Contemporary Issues in Biomedicine, Ethics, and Society – serie

Not long ago, a colleague chided me for using the term "the biological revolution. " Like many others, I have employed it as an umbrella term to refer to the seemingly vast, rapidly-moving, and fre­ quently bewildering developments of contemporary biomedicine: psy­ chosurgery, genetic counseling and engineering, artificial heart-lung machines, organ transplants-and on and on. The real "biological revo­ lution," he pointed out, began back in the nineteenth century in Europe. For it was then that death rates and infant mortality began to decline, the germ theory of disease was firmly established, Darwin took his famous trip on the Beagle, and Gregor Mendel stumbled on to some fundamental principles of heredity. My friend, I think, was both right and wrong. The biological revolution did have its roots in the nineteenth century; that is when it first began to unfold. Yet, like many intellectual and scientific upheav­ als, its force was not felt for decades. Indeed, it seems fair to say that it was not until after the Second World War that the full force of the earlier discoveries in biology and medicine began to have a major impact, an impact that was all the more heightened by the rapid bi­ omedical developments after the war.

Women most fully experience the consequences of human reproductive technologies. Men who convene to evaluate such technologies discuss Itthem ": the women who must accept, avoid, or even resist these technologies; the women who consume technologies they did not devise; the women who are the objects of policies made by of women is neither sought nor listened to. The men. So often the input and perspectives that women bring to the privileged insights consideration of technologies in human reproduction are the subject of these volumes, which constitute the revised and edited record of a Workshop on "Ethical Issues in Human Reproduction Technology: Analysis by W omen" (EIR TAW), held in June, 1979, at Hampshire College in Amherst, Massachusetts. Some 80 members of the workshop, 90 percent of them women (from 24 states), represented diverse occupations and personal histories, different races and classes, varied political commitments. They included doctors, nurses, and scientists, lay midwives, consumer advocates, historians, and sociologists, lawyers, policy analysts, and ethicists. Each session, however, made plain that ethics is an everyday concern for women in general, as well as an academic profession for some.

Women have been the objects of scientific and ethical discussions about reproductive freedom and its control for over a century. And they have increasingly endured experiments on their bodies involving ever more powerful technologies, technologies that until now have been largely generated and socially controlled by men. Here, in this study women themselves raise critical questions bout the ethics, the scientific nature, and the social context of these developments.

Women most fully experience the consequences of human reproductive technologies. Men who convene to evaluate such technologies discuss "them": the women who must accept, avoid, or even resist these technologies; the women who consume technologies they did not devise; the women who are the objects of policies made by men. So often the input of women is neither sought nor listened to. The privileged insights and perspectives that women bring to the consideration of technologies in human reproduction are the subject of these volumes, which constitute the revised and edited record of a Workshop on "Ethical Issues in Human Reproduction Technology: Analysis by Women" (EIRTAW), held in June, 1979, at Hampshire College in Amherst, Massachusetts. Some 80 members of the workshop, 90 percent of them women (from 24 states), represented diverse occupations and personal histories, different races and classes, varied political commitments. They included doctors, nurses, and scientists, lay midwives, consumer advocates, historians, and sociologists, lawyers, policy analysts, and ethicists. Each session, however, made plain that ethics is an everyday concern for women in general, as well as an academic profession for some.

Women most fully experience the consequences of human reproductive technologies. Men who convene to evaluate such technologies discuss "them": the women who must accept, avoid, or even resist these technologies; the women who consume technologies they did not devise; the women who are the objects of policies made by men. So often the input of women is neither sought nor listened to. The privileged insights and perspectives that women bring to the consideration of technologies in human reproduction are the subject of these volumes, which constitute the revised and edited record of a Workshop on "Ethical Issues in Human Reproduction Technology: Analysis by Women" (EIRTAW), held in June, 1979, at Hampshire College in Amherst, Massachusetts. Some 80 members of the workshop, 90 percent of them women (from 24 states), represented diverse occupations and personal histories, different races and classes, varied political commitments. They included doctors, nurses, and scientists, lay midwives, consumer advocates, historians, and sociologists, lawyers, policy analysts, and ethicists. Each session, however, made plain that ethics is an everyday concern for women in general, as well as an academic profession for some.

