In modern industrial society the issue of access to healthcare is inseparable from the question of whether there is a right to healthcare and whether government has the correlative duty to assure a minimum level of care to all citizens. While discussion in terms of rights and duties tends to direct our attention to broader, more theoretical ethical issues, discussion in terms of ‘access’ invites consideration of more practical concerns. The news media rarely report in terms of whether a citizen's right to healthcare has been abridged or disregarded, but rather offers tales of people being denied access. Advocacy groups for specific illnesses do not necessarily argue for universal health insurance, but rather press that certain conditions, such as renal failure requiring dialysis, receive unlimited insurance coverage and that people with the condition be given automatic access to care.

Examining health policy and its recent reform misadventures in the United States from a moral viewpoint is painful. That the nation devotes 14% of its Gross Domestic Product to health services—sometimes of doubtful clinical efficacy and value for money—and yet lets more than 40 million citizens go without health coverage strikes critics, both foreign and domestic, as a disgrace explicable only by ethical deficiencies distinctive to the American value system. There is certainly merit in this critique, which understandably incites fire and brimstone about the urgent moral imperative of getting the nation on the path of righteousness at last.

In writing this paper I am reminded of a conference that I once attended. On that panel, the Jewish scholar spoke first. “Let me tell you what the Talmud says,” he began, and he gave a wonderful talk full of references to the legal rulings and stories of the Jewish tradition. Then the Catholic priest spoke. “Let me tell you what the Magisterium says,” he began, and he gave a wonderful talk carefully attentive to the moral tradition of the Catholic Church. Finally, a Protestant spoke. “You have heard what the Talmud says and what the Magisterium says,” he began, “Now let me tell you what I think.” I didn't know whether to laugh or cry, but now I find myself in a similar situation.

My discussion is presented in three steps: The present position of the Catholic Church; why it is a relatively recent tradition; and the roots of the tradition.

Can anyone doubt that the Jewish tradition mandates universal access to healthcare? In a comprehensive and illuminating discussion, A.L. Mackler seems to have already said all that needs to be said. After aptly analyzing the principles of the traditional institutions and norms relating to tzedakah (social justice, or welfare), Mackler proceeded to apply these traditions to the context of healthcare, concluding that

Society has the responsibility to ensure that needed medical care is provided to those who would otherwise be unable to receive it... Medical care for potentially life-threatening conditions justifies extraordinary expenditures, and represents an urgent obligation of society. (p. 150)

Among those who criticize the concept of ‘medical futility,’ a common refrain is that we really have no idea what futility means. For example, physicians seem to disagree on whether a treatment being futile means that it has a less than 5% chance of working or a 20% chance of working. If the concept is so unclear, then it seems a thin reed upon which to base a momentous ethical decision—namely, that the physician's judgment should be allowed to override the wishes of the competent patient or the patient's duly appointed surrogate.

Howard Brody expresses concern that citing the “two cases that put futility on the map,” namely Helga Wanglie and Baby K, may be providing ammunition to the opponents of the concept of medical futility. He in fact joins well-known opponents of the concept of medical futility in arguing that it is one thing for the physician to say whether a particular intervention will promote an identified goal, quite another to say whether a goal is worth pursuing. In the latter instance, physicians are laying themselves open “to the criticism of taking on basic value judgments that are more appropriately left to patients and their surrogates.” Brody states that in both the Wanglie and Baby K cases, the “basic value judgments” had to do with the worthiness of maintaining unconscious life via medical technology. He classifies this as “a question of professional integrity—but not a question of futility,” adding that “more than semantics hinges on this distinction.” The “more than semantics” factor is a pragmatic, even political one. Failure to make this distinction renders physicians “that much more suspect and less trustworthy in the public debate.”

Although there are important moral arguments against cloning human beings, it has been suggested that there might be exceptional cases in which cloning humans would be ethically permissible. One type of supposed exceptional case involves infertile couples who want to have children by cloning. This paper explores whether cloning would be ethically permissible in infertility cases and the separate question of whether we should have a policy allowing cloning in such cases. One caveat should be stated at the beginning, however. After the cloning of a sheep in Scotland, scientists pointed out that using the same technique to clone humans would, at present, involve substantial risks of producing children with birth defects. This concern over safety gives compelling support to the view that it would be wrong to attempt human cloning now. Thus, we do not reach the debate about exceptional cases unless the issue of safety can be set aside. I ask the reader to consider the possibility that in the future humans could be cloned without a significantly elevated risk of birth defects from the cloning process itself. The remainder of this paper assumes, for sake of argument, that cloning technology has advanced to that point. Given this assumption, would cloning in the infertility cases be ethically permissible, and should it be legally permitted?

Early last year, the GenEthics Consortium (GEC) of the Washington Metropolitan Area convened at George Washington University to consider a complex case about genetic testing for Alzheimer disease (AD). The GEC consists of scientists, bioethicists, lawyers, genetic counselors, and consumers from a variety of institutions and affiliations. Four of the 8 co-authors of this paper delivered presentations on the case. Supplemented by additional ethical and legal observations, these presentations form the basis for the following discussion.

Clinical bioethics is big business. There are now hundreds of people who “do” bioethics in community and university hospitals, nursing homes, rehabilitation and home care settings, and some (though quite a few less) who play the role of clinical ethics consultant to transplant teams, managed care companies, and genetic testing firms. Still, there is as much speculation about what clinically active bioethicists actually do as there was ten years ago. Various commentators have pondered the need for training standards, credentials, “certification” exams, and malpractice insurance for ethicists engaged in clinical consultation. Much of the discussion seems to accept an implicit presumption that all clinical ethics consultation practices look pretty much alike. But is this accurate? What do clinical ethicists do, how and where do they do it, and what kind of clinical ethics is useful in the hospital and in other settings?

The increasing role played by medical ethicists in the clinical setting both as teachers and consultants has brought with it a demand for new methodologies that speak more precisely to the multiple problems encountered in actual attempts at case resolution. Some of these moves have to do with a revival of the truly classic case study approach to ethics, casuistry. This approach is anchored in the revelatory text of Jonsen and Toulmin, The Abuse of Casuistry. A fine example of this methodology is an article in The Journal of Clinical Ethics, “Gathering Information and Casuistic Analysis.” Conjoined to this approach is a renewed interest in virtue ethics. The groundwork for this was laid by MacIntyre's masterful history of its demise in After Virtue. A clear and concise application of this ancient but always new approach is given in Pellegrino and Thomasma's book The Virtues in Medical Practice. This way of doing ethics is particularly congenial to the practice of healthcare ethics in that it understands that virtue is just a rather fancy name for a good habit or skill. Since the practice of clinical medicine is quintessentially the learning and application of a range of often highly complex patterns of professional abilities and skills, a virtue ethics approach will allow for the concomitant development of a whole set of ethical skills. But both casuistry and virtue ethics may well be seen to be operative in a larger context now known as narrative ethics.

Each of these hospice officials makes several criticisms of my paper, “Goldilocks and Mrs. Ilych: A Critical Look at the ‘Philosophy of Hospice’.” I will treat these criticisms in turn.

Bioethicists recognize the conflicts of interest that can arise for clinicians and scientists. However, few scholars exploring the moral dimensions of medicine and the sciences publicly address potential conflicts of interest concerning their own research. Increasingly, however, bioethicists will be confronted with difficult choices in which opportunities to obtain funding will sometimes conflict with the pursuit of critical, rigorous scholarship conducted without regard for corporate interests.

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 Kenneth V. Iserson care of CQ. If you do not like the editorial comments, this will igve you an opportunity to respond in the letters section. Your input is desired and anticipated.