Alastair V. Campbell, President, International Association of Bioethics (IAB)

This Congress aims to unite people from all four points of the compass in a unified, "global" bioethics. But is this a dream of reconciled humanity, like the famous dream of Martin Luther King? Or is it the nightmare of a homogenized, lowest common denominator ethics? - or, worse, of the cultural domination of world bioethics by one set of moral assumptions and style of reasoning?

In this paper I consider the toleration and pluralism enshrined in the Constitution of the International Association of Bioethics. I argue that, given this starting point, global bioethics has to be based on a respect for the richness of human cultures and the fragility of the physical and social environments that sustain human life. The fundamental value of global bioethics is, therefore, humility about our own ethical wisdom, based on an awareness of the limits of rational argument and of the prejudice which distorts our claims to ethical impartiality. The does not mean that rational discourse about ethics across cultures is ruled out, but it does require a critical re-examination of the assumptions on which the "-isms" of bioethics rely. A lively debate at the level of meta-ethics may help to ensure that global bioethics retains a rich texture of moral values and of styles of moral reasoning.

Hyakudai Sakamoto, Professor Emeritas, Aoyamagakuin University, Tokyo

In this talk, I will propose a philosophical foundation of a possible post-modern "Global Bioethics" based on the assessment of scientific and technological achievement of recent bio-sciences, together with deliberate consideration on ethical traditions of each region on the Globe. Then, referring to recent topics of genetics as well as of the environmental crisis, and also arguing the essential distinction between "Genetic Identity" and "Personal Identity", I will sketch a newly emerging "Global Communitarian Bioethics" which is based on the Global-value oriented conceptual scheme specially referring to Asian Mentality instead of the classical idea of "humanism" and, therefore, an alternative to a basis expressed in "fundamental human rights".

Jean-Pierre Changeux, National Consultative Ethics Committee for Health and Life Sciences, Paris, France

The increased globalization of economy, of communication, and of medical assistance raises many issues of ethics at the world scale, 1) A first critical question to consider is the actual possibility of a common agreement on ethical issues between citizens sharing different moral, philosophical or religious traditions. Common predispositions to moral judgment, proper to the human species, may plausibly give access to common ethical values through shared deliberations, despite differences in cultural traditions and social conventions. 2) Among the institutions which have contributed to the opening of the ethical debate at the national level are the various National Bioethics Committees, the first of which was created by France in 1983. Largely on the basis of its deliberations, in 1994 France parliament voted favorably for the Laws of Bioethics which constrain both public and private biomedical research, 3) Extension of the ethical debate at the multi-national scale is achieved in Europe with the Council of Europe and a 8pecialized Advisory committee at the European Union. Furthermore, the UNESCO International Bioethics Committee has recently proposed an Universal declaration on the Human Genome Project and on human rights. Major issues still need urgent consideration at the world scale (e.g. equal access to the benefits of biomedical knowledge and its applications, equal respect of the dignity and human rights of each individual despite poverty and submission to blind and anonymous economic forces). It is proposed to make a further step in creating a Council of Bioethics directly at the level of the United Nations, Its first task would be to propose bioethics guidelines on the world scale and, if successful, in a second step, to elaborate international conventions with Juridical power on bioethical issues. Meanwhile, the French National Consultative Ethics Committee offers to establish a freely open data bank on bioethics at the world scale, at least to find some common ground.

Tom Beauchamp, Kennedy Institute of Ethics, USA

The Foundations of Global Bioethics are independent of the norms of any particular culture, because foundational moral values transcend particular cultural values. The universality of these norms permits criticism of local actions and practices that violate the norms even if these actions and practices are dominant in the culture. These norms cannot be compromised without compromising morality itself. However, this claim does not entail a universality of all moral judgments and conclusions, because there are many forms of legitimate disagreement in bioethics. Universality pertains exclusively to foundational values, not to derivative values. Informed consent and medical paternalism will be used as a test of these theses.

Wendy Orr, Truth and Reconciliation Commission, South Africa

The death of Steve Biko in 1997 was a watershed for the issue of ethics and human rights in the health care sector in South Africa. Not only were the circumstances of his death horrific, but the failure of both the professional and statutory organizations to take any disciplinary action against or even voice disquiet at the conduct of the doctors involved, indicated a shattering disregard for the ethical principles supposedly guiding the profession.

However, human rights abuses by health professionals and in the health care sector predated the death of Steve Biko by decades, Through acts of omission and commission, complicity and collusion, apathy and failure to question, health care workers systematically violated the human rights of millions of South Africans.

Through a number of case studies, this paper will examine the ways in which ethical medical practice was eroded and abuses of the rights of patients became commonplace and accepted in South Africa. The social circumstances and political environment which allowed such a situation to develop, will also be briefly studied.