The Direction of Medical Ethics The direction bioethics, and specifically medical ethics, will take in the next few years will be crucial. It is an emerging specialty that has attempted a great deal, that has many differing agendas, and that has its own identity crisis. Is it a subspecialty of clinical medicine? Is it a medical reform movement? Is it a consumer pro­ tection movement? Is it a branch of professional ethics? Is it a ra­ tionale for legal decisions and agency regulations? Is it something physicians and ethical theorists do constructively together? Or is it a morally concentrated attack on high technology, with the prac­ titioners of scientific medicine and the medical ethicists in an adversarial role? Is it a conservative endeavor, exhibiting a Frankenstein syn­ drome in Medical Genetics ("this time, they have gone too far"), or a Clockwork Orange syndrome in Psychotherapy ("we have met­ hods to make you talk-walk-cry-kill")? Or does it suffer the afflic­ tion of overdependency on the informal fallacy of the Slippery Slope ("one step down this hill and we will never be able to stop") that remains an informal fallacy no matter how frequently it's used? Is it a restricted endeavor of analytic philosophy: what is the meaning of "disease," how is "justice" used in the allocation of medical resources, what constitutes "informed" or "consent?" Is it applied ethics, leading in clinical practice to some recommenda­ tion for therapeutic or preventive action? This incomplete list of questions indicates just how complex,

Many of the demands being voiced for a "humanizing" of health care center on the public's concern that they have some say In determining what happens to the individual in health care institutions. The essays in this volume address fundamental questions of conflicts of rights and autonomy as they affect four selected, controversial areas in health care ethics: the Limits of Professional Autonomy, Refusing! Withdrawing from Treatment, Electing "Heroic" Measures, and Advancing Reproductive Technology. Each of the topics is addressed in such a way that it includes an examination of the locus of responsibility for ethical decision­ making. The topics are not intended to exhaustively review those areas of health care provision where conflicts of rights might be said to be an issue. Rather they constitute an examination of the difficulties so often encountered in these specific contexts that we hope will illuminate similar conflicts in other problem areas by raising the level of the reader's moral awareness. Many books in bioethics appeal only to a limited audience in spite of the fact that their subject matter is of deep personal concern to everyone. In part, this is true because they are frequently written from the perspective of a single discipline or a single profession. As a result, one is often left with the impression that such a book views the philosophical, historical, and! or theological problems as essentially indifferent to clinical, legal, and! or policy-making problems.

This volume is a collection of essays concerned with the morality of hu­ man treatment of nonhuman animals. The contributors take very different approaches to their topics and come to widely divergent conclusions. The goal of the volume as a whole is to shed a brighter light upon an aspect of human life-our relations with the other animals-that has recently seen a great increase in interest and in the generation of heat. The discussions and debates contained herein are addressed by the contributors to each other, to the general public, and to the academic world, especially the biological, philosophical, and political parts of that world. The essays are organized into eight sections by topics, each sec­ tion beginning with a brief introduction linking the papers and the sec­ tions to one another. There is also a general introduction and an Epilog that suggests alternate possible ways of organizing the material. The first two sections are concerned with the place of animals in the human world: Section I with the ways humans view animals in literature, philosophy, and other parts of human culture, and Section II with the place of animals in human legal and moral community. The next three sections concern comparisons between human and nonhuman animals: Section III on the rights and wrongs of killing, Section IV on the humanity of animals and the animality of humans, and Section V on questions of the conflict of human and animal interests.

Suppose an accountant discovers evidence of shady practices while ex­ amining the books of a client. What should he or she do? Accountants have a professional obligation to respect the confidentiality of their cli­ ents' accounts. But, as an ordinary citizen, our accountant may feel that the authorities ought to be informed. Suppose a physician discov­ ers that a patient, a bus driver, has a weak heart. If the patient contin­ ues bus driving even after being informed of the heart condition, should the physician inform the driver's company? Respect for patient confidentiality would say, no. But what if the driver should suffer a heart attack while on duty, causing an accident in which people are killed or seriously injured? Would the doctor bear some responsibility for these consequences? Special obligations, such as those of confidentiality, apply to any­ one in business or the professions. These obligations articulate, at least in part, what it is for someone to be, say, an accountant or a physician. Since these obligations are special, they raise a real possibility of con­ flict with the moral principles we usually accept outside of these spe­ cial relationships in business and the professions. These conflicts may become more accentuated for a professional who is also a corporate employee-a corporate attorney, an engineer working for a construction company, a nurse working as an employee of a hospital.

