Responsibility for health: personal, social, and environmental.

Most of the discussion in bioethics and health policy concerning social responsibility for health has focused on society's obligation to provide access to healthcare. While ensuring access to healthcare is an important social responsibility, societies can promote health in many other ways, such as through sanitation, pollution control, food and drug safety, health education, disease surveillance, urban planning and occupational health. Greater attention should be paid to strategies for health promotion other than access to healthcare, such as environmental and public health and health research.

Eliminating the daily life risks standard from the definition of minimal risk.

The phrase "minimal risk," as defined in the United States' federal research regulations, is ambiguous and poorly defined. This article argues that most of the ambiguity that one finds in the phrase stems from the "daily life risks" standard in the definition of minimal risk. In this article, the author argues that the daily life risks standard should be dropped and that "minimal risk" should be defined as simply "the probability and magnitude of the harm or discomfort anticipated in research are not greater than those encountered during the performance of routine physical or psychological examinations or tests".

Response to Kuhse.

In this short paper, we respond to critics of our original paper, The agony of agonal respiration: is the last gasp necessary?. A common thread in both Hawryluck's and Kuhse's responses is the difficulties encountered when using the agent's intentions to make moral distinctions between using neuromuscular blocking drugs to palliate versus using neuromuscular blocking drugs to kill. Although this difficulty does exist we maintain that the intentions of the physician must matter when providing end-of-life care.

The agony of agonal respiration: is the last gasp necessary?

Gasping respiration in the dying patient is the last respiratory pattern prior to terminal apnoea. The duration of the gasping respiration phase varies; it may be as brief as one or two breaths to a prolonged period of gasping lasting minutes or even hours. Gasping respiration is very abnormal, easy to recognise and distinguish from other respiratory patterns and, in the dying patient who has elected to not be resuscitated, will always result in terminal apnoea. Gasping respiration is also referred to as agonal respiration and the name is appropriate because the gasping breaths appear uncomfortable and raise concern that the patient is suffering and in agony. Enough uncertainty exists about the influence of gasping respiration on patient wellbeing, that it is appropriate to assume that the gasping breaths are burdensome to patients. Therefore, gasping respiration at the end of life should be treated. We propose that there is an ethical basis, in rare circumstances, for the use of neuromuscular blockade to suppress prolonged episodes of agonal respiration in the well-sedated patient in order to allow a peaceful and comfortable death.

Human germline gene therapy reconsidered.

This paper reevaluates the notion of human germline gene therapy (HGLGT) in light of developments in biomedicine, biotechnology, and ethical and policy analysis. The essay makes the following key points. First, because the distinction among "therapy," "prevention," and "enhancement" is not clear in human genetics, "gene therapy" is an inadequate descriptor of the process and goals of germline genetic alterations. The alternate use of the phrase "human germline genome modification" (HGLGM) could avoid a misleading label. Second, procedures that could be construed as genetic "enhancement" may not be as morally problematic as some have supposed, once one understands that the boundaries between therapy, prevention, and enhancement are not obvious in genetic medicine. Third, HGLGM might be the medically and morally most appropriate way of avoiding the birth of a child with a genetic disease in only a small range of cases. Fourth, there are still many ethical and scientific problems relating to the safety and efficacy of HGLGM.

DNA patents and scientific discovery and innovation: assessing benefits and risks.

This paper focuses on the question of whether DNA patents help or hinder scientific discovery and innovation. While DNA patents create a wide variety of possible benefits and harms for science and technology, the evidence we have at this point in time supports the conclusion that they will probably promote rather than hamper scientific discovery and innovation. However, since DNA patenting is a relatively recent phenomena and the biotechnology industry is in its infancy, we should continue to gather evidence about the effects of DNA patenting on scientific innovation and discovery as well the economic, social, and legal conditions relating to intellectual property in biotechnology. We should give the free market, the courts, researchers, and patent offices a chance to settle issues related to innovation and discovery, before we seek legislative remedies, since new laws proposed at this point would lack adequate foresight and could do more harm than good. However, we should be open to new laws or regulations on DNA patents if they are required to in order to deal with some of the biases and limitations of the free market.

Ethical dilemmas in communicating medical information to the public.