The case studies will be wide ranging and will highlight national issues e.g. differential allocation of health care resources based on racial classification of the service users; conditions at academic institutions; prison health care; individual violations; manipulation of forensic evidence and the failure of professional bodies to provide appropriate moral and ethical leadership.

Examples of resistance to abuses will also be presented. The role of the Truth and Reconciliation in examining the above issues will be briefly described and the value of such "investigations" will be discussed. The insights gained from the above will then be used to propose ways in which medical ethics can be upheld and a human rights culture established and protected in the health care sector. The lessons learned through the examination of the South African situation will, it is believed, provide valuable guidelines and warning signals for other countries.

Finally, the importance of the link between medical ethics and human rights will be emphasized. The need to translate ethical principles into daily practice will be highlighted.

Dan Brock, Brown University, USA

In the face of scarce health care resources, many assume that resources should be used to maximize the health of populations served. Cost effectiveness analysis (CEA) for the maximization of quality-adjusted life years (QALYs) is the usual quantitative methodology employed. CEA discriminates against persons with disabilities in two important respects. First, QALYs assign different value to life lived in different health states, typically by determining people's preferences for life lived in those health states. Because of adjustment to their disabilities, persons with disabilities typically evaluate their quality of life higher than nondisabled persons evaluate it. If disabled persons' preferences are used to evaluate quality of life in different health states, prevention of disabilities will be unjustifiably undervalued. If nondisabled persons preferences are used, extending the lives of disabled persons will be unjustifiably undervalued. Second, CEA often assigns less value to life extending or quality of life improving treatment for disabled than for similarly situated nondisabled persons. However health states are evaluated, CEA assigns less value to extending disabled than nondisabled persons' lives both because of their lower quality of life and when their disabilities give them a lower life expectancy. With treatments that improve quality of life, treating disabled patients will receive lower priority when their disabilities act as comorbid conditions making treatment less effective and/or more costly. These difficulties challenge fundamental features of CEA for prioritizing health interventions.

Darryl Macer, Eubios Ethics Institute, Japan / New Zealand

Bioethics is both a word and a concept. The word comes to us only from 1970, yet the concept comes from human heritage thousands of years old. I will argue that bioethics is the concept of love, balancing benefits and risks of choices and decisions. This heritage can be seen in all cultures, religions, and in ancient writings from around the world. We in fact cannot trace the origin of bioethics back to their beginning, as the relationships between human beings within their society, within the biological community, and with nature and God, are formed at an earlier stage then our history would tell us.

In this paper I will introduce the alternative language for bioethics outlined in the book Bioethics is Love of Life, arguing that love is a universal virtue, and principle of bioethics. I will argue that love is not only the highest good, but is a normative principle. There are a set of principles or ideals which people use as a common ground for bioethics, or which at least have been suggested to be the key ones. They include the autonomy of individuals to make choices, while respecting the choices of others, justice. In all things we do, the ideal is to avoiding doing harm, and try to do good. I will argue these four principles can be summarized by the word love, as self-love, love of others, loving life and loving good.

I will review the results of the session held on the 31st October where people from a dozen countries discussed the use of love as a fundamental principle of bioethics (see abstracts 31B). Their views support the universal literature found which places love as a premier principle. I will also discuss whether a person who fails to love morally deficient? Does the presence of an ideal put someone off striving harder to help others? Do people just give up totally and become bad? Generally we would not think so, though some hope should be given when we are disappointed by our own failings to reach the ideal. At least we can conclude that we should all try a little harder to reach the common ideal, and the world would be a better place.

William P. Shantz, Private Practice -Psychiatry, Canada

In this century, medical practitioners have developed awe-inspiring abilities and skills to alter disease processes. In addition to the magnified importance and assigned hubris that are associated with such 'healing' ability, the doctor and associated services cost a lot, threatening financial bankruptcy of society - I propose that patients be viewed as participants in procreative endeavour, rather than as complex machines to be 'repaired' or biochemical mixtures to be 'balanced' . Matters of transitive ' healing ' and ' health ' provision can readily be formulated as analogous to heterosexual procreative interaction: the spermatocyte 'heals' - makes whole the oocyte, and the oocyte provides 'health, - wholeness for the sperm cell. 'Doctor' derives from - teacher; physician' from - one who and ' medicine ' means - studies nature ; some thing to be administered to relieve distress. A medical practitioner can carry out these tasks plus work as an ' agent-technician' - one who has been authorized (e.g. by a patient of family member) to perform a technique that he/she has expertise to do without assuming the prerogatives, responsibilities, and 'hubris' of a 'healer'. The ethics of a 'teacher', 'scientist', and 'agent' are different than those of a 'healer', and the essential interaction of medical practice may be better thought of as the 'Patient-Physician Relationship' than 'Physician-Patient Relationship' .