People of Socrates' time were frequently aghast at the questions he would ask. Their responses were of the sort elicited by very dumb or ex­ tremely obvious questions: "Don't you know? Everyone else does. " Socrates was hardly alone in his knack for asking such questions. Phi­ losophers have always asked peculiar questions most other people would never dream of asking, convinced as the latter are that the answers were settled long ago in the collective "wisdom" of society, including ques­ tions about woman: should women be educated? should they rule socie­ ties? should they be subordinate in marriage? do women and men have the same virtues, or are there separate virtues for each? which of the dif­ ferences between women and men are conventional, and which are natu­ ral? is there a woman's work? do women and men have different types or degrees of rationality? Philosophers of the most diverse periods have raised these questions and their answers were often quite creative, not merely reflecting the conventions and mores of their societies. With the publication of this anthology, their writings will be brought together in a single volume for the first time. This anthology differs from others not just in its inclusiveness. It also contains several translations of material previously unavailable in English.

This volume is a collection of essays concerned with the morality of hu­ man treatment of nonhuman animals. The contributors take very different approaches to their topics and come to widely divergent conclusions. The goal of the volume as a whole is to shed a brighter light upon an aspect of human life-our relations with the other animals-that has recently seen a great increase in interest and in the generation of heat. The discussions and debates contained herein are addressed by the contributors to each other, to the general public, and to the academic world, especially the biological, philosophical, and political parts of that world. The essays are organized into eight sections by topics, each sec­ tion beginning with a brief introduction linking the papers and the sec­ tions to one another. There is also a general introduction and an Epilog that suggests alternate possible ways of organizing the material. The first two sections are concerned with the place of animals in the human world: Section I with the ways humans view animals in literature, philosophy, and other parts of human culture, and Section II with the place of animals in human legal and moral community. The next three sections concern comparisons between human and nonhuman animals: Section III on the rights and wrongs of killing, Section IV on the humanity of animals and the animality of humans, and Section V on questions of the conflict of human and animal interests.

People of Socrates' time were frequently aghast at the questions he would ask. Their responses were of the sort elicited by very dumb or ex­ tremely obvious questions: "Don't you know? Everyone else does. " Socrates was hardly alone in his knack for asking such questions. Phi­ losophers have always asked peculiar questions most other people would never dream of asking, convinced as the latter are that the answers were settled long ago in the collective "wisdom" of society, including ques­ tions about woman: should women be educated? should they rule socie­ ties? should they be subordinate in marriage? do women and men have the same virtues, or are there separate virtues for each? which of the dif­ ferences between women and men are conventional, and which are natu­ ral? is there a woman's work? do women and men have different types or degrees of rationality? Philosophers of the most diverse periods have raised these questions and their answers were often quite creative, not merely reflecting the conventions and mores of their societies. With the publication of this anthology, their writings will be brought together in a single volume for the first time. This anthology differs from others not just in its inclusiveness. It also contains several translations of material previously unavailable in English.

The place of drugs in American society is a problem more apt to evoke diatribe than dialog. With the support of the Na­ tional Science Foundation's program on Ethics and Values in Science and Technology, and the National Endowment for the Humanities' program on Science, Technology, and Human Values, * The Hastings Center was able to sponsor such dialog as part of a major research into the ethics of drug use that spanned two years. We assembled a Research Group from leaders in the scientific, medical, legal, and policy com­ munities, leavened with experts in applied ethics, and brought them together several times a year to discuss the moral, legal and social issues posed by nontherapeutic drug use. At times we also called on other experts when we needed certain issues clarified. We did not try to reach a consensus, yet several broad areas of agreement emerged: That our society's response to nontherapeutic drug use has been irrational and inconsistent; that our attempts at control have been clumsy and ill-informed; that many complex moral values are entwined in the debate and cannot be reduced to a simple conflict between individual liberty and state paternalism. Of course each paper should be read as the statement of that particular author or authors. The views expressed in this book do not necessarily represent the views of The Hastings Center, the National Science Foundation, or the National En­ dowment for the Humanities.

