming even more parsimonious in negotitation reimbursement levels.

In the last issue of Cambridge Quarterly, I summarized several sessions on bioethics held at conferences sponsored by organizations that are not usually thought of as being in the mainstream of bioethics. In particular, I mentioned the American Public Health Associtation and the American Anthropological Association as examples of organizations with broad interdisciplinary memberships that have developed specialized interests in the relationships between their respective fields (Public health and anthropology) and healthcare ethics. The article pointed out that there are other voices outside the field of bioethics that make valuable contributions to the shape, function, and direction the field takes.