Jonathan Chan, Hong Kong Baptist University, Hong Kong

There are two different views as to the foundations of bioethics. One maintains that conflicts in respect of bioethical issues can be resolved only among people who live in the same community or belong to the same tradition. This is so because people living in different communities or traditions hold different or even conflicting comprehensive doctrines. In consequence, people belonging to different communities or traditions do not share the same set of fundamental moral principles. And it is also impossible to find out a set of universally accepted fundamental moral principles, to which people belonging to different traditions can appeal so as to resolve their conflicts. Let us call this 'the local view'. The other maintains that some form of global bioethics is not only possible but also inevitable if people do not want to resolve their conflicts by force or manipulation., According to this view, the global bioethics pursued is beyond and above the traditions that people adhere. Let us call this 'the global view'. In this paper, it will be argued that neither the local view nor the global view is the only plausible view as the foundations of bioethics and that there is a 'middle way' which is also plausible in respect of understanding the foundations of bioethics.

Daniel Fu-chang Tsai, University of Manchester and National Taiwan University Hospital

The four principles approach to biomedical ethics (4PBE) has, since the 1970s, been developed as a universal bioethics method. Despite its wide acceptance and popularity, the 4PBE has received many challenges to its cross-cultural plausibility. This paper first specifies the principles and characteristics of ancient Chinese medical ethics (ACME), then makes a comparison between ACME and the 4PBE with a view to testing out the 4PBEís cross-cultural plausibility with one particular but very extensive and prominent cultural context. The results show that the concepts of respect for autonomy, nonmaleficence, beneficence and justice are clearly identifiable in ACME. Beneficence and nonmaleficence have always been the keynotes of ACME since humaneness (jen) is the central theme of Confucianism, on which ACME was founded. ACME is also familiar with the concept of yi (righteousness), the equal treatment of all persons and extended help to the worst-off, therefore it is not in want of the concept of justice. Regarding the principle of respect for autonomy, ACME requires physicians to respect their patients as ends but not means via a sincere, decorous, devoted, absorbed and selfless attitude towards medical practice and to appreciate the value of life with equal respect; ACME also contains the rules of confidentiality and telling the truth. However, being influenced by certain socio-cultural factors, the application of the 4PBE in Chinese society may tend to adopt a beneficence-oriented, rather than autonomy-oriented approach, which, in general, is dissimilar to the practice of contemporary Western bioethics where autonomy often triumphs.

Sunil K. Pandya, Jaslok Hospital & Research Centre, India

India has been blessed with a glorious code on medical ethics since the days of Caraka and Susruta (circa 600 BC). This Ayurvedic code embodies the criteria for a good teacher and who should study medicine. It also offers counsel on behaviour with patients and their relatives and pointers that can be used by us when dealing with such issues as brain death and organ transplantation. Especially striking is the emphasis on transcending the needs of the body, mind and intellect in order to reach a state where the cycle of birth - death -rebirth is broken.

This ancient code is reflected in the codes set up by Buddhism and Jainism - offshoots from the Hindu faith. The Islamic code of ethics was not as well defined in India. Based on the teaching in the Koran, the Muslim doctor was expected to do all he could to save life and promote morality.

Modern Indian doctors appear to have forgotten their ancient heritage. The Medical Councils in New Delhi and the various states have failed to ensure a high moral standard in the medical profession. Much needs to be done if we are to return to the standards that prevailed when Caraka and Susruta practiced medicine here.

Soren Holm, University of Copenhagen, Denmark

It is now generally accepted and uncontroversial that biomedical research with human subjects usually requires informed consent. Informed consent is, however, neither a sufficient nor an absolutely necessary condition for the ethical conduct of research. Research may be unethically conducted even in cases where full informed consent has been obtained. It is argued that such cases are not rare, and it is discussed how research ethics committees can participate in minimizing the problem. There are also cases where standard informed consent cannot be obtained. It is discussed whether other forms of consent are available, and further what a researcher and a research ethics committee should do if no informed consent can be obtained. It is concluded that the research ethics committee of the 21st century must take on a much larger role than just approving research projects. It will have to engage itself in active monitoring of research conduct, and in constructive moral thinking to solve more and more complex consent problems.

Richard Ashcroft, University of Bristol, UK

It is widely maintained that a clinical trial is ethical only if some form of equipoise between the treatments being compared is obtained. This condition, if sound, provides a useful test of whether the trial is beneficent and fair to all of its participants. Since the condition was devised by Benjamin Freedman, a number of competing modifications have been proposed. All debates over versions of the condition refer to the social context of clinical research: depending on the version in question, equipoise should be expressed by one of the practitioner, researcher, profession, founder/sponsor, affected patient population or society at large. But the core of the condition is epistemic: equipoise reflects individual or collective indifference between assertion of the proposition "treatment A is superior to treatment B" and its converse. Equipoise justifications of trials turn on socially controlled and negotiated judgments of epistemic indifference.

