Contributors.

Contributors.

Contributors.

One of bioethics' most singular strengths is fostering debates on human conundrums, not those relegated to dusty archives, but those forming the moving, developing present. Bioethics is future looking, not quite crystal ball gazing but struggling to ascertain what the consequences of our choices and actions will be. And, although the methodology is still to be fully articulated (see CQ Vol. 16, No. 4, Fall 2007 “An Ethical Competition: The Method in Bioethics Research”) a challenge is to navigate intellectual errors such as a Manichaean oversimplification of seeing things in black and white or falling prey to moral relativism where we are blind to blurred distinctions.

Among the greatest challenges to improving health is determining how cultural diversity should influence healthcare practices and organizations, public health measures, biomedical research, and community partnering. Important but seldom addressed are challenges for bioethicists.

In the advent of the 21st century there can be no doubt that we have entered uncharted territory as we continue to employ diverse information and communication technologies (ICT) within healthcare. This is simply a matter of fact, at least for the Western world. But, as a question of value, what are the ethical and social ramifications of this healthcare trek? What assessments can we render on this murky, barely explored topography? A utopian answer is that ICT would deliver us to a technologic garden of healthcare delights. Here, health-related information and services abound and healthcare professionals and patients, under the protection of an electronic, global umbrella, operate in perfect harmony for the good of patients.

In 1978 a small group of editors of general medicine journals met informally in Vancouver, British Columbia, to establish guidelines for manuscripts submitted to their journals. The resulting “Uniform Requirements for Manuscripts Submitted to Biomedical Journals” was published in 1979 and has become the standard editorial policy guiding the medical literature.

The recent success in generating live offspring from embryonic stem cell (ESC) –derived gametes in mice sparked visions of growing tailor-made sperm for men faced with infertility. However, although this development will almost certainly lead to new insights into the processes underlying spermatogenesis and thus in the possible causes of male infertility, it is less certain if deriving sperm from ES cells, which are in turn derived from a sterile man, can make someone a genetic parent. As the gap between newly envisioned reproductive technologies and natural reproduction widens, the question thus needs to be asked if these possible therapies still lead to genetic parenthood.

Empirical evidence demonstrates that minority and marginalized populations receive less and lower quality healthcare than more advantaged groups. Ethical analyses of these disparities explain their injustice. That disparities exist and constitute a moral wrong are uncontroversial views. Less clear are the exact causes of healthcare disparities.Thanks go to several reviewers who read and commented on earlier drafts, including John Stone, John Arras, Jay Baruch, Terry Rosell, and an anonymous CQ reviewer.

The intersection of ethics, computing, and genetics plots a space not yet adequately mapped, despite its importance, indeed, its rapidly growing importance. Its subdomains are well-enough known: “Genethics,” or the study of ethical issues in genetics and genomics, is part of core curricula everywhere. Ethics and computing is an established subfield. Computing and genetics—bioinformatics—has in little more than a decade progressed from subsubspecialty to the sine qua non of contemporary biomedical research, and it bids fair to transform clinical practice. We must prepare for the complete digitization of the genomes of individual patients and the storage of millions of these genomes in very large databases.

At a large bioethics conference in the early 1990s, the International Bioethics Institute presented a panel discussion on the newly-hot issue of “medical futility.” Erudite experts held forth from various perspectives, with convincing if conflicting arguments. During the question-and-answer session that followed, however, one attendee gently offered the one remark most recalled from that session. He was, if memory serves, a Latino physician working near the Mexico/USA border. “Thank you for your presentations,” he said, apparently with great sincerity. “I learned a lot. But on behalf of my own patients, I would ask that before you give them the right to say ‘no’ to medical treatment, we first give them the option of saying ‘yes’.”

The number of legal and nonlegal ethical regulations in the biomedical field has increased tremendously, leaving present-day practitioners and researchers in a virtual crossfire of legislations and guidelines. Judging by the production and by the way these regulations are motivated and presented, they are held to be of great importance to ethical practice. This view is shared by many commentators. For instance, Commons and Baldwin write that, within the nursing profession, patient care can be performed unethically or ethically depending on the professional standards the nurses have set for themselves. They also hold that such standards are set when nurses become aware of the ethical codes available. As nurses are often not familiar with the codes, they do not all conform to them. Commons and Baldwin argue that nurses' ability to deal with ethical dilemmas is effectively secured with education on guidelines, creating a “barrier” between personal and professional values (p. 5).