The National Institute on Aging (NIA) has historically been concerned with the protection of human subjects. In July 1977, the NIA sponsored a meeting to update and supplement guide­ lines for protecting those participating in Federal research pro­ jects. Although the basic guidelines had been in effect since 1966, it had been neglected to include the elderly as a vulnerable population. In November 1981, the NIA organized a conference on the ethical and legal issues related to informed consent in senile dementia cases. The present volume offers the latest and best thinking on Alzheimer's Dementia to have emerged from the dialog that was first embarked upon at the NIA meeting. Indeed, the issues and concerns it treats now seem even more relevant than they appeared historically because of the vastly greater awareness in the community of the entire spectrum of problems Alzheimer's disease confronts us all with. Our interest and concern is both humanitarian and self­ serving. Clearly older people must be protected from in­ appropriate research and careful attention must be paid to the circumstances under which research is conducted on those older persons who have given anything less than full consent. It is equally necessary, however, for the research enterprise to be protected so that today's elderly and those of the future can benefit from the fruits of research.

The fate of seriously ill newborns has captured the atten­ tion of the public, of national and state legislators, and of powerful interest groups. For the most part, the debate has been cast in the narrowest possible terms: "discrimination against the handicapped"; "physician authority"; "family autonomy." We believe that something much more profound is happening: the debate over the care of sick and dying babies appears to be both a manifestation of great changes in our feelings about infants, children, and families, and a reflection of deep and abiding attitudes toward the newborn, the handi­ capped, and perhaps other humans who are "less than" nor­ mal, rational adults. How could we cast some light on those feelings and attitudes that seemed to determine silently the course of the public debate? We chose to enlist the humanities-the dis­ players and critics of our cultural forms. Rather than closing down the public discussion, we wanted to open it up, to illuminate it with the light of history, religion, philosophy, literature, jurisprudence, and humanistically oriented sociol­ ogy. This book is a first effort to place the hotly contested Baby Doe debate into a broader cultural context.

The roles of both the consumer and the health advocate professional have become increasingly significant in to­ day's climate of "rationed" health care. It seems clear that the timely exchange of ideas among seasoned health care advocates is necessary if we are to deal with the complex problems of a technologically advanced so­ ciety seeking to ration its heath care in a truly humane way. Toward such a timely exchange, the first Confer­ ence on Advocacy in Health Care was organized by the Health Advocacy Program of Sarah Lawrence College and recently held. Advocacy in Health Care: The Power of a Silent Constituency is the proceedings of the conference and will, we believe, greatly extend our efforts to share both the problems and solutions that effective patient advocacy entails. Never before has the issue of advocating for special population groups by combining the resources of consumers and professionals been the exclusive focus of one volume. This book discusses the power of such an alignment and describes specific organizational techniques that have been effective in bringing about changes in the delivery system. The final section of the book, "Questions, Com­ ments and Answers," presents a selection of topics of special interest that surfaced during the open disc- vii viii Preface sion at the last conference session. The comments were forthright in their criticism of public policy, and the vigor of the argument underscored the vitality of the co­ alition between professionals and consumers.

The idea for an anthology on personhood grew out of two things, viz. , the work I did with Martin Benjamin during the Summer of 1982 at Michigan State University on the question, What is a person?, and the amount of time, effort, and expense required for serious research on the topic itself. The former experience taught me the importance of, among other things, attempting to get clear about what we are to mean by 'person,' while the latter experience suggested a possible course of action whereby getting clear might be made more manage­ able simply by having relatively convenient access to some of the most insightful and stimulating writings on the topic. The problems of personhood addressed in this book are central to issues in ethics ranging from the treatment or termination of infants with birth defects to the question whether there can be rational suicide. But before questions on such issues as the morality of abortion, genetic engineering, infanticide, and so on, can be settled, the prob­ lems of personhood must be clarified and analyzed. Hence What Is a Person? has as its primary theme the examination of various proposed conditions of personhood.