In terms of ethical justification of trials (in particular cases or in general), equipoise theories do us the service of underscoring the social element in trial planning, design and governance. But they do so by translating ethical judgments into epistemic judgments; and the debate over the various theories of equipoise rest on some quite vague ideas about knowledge and belief. I will argue that the most natural way to theorize the epistemic content of equipoise theories is by applying Bayesian ideas in epistemology. I will discuss some problems this approach raises for justifying the equipoise condition, by showing that the social problems raised in the equipoise debate thus far arise quite generally in epistemic guise in the Bayesian theory. In particular I will discuss the social and epistemic problems that arise in stopping trials early and in determining the minimum effective (and ethically legitimate) size of a trial. I will conclude by discussing the ramifications these problems have for the project of Evidence-Based Medicine.

Christian Munthe, Goteborg University, Sweden

Standard versions of the requirement of informed consent state that patients who are offered to enter a clinical trial of a medical procedure should be informed about risks and possible benefits of this procedure (compared to available alternatives) in order to facilitate a rational decision whether or not to participate. However, in many real cases where new medical procedures are to be clinically tested for the first time the information available for such communication to prospective patients is very scarce, vague and/or uncertain. This phenomenon is illustrated by the clinical introduction of new procedures in reproductive medicine, such as preimplantation genetic diagnosis (PGD). Regarding such procedures, it has been argued that, in such cases, the quality of the available information may be too low for the obtaining of informed consent to be possible, even if it is successfully communicated. Others, instead, holds that informed consent may always be obtained regardless of the quality of the available information. Unfortunately, the standard literature on informed consent give no clue as to which of these interpretations is correct. This issue is explored by connecting the concept of informed consent to ethical ideas of respect for autonomy and ideas of rational decision making. It is argued, first, that low quality of available information regarding the risks and possible benefits of a medical procedure may indeed make the obtaining of informed consent from patients to undergo this procedure impossible even in theory. However, it is also argued that whether or not this is the case must be relativized to the actual needs and desires of individual patients. Thus, regarding one and the same procedure, informed consent may be impossible to obtain from some patients due to the low quality of the available information regarding this procedure, but still be possible to obtain from other patients.

Emilio Mordini, Psychoanalytic Institute for Social Research, Italy (Cancelled)

Important changes occurred in vaccination due to new molecular biology and the better understanding of the immune system. The ability to manipulate DNA, the ability to synthesize oligopeptides and "package" them in different ways, the development of new adjuvants, the ability to enhance the type and persistence of the immune response have overturned conventional views on vaccination. There are currently about 25 vaccines in use, but about 34 other different vaccines are being developed. A likely timetable for new vaccines forecasts for instance vaccines for varicella, hepatitis A and cytomegalovirus within 5 years and vaccines for many STDs, including HIV, herpes, and chlamydia, within 10 years. Moreover new vaccines have been proposed as a therapeutic agent (i.e., to improve the immune response) in several diseases, such as AIDS, rheumatoid arthritis, multiple sclerosis, melanoma, breast and colon cancers. Yet dramatic results are expected in new vaccines in veterinary and agriculture. Another important improvement is expected in vaccine production. The cost of administering an EPI vaccine is at least 10 times the cost of the vaccine. Although it is unlikely that this ratio will hold for many future vaccines, reducing the number of visits of health care workers for vaccine administration could clearly result in great savings. The Children's Vaccine Initiative (CVI), established in 1990 by the Rockefeller Foundation, United Nations Development Programme, UNICEF, the World Bank, and WHO. It aims at developing a single vaccine involving the use of DNA recombinant preparations, which could protect against all infectious diseases with a single oral dose administered any time after birth. It has been also proposed to use lactic acid bacteria (LAB), which are commonly used in fermented food and feed, as vehicles for oral vaccination. The idea of using crop plants for producing recombinant edible vaccines is also being investigated. All this promises to overturn every current ethical, legal, and social standard surrounding vaccines and vaccination.

In April 1998, the European Commission launched a research project on "Ethical, legal, and social aspects of research on new vaccines and vaccination policies" (EURO ELSAV, contract nr BMH4 98 3197), involving the Psychoanalytic Institute for Social Research (IT), the Unit of Biochimie Cellulaire of the CNRS (FR), Center for International Health of the University of Bergen (NO), the Centre for Professional Ethics of the University of Central Lancashire (UK), and the Dept. of Immunological Research of the Immuno AG (AT). This paper intends to present some midway results of EURO ELSAV.