We have all heard a refrain much like this one over the last decade, increasingly so, as the cost of genetic sequencing has been drastically reduced with improvements in associated techniques and technologies. Already, discoveries are being made in laboratories that can help doctors determine from which drug a particular patient will receive the most efficacious treatment. The working presumption is that, eventually, individuals’ genetic sequence information will be included in each of their personal medical records.

Three of the bioethical issues recently discussed in Sweden appear to be particularly interesting also to an international audience. A new law allowing restrictive use of preimplantation genetic diagnosis (PGD)/human leukocyte antigen (HLA) (“savior siblings”) has been implemented, a new recommendation for the cessation of life-sustaining treatment has been issued, and the scope of individual responsibility for medical mistakes has been rather thoroughly discussed.

Taking seriously the value of cultural competence in healthcare requires at least three general commitments. First, it involves accepting the view that patients' health beliefs and behaviors are influenced to a significant degree by their own social and cultural practices. Second, it requires careful attention to how health professionals typically respond to patients' different social and cultural standards at various levels of the healthcare delivery system. And third, it calls for developing interventions that are sensitive to these first two issues to assure the delivery of quality healthcare for culturally diverse patients. This much is plain, insofar as we are talking about the broadest of commitments necessary to support the value of cultural competence in healthcare. But what other, more specific commitments are implied in accepting the value of cultural competence?I thank the guest editors of this issue, John R. Stone and Erika Blacksher, for their helpful suggestions on an earlier draft of this paper.

Today Asia is attracting attention in the area of bioethics. In fact, the potential of bioethics is beginning to be discussed seriously at academic centers across Asia. In Japan, this discussion began a decade ago with the publication “Japanese and Western Bioethics.” The book is one of the principal explorations of biomedical ethics involving Japan to date. Tom Beauchamp, an author of one of the book's chapters, compares Japanese and American standards of informed consent and refutes relativistic positions, concluding that:

There are deep structural conflicts between the mission of healthcare as cooperative care to the sick and injured and that of healthcare as a business whose mission is maximizing profits. These conflicts come to the fore in the medical pharmaceutical industry. I first set these out in a context that addresses the mission of healthcare, then examine the relative roles of competitive and cooperative systems of distributive justice, and then argue for the creation of nonprofit pharmaceutical companies and the transformation of many for-profit companies into companies subject to public oversight and profit curbs. The recommendations are aspirational for the United States (because it does not yet offer universal health coverage) but it is meant to be action guiding for those industrialized countries wealthy enough to provide universal health coverage.

The shared values, beliefs, and behaviors by which people interpret life events are what we call culture. More than medical science, culture determines how people react to illness and death. Science may determine which drug or surgery best treats the disease, but culture often determines how the health professional best treats a patient with the disease. Culture influences when the patient believes he is ill, which treatments he accepts, and which results he prefers. Because culture surely affects illness outcomes, health professionals must not ignore it.This project received financial support from the Mexican American Medical Treatment Effectiveness Research Center and the Aging Research and Education Center at The University of Texas Health Science Center and from the Ecumenical Center for Religion and Health, San Antonio. Presented in an earlier version at the Seventh Annual David C. Thomasma, Ph.D., Memorial International Bioethics Retreat, Medical Faculty, University of Padova, and Fundazione Lanza, Padova, Italy, 26 June 2004; presented at the Second International Conference on Clinical Ethics Consultation, Basel, Switzerland, 19 March 2005; and accepted for presentation at the national meeting of the Society of General Internal Medicine, New Orleans, Louisiana, 13 May 2005. Erika Blacksher, John Stone, Susan Bagby, and David J. Doukas thoughtfully critiqued earlier drafts of this article. Andrew K. Diehl and Helen P. Hazuda critiqued a research abstract of the material. I thank all these people for their many helpful suggestions.

According to a 2001 market report, titled “The Cure Is in Hand,” handheld computers, or personal digital assistants (PDAs), will “dramatically change the way that physicians practice medicine.” Such enthusiasm has resulted in an extraordinarily rapid diffusion of PDAs into a wide range of clinical settings. One report states that 47% of internists use PDAs once a day with rates of daily usage reaching 70% for resident physicians. Another study found clinical usage as high as 85% in teaching hospitals. The rapidly expanding employment of PDAs, however, has been uneven. Some clinicians have explored the devices’ benefits more thoroughly than their colleagues. Similarly, a number of potentially valuable uses of the handheld computer have been ignored or remain insufficiently developed by the medical community and the health delivery system at large.