In the early 1970s, well before the field ofbioethics had established itself in medicine or anywhere else, the Hastings Center organized a small meeting of law school professors. The question we put to them was: what could or should be done to stimulate legal interest in the field? The answer we got was a wise one. We should do nothing to forcefeed the interest. It should simply be allowed to develop on its own, by the ordinary route of attracting a following because of its inherent importance. That is just what happened, and one of the first young legal scholars drawn to what remains (oddly enough) a relatively small field was George Annas. The idea of a column on law and ethics for the Hastings Center Report was not by 1976 a particularly bold one. It had been clear to us from the outset of the Center in 1969, and the establishment of the Report in 1971, that the rapidly emerging moral problems in medicine and biology would have enormous legal and policy implications. Even so, we were hardly prepared for the large and steady number of cases that were to come before the courts during the 1970s and that were to continue unabated in the 1980s. But our concern about a column on the subject was of a more pedestrian kind.

There is the world of ideas and the world of practice; the French are often for sup­ pressing the one and the English the other; but neither is to be suppressed. -Matthew Arnold The Function of Criticism at the Present Time From its inception, bioethics has confronted the need to reconcile theory and practice. At first the confrontation was purely intellectual, as writers on ethical theory (within phi­ losophy, theology, or other humanistic disciplines) turned their attention to topics from the world of medical practice. Recently the confrontation has grown more intense. The ap­ pointment of clinical ethicists in hospitals and other health­ care settings is an accelerating trend in North America. Concomitantly, those institutions involved in training peo­ ple in clinical ethics have added organized exposure to the world of practice , in the form of placement requirements, to the normal academic course load. In common with other dis­ ciplines, bioethics has begun to see clinical training as a con­ dition of didactic theory and apprenticeship.

The Project on Reproductive Laws for the 1990s began in 1985 with the realization that reports of scientific developments and new technologies were stimulating debates and discussions among bioethicists and policymakers, and that women had little part in those discussions either as participants or as a group with interests to be considered. With the help of a planning grant from the Rutgers University Institute for Research on Women, the Women's Rights Litigation Clinic at Rutgers University Law School-Newark held a planning meeting that June attended by approximately 20 theorists and activists in the area of reproductive rights. Project purposes, methods, and general shape took form at the meeting. Two goals have characterized the Project's work since then: first, to generate discussion, debate, and, where possible, consensus among those committed to reproductive autonomy and gender equality as to how best to respond to the questions raised by re­ ported advances in reproductive and neonatal technology and new modes of reproduction; and second, to ensure that those shaping reproductive law and policy appreciate the ramifications of these developments for gender equality. In meeting this twofold agenda, the Project focused on six areas: time limits on abortion; prenatal screening; fetus as patient; reproductive hazards in the workplace; interference with reproductive choice; and alternative modes of reproduction. The Project identified individuals to take respon­ sibility for drafting model legislation and position papers in the six areas (for the drafters, see the Appendix).

Arthur L. Caplan It is commonly said, especially when the subject is assisted reproduction, that medical technology has out­ stripped our morality. Yet, as the essays in this volume make clear, that is not an accurate assessment of the situ­ ation. Medical technology has not overwhelmed our moral­ ity. It would be more accurate to say that our society has not yet achieved consensus about the complex ethical iss­ ues that arise when medicine tries to assist those who seek its services in order to reproduce. Nevertheless, there is no shortage of ethical opinion about what we ought to do with respect to the use of surrogate mothers, in vitro fertil­ ization, embryo transfer, artificial insemination, or fertil­ ity drugs. Nor is it entirely accurate to describe assisted repro­ duction as technology. The term "technology" carries with it connotations of machines buzzing and technicians scurrying about trying to control a vast array of equip­ ment. Yet, most of the methods used to assist reproduc­ tion that are discussed in this volume do not involve exotic technologies or complicated hardware. It is technique, more than technology, that dominates the field of assisted reproduction. Efforts to help the infertile by means of the manipu­ lation of human reproductive materials and organs date 1 2 Caplan back at least to Biblical times. Human beings have en­ gaged in all manner of sexual practices and manipulations in attempts to achieve reproduction when nature has balked at allowing life to begin.