Nikola Biller, University of Goettingen, Germany

The placebo effect tends to have a bad reputation in biomedical ethics. It evokes the notion of deception, paternalism, and outdated clinical practice. Until the Seventies, bread or sugar pills were liberally distributed as therapy, and even sham procedures were performed. With the patient autonomy movement, however, the image of the placebo effect changed. It came to be seen as an undue attempt on the doctors' side to have the patient rely on his or her care even if they had no clear idea about diagnosis and no specific treatment at hand.

Recently, however, with growing financial constraints in health care as well as an increasing appreciation of "complementary medicine", there have been voices in the medical community that call for a reappraisal of the placebo effect, understood in a broader sense as non-specific therapy or "remembered wellness". Psychopharmacological research, psychoneuroimunology and a biopsychosocial approach to medicine that focuses in treatment on the individual's suffering rather than on disease entities provide the theoretical frame for this reconceptualization and reintegration of the placebo effect into medicine.

So far, these changes has not yet been explicitly addressed by medical ethics. This. paper will therefore: 1) describe the reconceptualization of the placebo effect taking place within the medical community, 2) outline its current and potential therapeutic use and 3) attempt a bioethical reevaluation. Contributions from discussants illuminating the perception of the placebo effect in other cultures will be welcomed.

Erin D. Williams, Leslie A. Platt, & Stephen J. McCormack, Foundation for Genetic Medicine, USA

In the public discourse relevant at the inception of the era of genetic medicine, many public and private interests, groups and individuals around the world have expressed a range of views on the ethical, legal, and social implications of genetics and its potential applications. Amid the discourse, widespread "genomic illiteracy" and a lack of consensus on acceptable practices have confused exchanges regarding science policy and scientific issues. In this climate, an approach that supports development of standards for privacy safeguards, informed consent, weighing risks and benefits, and other areas impacted by genetics is needed. For example, a common set of genomics terminology would help enable genomic literacy and support informed discourse in the development of appropriate, broadly acceptable practices and policies related to genetic medicine and its applications. Another helpful step would be the articulation of statements of recognized common ground that integrate the disciplines, underpinnings, and procedures surrounding genetic medicine. These "Generally Accepted Principles, Protocols and Practices" (GAPPP), can serve as guidelines suggested to improve practices and prevent misuse of genetic medicine. GAPPP have the potential to address issues that extend beyond professional conduct into the broader sciences as well as the human condition.

Keith Joseph, Plunkett Centre for Ethics in Health Care, St. Vincent's Hospital, Australia

One major line of argument against germ-line genetic engineering upon humans is that the consequences are unknown or unpredictable, Thus, it is claimed, we should invoke the precautionary principle, and as a matter of caution not proceed with germ-line genetic engineering. Critics of this view argue that there have been many technological interventions where the consequences have been unpredictable and even risky, but from which we have benefited. Fear of the unknown and caution about the unpredictable nature of genetic interventions are, by themselves, not sufficient cause for refusing to early out germ-line genetic engineering. This is particularly so given the tremendous benefits that the technique promises in terms of the treatment and relief of disease.

However, recent research has shown that genetic algorithms are chaotic; as a consequence genetic interventions will also be chaotic. Furthermore, germ-line genetic engineering IS designed to be long-lasting and to amplify throughout succeeding generations. Thus we can reasonably expect, as a result of the unpredictable nature of such interventions, that there will be long-term and lasting adverse results from genetic engineering which will be amplified rather than dampened as time goes on.

This means that germ-line genetic engineering is unlike other technological interventions: for In other interventions the intervention is not self-replicating or exponentially amplified, and with therefore have a tendency to be dampened and washed out by the environment. Consequently the precautionary principle, which is fairly weak when applied to most new technologies, may have a far stronger application in relation to germ-line genetic engineering upon humans.

Soren Holm, University of Copenhagen, Denmark

The paper discusses to what extent we can expect to attain informed consent when we perform gene therapy experiments. It is shown that such experiments differ from standard drug testing in three ways: 1)They occur much earlier in the development of the technology; 2) Their outcome is more uncertain; 3) They may take the form of an "offer you cannot refuse". It is argued that although these differences between gene therapy research and standard drug testing do cast doubt on the informed nature and the voluntariness of the consent, these doubts are not sufficiently strong to rule out genetic experimentation on humans.