This paper examines arguments for and against objective communication between health-care experts (HCEs) and the public concerning matters of health and disease. It argues that HCEs should have neither a purely objective approach nor a paternalistic approach to communications with the public. The informed consent model is the best way to promote public health, prevent disease, respect individual autonomy, and safeguard scientific honesty and openness. In following this model, HCEs should provide lay people with the information and advice they need to make sound decisions. They should not manipulate, distort, exaggerate, or conceal relevant information, nor should they use coercive means to induce the 'correct' decisions. Paternalistic communication only makes sense under the extraordinary challenges posed by bona fide public-health emergencies. Of course, informed people may still make unwise choices, but this is a cost that one must accept in a free, open, and democratic society.

Developing drugs for the developing world: an economic, legal, moral, and political dilemma.

This paper discusses the economic, legal, moral, and political difficulties in developing drugs for the developing world. It argues that large, global pharmaceutical companies have social responsibilities to the developing world, and that they may exercise these responsibilities by investing in research and development related to diseases that affect developing nations, offering discounts on drug prices, and initiating drug giveaways. However, these social responsibilities are not absolute requirements and may be balanced against other obligations and commitments in light of economic, social, legal, political, and other conditions. How a company decides to exercise its social responsibilities to the developing world depends on (1) the prospects for a reasonable profit and (2) the prospects for a productive business environment. Developing nations can either help or hinder the pharmaceutical industry's efforts to exercise social responsibility through various policies and practices. To insure that companies can make a reasonable profit, developing nations should honor pharmaceutical product patents and adhere to international intellectual property treaties, such as the Trade-Related Aspects of Intellectual Property Rights (TRIPS) agreement. To insure the companies have a good business environment, developing nations should try to promote the rule of law, ethical business practices, stable currencies, reliable banking systems, free and open markets, democracy, and other conditions conducive to business. Overall, this paper advocates for reciprocity and cooperation between pharmaceutical companies and developing nations to address the problem of developing drugs for the developing world. In pursuing this cooperative approach, developing nations may use a variety of other techniques to encourage pharmaceutical companies to act responsibly, such as subsidizing pharmaceutical research, helping to design and implement research protocols, providing a guaranteed market, and bulk buying.

The undertreatment of pain: scientific, clinical, cultural, and philosophical factors.

This essay provides an explanation and interpretation of the undertreatment of pain by discussing some of the scientific, clinical, cultural, and philosophical aspects of this problem. One reason why pain continues to be a problem for medicine is that pain does not conform to the scientific approach to health and disease, a philosophy adopted by most health care professionals. Pain does not fit this philosophical perspective because (1) pain is subjective, not objective; (2) the causal basis of pain is often poorly understood; (3) pain is often regarded as a "mere" symptom, not as a disease; (4) there often are no "magic bullets" for pain; (5) pain does not fit the expert knowledge model. In order for health care professionals to do a better job of treating pain, some changes need to occur in medical philosophy, education, and practice.

Regulating the market for human eggs.

This essay provides a rationale for a regulated market for human oocytes. Although the commodification of human oocytes raises important moral concerns, these concerns do not justify laws banning commerce in human eggs. Given the burgeoning ART industry and the growing oocyte market, the most prudent course of action is to develop regulations for the human oocyte market that are designed to protect and promote important social values, such as health, safety, liberty, and respect for human life. Other responses, such as banning the sale of eggs altogether or allowing donors to be compensated only for their services, would either create a black market or would lead to corruption and abuse. Society still needs to debate specific rules and policies that should govern the human egg market, but further discussion of that important task is best left to legislative bodies and other commentators.

Of maize and men: reproductive control and the threat to genetic diversity.

The genetic diversity argument (GDA) is one of the most commonly voiced objections to advances in reproductive and genetic technologies. According to the argument, scientific and technological developments in the realm of genetics and human reproduction will lead to lower genetic diversity, which will threaten the health and survivability of the human population. This discussion explicates and analyzes the GDA and challenges its empirical assumptions. It also discusses the possible significance of the GDA in our overall thinking about genetics and human reproduction and examines two proposals for preserving "useful" genes.

The conflict between ethics and business in community pharmacy: what about patient counseling?

Patient counseling is a cornerstone of ethical pharmacy practice and high quality pharmaceutical care. Counseling promotes patient compliance with prescription regimens and prevents dangerous drug interactions and medication errors. Counseling also promotes informed consent and protects pharmacists against legal risks. However, economic, social, and technological changes in pharmacy practice often force community pharmacists to choose between their professional obligations to counsel patients and business objectives. State and federal legislatures have enacted laws that require pharmacists to counsel patients, but these laws have had mixed results. This essay argues that community pharmacy's patient counseling conundrum can be solved through additional moral education persuasion, not through additional legal mandates.