The Project on Reproductive Laws for the 1990s began in 1985 with the realization that reports of scientific developments and new technologies were stimulating debates and discussions among bioethicists and policymakers, and that women had little part in those discussions either as participants or as a group with interests to be considered. With the help of a planning grant from the Rutgers University Institute for Research on Women, the Women's Rights Litigation Clinic at Rutgers University Law School-Newark held a planning meeting that June attended by approximately 20 theorists and activists in the area of reproductive rights. Project purposes, methods, and general shape took form at the meeting. Two goals have characterized the Project's work since then: first, to generate discussion, debate, and, where possible, consensus among those committed to reproductive autonomy and gender equality as to how best to respond to the questions raised by re­ ported advances in reproductive and neonatal technology and new modes of reproduction; and second, to ensure that those shaping reproductive law and policy appreciate the ramifications of these developments for gender equality. In meeting this twofold agenda, the Project focused on six areas: time limits on abortion; prenatal screening; fetus as patient; reproductive hazards in the workplace; interference with reproductive choice; and alternative modes of reproduction. The Project identified individuals to take respon­ sibility for drafting model legislation and position papers in the six areas (for the drafters, see the Appendix).

Itisonlyrecently thatthe naturaloccurrenceoffree radicalsin biological tissue has become widely accepted, and that the suspi- cion with which biologists previously viewed the free radicals of radiationchemistryhas beenplacedin a broaderperspective. Now, oxygen-derived free radicals are considered respectable biochemi- cal intermediates, given always the caveat that unwanted tissue damage may arise if these active species are produced in such abundance that they overwhelm the natural antioxidant and free- radical defense mechanisms, or if these systems have become hypoeffective. Many factors, including several dietary manipula- tions, can lead toelevatedproductionofsuperoxide and may result in free radical overload, whereas a deficiency of those micronutri- ents associated with the antioxidant defense mec.hanisms may re- sult in substantially diminished antioxidant capacity. By now, antioxidants have become a household word and al- most everyone is aware of their imponance in protecting the body against attack by active oxygen species. Indeed, it is a paradox of nature that oxygen, which is so essential to sustain aerobic life, ul- timately contributes to its destruction.Not surprisingly, recogni- tion ofthis dilemma has generated a spate ofantioxidant strategies intended to reduce the risk of tissue damage by rampant oxygen radicals, some sadly based less on science than on speculation.

In the early 1970s, well before the field ofbioethics had established itself in medicine or anywhere else, the Hastings Center organized a small meeting of law school professors. The question we put to them was: what could or should be done to stimulate legal interest in the field? The answer we got was a wise one. We should do nothing to forcefeed the interest. It should simply be allowed to develop on its own, by the ordinary route of attracting a following because of its inherent importance. That is just what happened, and one of the first young legal scholars drawn to what remains (oddly enough) a relatively small field was George Annas. The idea of a column on law and ethics for the Hastings Center Report was not by 1976 a particularly bold one. It had been clear to us from the outset of the Center in 1969, and the establishment of the Report in 1971, that the rapidly emerging moral problems in medicine and biology would have enormous legal and policy implications. Even so, we were hardly prepared for the large and steady number of cases that were to come before the courts during the 1970s and that were to continue unabated in the 1980s. But our concern about a column on the subject was of a more pedestrian kind.

New Harvest includes contributions from specialists in medical, philosophical, psychological, religious, and legal fields. These essays are not simply a collection, but were developed from a single conception of the four ethical concerns of trans plan tation described in the first chapter. The indi vid ual chapters are all parts of a structure unified by the search for ethical foundations basic to the four concerns. Transplantation is surrounded by a great deal of under­ standable emotional sensitivi ty. The authors trust that words like "procurement," "harvest," and possibly other expressions found in this book will not offend. We use the current lan­ but do so with objectivity and respect for those who guage, are personally involved in transplantation. We have made room for, and indeed have invited, different and sometimes conflicting points of view on the complicated ethical ques­ tions raised by transplant operations. We can not assume that there is one right answer to these questions, at least at our present level of scientific knowledge and ethical wisdom. We do not presume to have identified and analyzed all the ethical questions raised with equal thoroughness. There are four ways in which the scope of the book is limited. Identifying these limitations also helps designate what it is in its own right. First, some questions have been given more attention than others.