Kaori Muto Yamamoto, The Health Care Institute, Japan

In many countries, Huntington's Disease (HD) is a symbolic disease in bioethics and often discussed when considering pre-onset genetic predictive testing. In Japan, however, we don't have patients' association of HD. Guidelines for the molecular genetics predictive test in Huntington's Disease (International Huntington Association / World Federation of Neurology (1994)) is not known to either families with HD or physicians. Even health care professionals (nurses, social workers and public health nurses) are not familiar with HD. The reason is the small number of HD patients in Japan. Even so, we need to know what is happening now and should construct some guidelines for predictive testing. The objectives of this research were: 1) to clarify the comprehensive and actual condition (informed consent and genetic predictive testing) in Japan; 2) to discuss the need for guidelines and patients' association for HD; 3) to compare the situations in some countries which have Huntington's Associations of their own. The subjects where family members with HD and their physicians in Japan, and semi-structured interviews were conducted.

Some family members did not know predictive testing is possible. One of the big reasons is that the genetic counseling system is still not popular in Japan so that physicians hesitate to tell them. Physicians seem to be reluctant to undergo predictive testing. Others are isolated in the community because they try to hide the name of their disease, even within the family. They are afraid of marriage discrimination and seem not to be interested in patients' association.

Miyako Okada-Takagi, Toyoko Gakuen Women's College, Tokyo, Japan

Japan's first gene therapy was performed in the summer of 1995 by Hokkaido University researchers on a 4 year old boy who suffered from adenosine deaminase deficiency. University team used the same method as the one used in the U.S. as the first gene treatment. Being 5 years after the first use of gene therapy in the U.S., this is evidence enough of Japan's slow progress in the field. The Institute of Medical Science (IMS) of Tokyo University approved a gene therapy for cancer patients in 1995, but the Health & Welfare Ministry called a temporary halt to the plan, forcing IMS to postpone the approval until 1998. The ministry complained that IMS had not done enough to confirm the safety of a virus used to transport the normal gene to the cancer cell. The main cause of this problem is that a system to confirm gene therapy's safety has yet to be established in Japan. Another problem is the examining process. Bureaucratic obsession with turf has once again presented itself with the two ministries maintaining separate panels devoted to the same purpose. The review process should be streamlined.

The U.S. National Institute of Health (NIH) won a patent for the technique of ex vivo gene therapy in 1995. NIH has been awarded a patent for the well-established procedure of ex vivo gene therapy. The problem is that many of the protocols being developed in labs around the world infringe this patent. Japan and Europe take a more narrow view on such patents, and that is the source of the bone of contention.

Vladimir I. Ivanov, Research Centre for Medical Genetics and The Russian State Medical University, Russia

Modern genetics offers quite a number of research, diagnostic, prognostic, and therapeutic technologies, medical application of which can interfere with human somatic, reproductive, mental, and moral status. In the last decade this situation has attracted public attention at the national and international levels. At the latter, respective documents were recently issued by UNESCO, WHO, Council of Europe, etc. In ethnically and culturally heterogeneous nations, like Russia it is especially difficult to find a "common denominator" to diverse viewpoints and estimates of good vs. evil consequences of particular invasive medical genetic procedures. The moral aspects of the problem comprise now a major topic of public debate in scientific, medical, and religious circles. The legal regulation of the use of genetic technologies in public health care and in research is restricted as yet to general legislation of the health care and the federal bill regulating the activities in genetic engineering.

Sarah Marchand, Daniel Wikler, Bruce Landesman, University of Wisconsin, USA

Research over the past 15 years has demonstrated conclusively that class is a powerful determinant of health, even when all have access to health care. Class inequalities in health are intuitively unjust; but what, precisely, is the nature of this injustice? We present four alternative views. Three call on health policy to maximize health, but differ in what they want maximized (the sum total of health in a society; the health of the lowest social class; and the health of the sickest individuals, respectively); the fourth calls for equalization of health status across class lines.

Paul Menzel, Pacific Lutheran University, USA (presenting work co-authored with Marthe Gold, Erik Nord, Jose-Luis Pinto Prades, Jeff Richardson, and Peter Ubel)

Conventional cost-effectiveness analysis in health care is relatively insensitive to many "societal values" that emerge if people are asked interpersonal trade-off questions rather than questions focused more on individual health utility. Such societal values include special considerations for severity of illness, lifesaving, and limited health potential, as well as those for maintenance of hope, age, and duration discounting. The recognition of such societal values in measuring "effectiveness" also reveals other structural problems in conventional cost-effectiveness analysis. The selective expansion of economic analysis to incorporate such societal values may be justified; in any case, cost-effectiveness analysis as currently practiced seriously misrepresents the priorities of citizens or subscribers living within a health care system.

Leo Pessini, Brazilian Society of Bioethics

Bioethics in Latin America is experiencing an extraordinary growth in this last decade of the millennium. All over the continent, is happening many new initiatives in terms of events, seminaries and congresses. Recently was celebrated a mega event in Colombia(Bogota, June 98) the III Latin American Congress of Latin America and Caribbean region, with the participation of 1600 ( on thousand and six hundred people) of all region, with the coordination of FELAIBE ( Latin American Federation of institutions of bioethics) the main body of bioethics in the region. Besides this, in many countries of the region were created new associations of bioethics in a national level, as well as, many ethics committee for ethics on research involving human beings (case of Brazil).

