The Cambridge Quarterly has a history of presenting multidisciplinary perspectives in bioethics, welcoming a lively dialogue between clinicians, philosophers, theologians, social scientists, lawyers, and others on a range of bioethics concerns. This special issue of the journal focuses explicitly on contributions from anthropologists to the field.

This issue is devoted to the delicate balance of a prominent, now-traditional principle of autonomy with other important values. Today it is a truism that autonomy must be balanced against paternalism. In fact, for most bioethicists, respecting autonomy has triumphed over paternalism as a primary moral duty in healthcare. Yet autonomy must also be weighed against other values such as professionalism, social interests, and of course, the good of the patient; thus our illustration from Paul Klee of a tightrope walker making his cautious way across the wire as he tries to maintain the perfect balance.

This issue of CQ was conceived in Salt Lake City, at the third annual meeting of the American Society of Bioethics and Humanities (ASBH). There, President-elect Laurie Zoloth delivered a stirring address, emphasizing the role of bioethics in responding to social deprivations and suggesting that ASBH “take a stand” on important issues where members share consensus. Not all the stirrings were pleasant. Debate erupted about the propriety of consensus statements, especially regarding possible deleterious effects on academic discourse, misappropriation of dues, and the proliferation of quasi-political factions. The roots of this controversy extend deeply into the collective psyche of contemporary bioethics.

This issue of the journal had already been planned when CQ lost its own “first voice,” David Thomasma. David died unexpectedly on April 25, 2002, after undergoing surgery. The Special Section herein titled “First Voices,” with collected reminiscences of some early bioethics pioneers, had been David's idea from beginning to end. As such, we had decided to deviate from our usual practice of a collaborative editorial and to have David offer a solo voice from the perspective of someone who intimately participated in molding the discipline. This issue of CQ, which we dedicate to him, was his last project.

Can it be already 30 years since the first days of modern, secular bioethics? As those of us in the field for almost all these years arrive near the end of our careers, we find that time has truly flown and the challenges have not diminished one bit. If anything, they are even greater than in the early years. Along the way it was tempting to think that the broad consensus reached on research ethics, on the four principles, on the need for consent in clinical ethics, and then on rights in reproduction and dying, would paint the picture rather well. Only fill-in would be needed by the apprentices coming afterward. Yet time and again new biological and medical discoveries continued to challenge that painting. A new canvas had to be hung. Among the major newer developments were the challenges of healthcare reform, genetics, antifoundationalism, the certification of ethics consultants, and now, the internationalization of bioethics, its relationship to the environment and world politics, and biotechnology.

Special moral, regulatory, and scientific questions surround the inclusion of children in health-related research. These questions arise from a fundamental moral tension between the obligation to expose children to research participation to ensure that they share in the benefits that arise from it and the obligation to protect them from the harms associated with their inappropriate involvement in research. This tension is felt in the development of moral and regulatory frameworks for the protection of child research subjects and in the implementation and interpretation of these frameworks by institutional review boards (IRBs).

A major shift has taken place since the 1960s concerning disclosure to patients that they have a diagnosis of cancer and that their disease is considered terminal. Full disclosure is now considered the patient's right in the United States. However, there remain many countries in which nondisclosure is still the norm. When patients from those countries are diagnosed with cancer in America, differences in attitudes and expectations can cause conflict and misunderstanding.

Bioethics is not merely a theoretical discipline but a practice as well. Indeed, bioethics is a sort of moral trade. Bioethicists serve on ethics committees, give expert testimony to courts, provide guidance for healthcare policy, and receive payment for these services. The difficulty is that their role as experts able to guide clinical choice and public policy formation is brought into question by the diversity of moral understandings regarding central moral issues at the heart of the culture wars in healthcare. The disconfirmation of the expert role of bioethicists by their apparent actual role as partisans of particular moral schools and perspectives could be set aside, were there an avenue to moral consensus, a door to a common moral vision to guide this new profession of moral experts. This brief article addresses the hunger for consensus in bioethics, its impossibility with respect to the controversial issues that mark the field, and the inclination nevertheless to deny this manifest diversity by appeals to a consensus that could allow bioethicists to function as ethics experts able substantively to guide clinical choices and public policy.