The Aging Self and the Aging Society Ethical issues involving the elderly have recently come to the fore. This should come as no surprise: Since the turn of the century, there has been an eightfold in­ crease in the number of Americans over the age of sixty­ five, and almost a tripling of their proportion to the general population. Those over the age of eighty-five-­ the fastest growing group in the country-are twenty­ one more times as numerous as in 1900. Demographers expect this trend to accelerate into the twenty-first century. The aging of society casts into vivid relief a num­ ber of deep and troubling questions. On the one hand, as individuals, we grapple with the immediate experience of aging and mortality and seek to find in it philosophical or ethical significance. We also wonder what responsi­ bilities we bear toward aging family members and what expectations of others our plans for old age can reasona­ bly include. On the other hand, as a community, we must decide: What special role, if any, do older persons occupy in our society? What constitutes a just distribution of medical resources between generations? And, How can institutions that serve the old foster imperiled values, such as autonomy, self-respect, and dignity? Only recently have we begun to explore these themes, yet already a rich and fruitful literature has grown up around them.

How much control do-or should-the courts and public policy have over the treatment of critically ill and disabled newborns? The Baby Doe incident of 1982 spurred the federal government to create a public policy making failure to treat severely disabled newborns a form of child neglect. Compelled Compassion focuses on public policy aspects of withholding treatment from critically ill, disabled infants, and especially dealing with why this policy was enacted and how it affects health care workers, the infants, and their families. Several contributors to this timely, controversial volume spearheaded the early debates on withholding treatment; others were active participants in the policymaking process itself. Compelled Compassion makes a valuable contribution to our awareness of the complex, difficult process of decision making for these infants: a process laden with emotional, legal, and clinical ramifications, and strives to help clarify how the various factors can be applied in reaching a compassionate, but logical, decision for everyone involved in reaching it.

The Aging Self and the Aging Society Ethical issues involving the elderly have recently come to the fore. This should come as no surprise: Since the turn of the century, there has been an eightfold in­ crease in the number of Americans over the age of sixty­ five, and almost a tripling of their proportion to the general population. Those over the age of eighty-five-­ the fastest growing group in the country-are twenty­ one more times as numerous as in 1900. Demographers expect this trend to accelerate into the twenty-first century. The aging of society casts into vivid relief a num­ ber of deep and troubling questions. On the one hand, as individuals, we grapple with the immediate experience of aging and mortality and seek to find in it philosophical or ethical significance. We also wonder what responsi­ bilities we bear toward aging family members and what expectations of others our plans for old age can reasona­ bly include. On the other hand, as a community, we must decide: What special role, if any, do older persons occupy in our society? What constitutes a just distribution of medical resources between generations? And, How can institutions that serve the old foster imperiled values, such as autonomy, self-respect, and dignity? Only recently have we begun to explore these themes, yet already a rich and fruitful literature has grown up around them.

The primary objective of The Health Care Ethics Con­ sultant is to focus attention on an immediate practical problem: the role and responsibilities, the education and training, and the certification and accreditation of health care ethics consultants. The principal questions addressed in this book include: Who should be considered health care ethics consultants? Whom should they advise? What should be their responsi­ bilities and what kind of training should they have? Should there be some kind of accreditation or certification program to ensure that those who call themselves ethics consultants are in fact qualified to advise, consult, research, and write in health care ethics? The distinguished authors ofthese articles are persons with diverse backgrounds, interests, presumptions, and val­ ues. Not surprisingly, therefore, diverse responses have emerged to the questions posed. Though the book's chapters are individually authored, they are informed by the group discussions that went on during active workshop sessions, and by knowledge of the contributions of others. All of the chapters meaningfully represent their consensus. This is not to say that there were no disagreements regarding specific details, but rather that there were no fundamental objections on the book's basic content among a panel of authors who share basic premises regarding the role, responsibilities, education, and certifica­ tion of health care ethics consultants.