Understanding bioethics as "a responsibility toward life" it's necessary to ask, about what kind of bioethics is urgent to build in order to respond to the cry of the people for more social justice, equity, quality of life, human rights and peace in the region, specially in politics, human procreation and in the front of biotechnology.

Pursuing this direction, our presentation points out come cultural characteristics of the Latin American people that have great impact in how to elaborate bioethics that has a message of life for this reality. In this paper our journey starts from the principles paradigm toward a Latin American perspective making some comments about the bioethics "made in EUA", and Europe in confront with Latin America. It's necessary broaden the horizon in terms of the ethics reflection, from the micro to macro level and to develop a "mystic" for the bioethics among other aspects. This agenda for the bioethics, can help in the task of constructing a bridge, not only toward the future (V.R. Potter) but also as a bridge of multi and transcultural dialogue for life among the different peoples and cultures.

Bela Blasszauer, Medical University of Pecs, Hungary

The title of the paper came as a natural and legitimate question after the author's 31 years of work at a medical university. He is convinced that in a feudalistic, highly hierarchical university system no humanistic, patient-oriented medicine can be promoted. The lack of democratic atmosphere within the walls of the university very much influence the behavior of the future physicians and has a very negative impact on the whole system of health care. There are still those who want to keep a rigid hierarchical system, together with such a paternalistic attitude which is very anachronistic even in Hungary. This system is self-serving, giving unlimited power to those who lead departments and clinics, while this tremendous power is uncontrolled, not even accountability exists. Medical students mainly learn and must learn to fall in line, constantly please the teachers and respect unconditionally those who are in power. In clinical setting they witness how clinicians deal with patients as ones who are in the bottom of the hierarchy, while their treat their superiors as gods. No doubt is in the author's mind that there are many medical schools around the word where humane health care is promoted, where colleges and universities exist for the sake of the students and not vice versa.

Frank Leavitt, Ben Gurion University of the Negev, Israel

Medical research is in the paradoxical situation that while, on the one hand, it is getting more and more difficult to perform even retrospective epidemiological studies within the constraints which ethics is demanding, intervention studies with no clear medical benefit to the patient are being performed on infants with no genuine informed consent. A salient example is the study, reported this year in the BMJ, of effects of 15% oxygen on breathing patterns and oxygenation in infants.

There can be no genuine informed consent in research on infants because it is impossible to explain the research to the patient (the baby). And the people who give the consent (the parents) are not the patient. Any intervention clinical research presents a possibility of iatrogenic harm to the patient. But retrospective epidemiology only threatens privacy, and computerized anonymization can nullify this danger.

So this paper suggests reversing the situation, forbidding intervention pediatric research (especially neonatal) when there is no clear medical value to the patients, while recouping the losses to medical research by relaxing ethical constraints on non-intervention, retrospective epidemiological research.

Billy F. Andrews. Dept. of Peds., University of Louisville School of Medicine, USA

Informed consent, especially for adults, arose in the 19th century; however, early pioneers in modern surgery, medicine and pediatrics pioneered the right of informed consent commensurate with age. The great interest in child abuse and the implications of medical research on infants and children led to legislation in the 1950's and 1960's in the United States. "The Children's Bill of Rights" (1968) which advocated informed consent for children was translated into all major and many languages and was used in areas of legislation. In 1989 the very comprehensive "United Nations Convention on the Rights of the Child" included the rights of the child for consent to medical therapies and procedures. Now the children of many nations enjoy varying degrees of this right. Vignettes and examples from famous scientists will be used to show students of medical ethics how and why the concept arose. The historical approach to the constantly changing patterns of medical discovery and the ethical awareness of their impact upon the human subject is worthy of study. "Ethics is the highest possible level of moral thought and action".

Leonardo D. de Castro, University of the Philippines, the Philippines

A study conducted at two medical centers in Metropolitan Manila surveyed attitudes of pediatricians towards the treatment of severely deformed neonates. The results may be contrasted with earlier findings by other authors using the same questionnaire in Victoria (Australia), Calgary (Canada), and Warsaw (Poland).

Compared to pediatricians in Victoria and Calgary, more Filipino physicians believe that in all circumstances every possible effort should be made to sustain life. They cite religious reasons for their response. Paradoxically, a big number of the respondents have had the experience of making decisions not to exert maximum efforts to preserve infants' lives. Explanations may be found in the distinction between ordinary and extraordinary means, in the distinction between active killing and allowing to die, and in an understanding of "sanctity of life" that is not thought incompatible with accommodating quality-of-life considerations. There may also be some ambiguities in the meanings physicians attach to above ethical categories.