I first met Van Potter nearly 40 years ago when I was 17 and entering the University of Wisconsin as a new freshman. During the summer of 1963, Van was a participant in a series of evening seminars designed to familiarize premed students to the community at the University of Wisconsin Medical School. I was immediately struck by Van's unique ability to cut straight to the core of virtually any issue having to do with biomedicine. As with many of his students, I quickly found myself in a father-son relationship of both our making. Van has been a source of inspiration and guidance to me ever since.

There was a remarkable outpouring of publications related to the concept of medical futility between 1988 and 1995, and there has been a substantial drop-off since then (Figure 1). A wide variety of definitions of the concept were offered from many corners of the medical profession, from medical social sciences, as well as from judges in several state and federal courts. Attention was drawn to the conflicts over when it is appropriate to declare further treatment futile, who has the authority to make such determinations, and what evidence is required.

Several months ago, I was walking down the hallway outside our medical school faculty offices and a colleague stopped me to ask a question. He phrased his query in the context of a “hypothetical” case that raised ethical issues for him, and he asked me to respond. I obligingly offered my opinion given the details he presented, ending my comments with the phrase, “at least, that is what I would say.” To this he kindly shot back, “OK, but what is the consensus of medical ethicists?” To be honest, this question caught me off guard. Though his particular dilemma was relatively well-trod territory for many bioethicists, I had done little research on the issue and could not immediately render a response to his latter query.

Alzheimer's disease and other forms of dementia are among the fastest growing health problems in America. Dementia incidence tends to increase with age, and the elderly are the fastest growing segment of the population. Medical and social sciences research on dementia involving demented patients is both ongoing and necessary. However, as noted in a report of the Office for Human Subjects Research, “while research with intellectually impaired people generates valuable … data, it also provides significant ethical challenges.

Despite a growing awareness within American biomedicine and bioethics that the social category “race” is of limited use in describing patients, some fields of medicine continue to use it interchangeably with, or instead of, the term “ethnicity.” Doing so reflects the assumption that social categories have a basis in physiology.

Van Rensselaer Potter was the first voice to utter the word “bioethics,” yet he is too little appreciated by the bioethics community. My expectations for my first visit with Professor Van Rensselaer Potter were primed by conversations with leaders and historians of the field of biomedical ethics, including Warren Reich, Al Jonsen, and David Thomasma. When mentioning my interest in environmental ethics and my concerns for the current state of biomedical ethics, I was told that I must meet Van. On my first visit to Madison, Wisconsin, Van met me at the McArdle Laboratories for Cancer Research at the University of Wisconsin, where he spent essentially his entire academic career as a basic oncological researcher. He was dressed informally and driving a rusting1984 Subaru station wagon with a license plate that read YES ZPG. We spent this first portion of our visit at the Institute where he is an Emeritus Professor and has contributed to understanding cancer metabolism as recognized by his election to the National Academy of Sciences. However, Van felt most at home in his shack located outside Madison. This country retreat included a rather primitive hut surrounded by acres of property owned by the family. I felt at the heart of Van's world when I sat in one of a pair of inexpensive plastic outdoor chairs in a particularly secluded part of the woods on the property, the place where Van himself communed with nature.

As one looks into the crystal ball concerning the future of medicine, what might be seen? One vision is of genetic testing being carried out by medical technicians and then, as a result of this analysis, patients will be given a diagnosis of what is wrong with them. Next, they will be given a list of courses of action based on the tests. (Again, this list could be obtained by a technician who merely transfers the test results to the accepted database.) Once the list is presented to the patient, then she will choose her treatment (with the help, perhaps, of some online tutorials). Then a clinician will inoculate her or otherwise administer the genetic therapy. The entire process might go forward without the intervention of a physician!

Contemporary bioethics is a peculiar creature. What was once a subdivision of moral theology and philosophy tended mainly within the confines of schools of arts and sciences or seminaries has now become a quasi-profession whose practitioners come from a wide variety of disciplines. Perhaps still more intriguing is that the “members” of this discipline routinely engage the public at the hospital bedside, in the institutional boardroom, and through public policy consultation. Bioethicists have actively embraced these roles as the natural outgrowth of their research and study. Contemporary bioethics is thus a “demi-discipline.” It is study and research but completes itself in public engagement.