Contributors.

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.

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.

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.

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.

At its root meaning a “crisis” is a separation. In our everyday lives we use the term crisis to designate a period of decision. A crisis is a moment of separation when one must make a decision about a direction. To make a crisis decision, a person needs some criteria or set of norms to guide the decisions that are made. Sometimes, at a moment of crisis decisionmaking, there is chaos when one does not know which norm to use in making a decision. Without some norm a crisis is a significant loss of direction because there are different criteria for deciding which way to turn or how to decide. It is in this most fundamental sense that one can say that contemporary medicine is in crisis.

Autonomy is good for you. A strong sense of competent self-control and effective choice-making promotes both physical and psychological well-being. Loss of autonomous control—and a sense of helplessness—causes depression, increased sensitivity to pain, greater vulnerability to disease, and death. Well established by a wide range of psychological and physiological studies, the positive effects of patient autonomy (and the harms of autonomy deprivation) are well known to competent physicians, nurses, and therapists. Conscientious caregivers are thus moving beyond grudging acceptance of informed consent toward clinical respect for patient autonomy.

These CQ Sources were compiled by Bette Anton.

In a recent article in this journal, we argued that living organ donation from a parent to a child should be described as a beneficent rather than an altruistic act. Emotional relationships can generate an obligation of beneficence to help those with whom we have these relationships. This may involve an obligation for a parent to donate an organ to a child, even though it entails some risk to the parent. The parent's donation is not altruistic because altruistic acts are not obligatory but optional, and they are motivated solely or primarily by other-regarding concerns. In contrast, donor parents' other-regarding concerns are inseparable from their own self-regarding concerns. An individual who donates to a stranger is acting altruistically. She may choose to help others to whom she is not emotionally related for a variety of reasons—sympathy, compassion, generosity, or a desire to give something back to humanity. But she does not have an obligation to do so. Although she may benefit as a consequence of donating, this is not her reason for donating. Instead, her action is motivated by a concern for the recipient's own sake. This is what makes the donation altruistic, and it can be justified without any expectation of benefit to the donor. However, although the potential competent donor decides whether the donation is in her best interests, physicians have the right to refuse to perform a transplant if the risks to the donor are too great or the potential benefits to the recipient are too small.

According to Glannon and Ross, for an act to be considered altruistic, it cannot be obligatory nor motivated by expectation of self-reward. Given that parents are obligated to help their children and stand to benefit greatly from donating, the authors conclude that parent to child organ donation is not altruistic. Are they correct? I am not sure. In my view, this is a semantic question and the answer depends upon how one defines altruism. Altruism is a complex subject that means different things to different people. If we say that an altruistic act is one that is performed voluntarily, is risky or costly to the actor, and is designed only to benefit others with no expectation of self-reward, then it may be difficult or impossible to identify any such acts. When one risks her own life to save a stranger, others may ask: “Did she really act solely to benefit another or was she motivated, at least in part, by a need to satisfy her conscience or a desire to feel good about herself?” This question is relevant to the motivation of living organ donors. In contrast to the authors' answer that strangers who donate organs do so only out of concern for other people, Carl Fellner argued that many living organ donors, even those who are not related to their recipients, act to benefit themselves. If Fellner is correct, and if organ donation by parents is not altruistic because of the possibility of self-reward, perhaps the same is true of organ donation by strangers.

Health care services are constantly assessed by their ability to accommodate values popular in contemporary societies. Autonomy, justice, and human dignity have for some time been among such values in the affluent West. Relative newcomers in the field are the notions of “precaution” and “solidarity,” which seem to attract, in particular, Continental European ethicists.This article was produced as a part of the projects Ethical, Legal and Social Aspects of Human Genetic Databases: A European Comparison (ELSAGEN), financed between 2002 and 2004 by the European Community (QLG6-CT-2001-00062); Public Policies, Law and Bioethics: A Framework for Producing Public Health Policy Across the European Union by Examining Concepts of European and Universal Ethical Standards (EuroPHEN), financed between 2003 and 2006 by the European Community (QLRT-2001-02320); and Ethical and Social Aspects of Bioinformatics (ESABI), financed between 2004 and 2007 by the Academy of Finland (SA 105139). My thanks are due to these institutions for their support, and to Peter Herissone-Kelly for checking my English.

“That's my dad on the floor.”

And there he was unconscious in a pool of blood in the bathroom. A paramedic who had accompanied him to the john was holding him off the ground, the USMC tattoo on his forearm cradling his head. My sister shrieked, and I went down on my knees to see about his airway. “We need a doctor here. Cardiac Team!” Could this really be happening to him? To us? Jesus Christ.

Elizabeth H. Blackburn, Ph.D., is a leader in the area of telomere and telomerase research—in fact, in 1984 she codiscovered the ribonucleoprotein enzyme telomerase, opening up new potentials in cancer research and therapy. This and subsequent work has earned her numerous honors, not the least of which are the National Academy of Science Award in Molecular Biology, an Honorary Doctorate of Science from Yale University, the American Cancer Society Medal of Honor, and many more awards. Dr. Blackburn is a Fellow of the American Academy of Arts and Sciences, the Royal Society of London, the American Academy of Microbiology, and the American Association for the Advancement of Science. She was elected to the National Academy of Sciences, and is a Member of the Institute of Medicine.

“Human rights” is a global topic. As soon as one agrees that a right is a human right, one cannot restrict it to certain groups. People have human rights by virtue of their humanity, not by virtue of their nationality, their status, their gender, their ethnicity, and so forth. This is why the topic is one of the most exciting, but also one of the most contentious discussed in the humanities and the social sciences. It is a topic that suggests numerous questions in three main areas: concept, content, and enforcement.

Global bioethics is a bold project. In its moderate form, it aims to find solutions to the dilemmas posed by modern medicine and the biological sciences through intercultural understanding of human obligations and opportunities. In its more ambitious form, it endeavors to cover all possible ethical problems arising with regard to life and living things on earth. Given the ambitiousness of even the moderate aim, it is unsurprising that disputes are frequent and agreements are scarce. One of the most contentious issues is whether human rights should play an important role in global bioethics or not.A longer version of this discussion paper will appear as “The Future of Human Rights—Human Rights and Bioethics.” In: van den Anker, C Smith R, eds. Essential Guide to Human Rights. London: Hodder Arnold; forthcoming in 2005.

Does a human right to healthcare imply individual obligations to healthy behavior? Or put another way: Is a self-induced condition a relevant criterion for some sort of restriction of this right—like withholding or modifying treatment in circumstances where choices have to be made? For instance, should a drunk driver bear the costs of medical care that he needs after a car accident he has caused? Should there be a difference in healthcare entitlements between the smoker with a heart attack who is seriously overweight and the 60-year old man who has always taken excellent care of himself and is suddenly stricken by leukemia? And how should we think about the risk-taking behavior of all the persons going on a skiing holiday or an exotic hiking trip?I am grateful to Claire Dawson, Kurt Devooght, Bart Engelen, Doris Schroeder, Ronald Tinnevelt, Toon Vandevelde, and two anonymous reviewers for their editorial assistance and helpful comments on a previous draft.

One of the most entrenched commandments in medicine is: “Never take away a patient's hope!” Often it is issued during the treatment of a terminally ill patient to spur and justify the continuation of aggressive life-prolonging efforts. Hope has been called one of a patient‘s “most powerful internal resources,” and “a powerful ally, our last defense against despair.” One editorialist confidently stated: “[C]ommunicating hope can improve patients’ prognosis.”

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.