The study further reveals an approach to clinical practice in the Philippine setting that puts physicians at the center of the process and minimizes the contributions of other members of the treatment team. It also shows that Filipino physicians do not believe at medical ethics should be controlled by legislation.

Zelina Ben-Gershon and Bracha Rager, The Chief Scientist's Office, Ministry of Health

The advances in human genetics that have occurred during the past decade have enabled us to obtain a large amount of information on the present and future health of a person and of his relatives, simply by testing a drop of his blood. Recent advancements may also enable genetic intervention, in addition to genetic testing. There is a need to balance between the right of the individual for privacy, the desire to use sophisticated solutions for problems of reproduction, the advancement of research in medicine and science, and the wish of representatives of the public to set limits to the use of such methods.

In an attempt to reach such a balance, two laws will soon be submitted to the Knesset, the Israel Parliament: 1) A law on the protection of genetic information 1998; 2) Legislation forbidding genetic intervention (cloning of human beings and the genetic changes in germ line cells) 1998. The purpose of the first law is to provide regulations for performing genetic tests in a way which will protect the confidentiality of an individual's genetic information, including the results of genetic tests, while not interfering with the quality of treatment or with research and development in medicine and in life sciences. The second law forbids the cloning of human beings and the use of germ line gene therapy. In addition, it establishes an advisory committee that will follow developments in medicine, science and technology involving genetic experimentation in humans and will report annually to the Minster of Health on these matters.

Kiran Prasad, University of Wisconsin, USA

Health information in medical records is arguably the most intimate and sensitive data maintained about a person. Medical record keeping is presently in the midst of an historic transformation, as the written chart gives way to the electronic medical record. While greatly enhancing administration and research, this new system neglects serious questions about privacy. Computerization of health information allows secondary use of sensitive personal data by employers, marketing firms, and insurance companies threatening the patient's job, health insurance, and even personal relationships. The public is largely unaware of these risks, and health care institutions have yet to address the issue...

Egbert Schroten, Utrecht University, The Netherlands

As chairman of the Dutch National Committee on Animal Biotechnology some of the issues discussed and policy formed will be discussed.

Robert Veatch, Director, Kennedy Institute of Ethics, USA

Any biomedical ethic that is complete and systematic must become explicit about its foundations. It must articulate its rock-bottom grounding, its foundational starting point (or defend the claim that one may do bioethics without a foundation). It must also make clear its epistemological assumptions-who can claim authority for knowing the moral content found at those foundations.

Some systems that purport to be ethics ground their norms in nothing more than the norms of a social group, a country, ethnic group, or religion. These are not really ethics, ultimate underpinnings for standards of moral conduct, but merely social mores. Any true ethic, and therefore any true bioethics must have universal foundations, that is, must be grounded in source that applies to all humans regardless of culture.

This does not rule out the existence of universal duties based on special role relations. Feminist bioethical theories that identify special duties growing out of special relations, for example, can still be universalistic. What cannot pass the universalistic test is any biomedical ethic that claims that the ground of professional duty is the consensus of the professional group or that only members of a professional group have epistemological authority to know the norms of the professional/lay relation. Hence, the Hippocratic Oath and the Declaration of Geneva are, in principle, have unacceptable foundations. They must be replaced by ethics that are more publicly grounded.

These foundational issues have implications for normative ethical theory as well. The presentation will argue that theories of morally right action (including principle-based theories) have more potential to meet the criterion of universalism than do virtue-based theories (including care theory and those based on benevolence, compassion, or the Hippocratic virtues of purity and holiness). Virtues are crucially important for a small, intense group (a Gemeinschaft) while action principles are more appropriate for bioethics among strangers. There are very different principle-based systems, however. They involve different numbers of principles and different theories for resolving conflict among the principles. Balancing theories will be contrasted with those that lexically rank principles and a mixed ranking/balancing strategy will be proposed.

Susan Sherwin, Dalhousie University, Canada

I shall explore the implications of the architectural metaphor at the heart of foundationalist approaches to ethics and bioethics and review some of the ways in which this metaphor directs (and constrains) thought. I shall argue that the metaphors of frameworks and of lenses better capture the ways we should pursue bioethical investigations and they cohere more closely with actual ethical practices as determined by cognitive scientists. Moreover, they encourage us to appeal to the insights available from multiple theories without binding us to the use of a single narrow, exclusionary approach.

H. Tristram Engelhardt, Jr., Baylor College of Medicine/Rice University, USA and Allyne L. Smith, Jr., University of Osteopathic Medicine and Health Sciences, USA

At first blush it might appear that the American standard version of bioethics replete with its principalism and ethics committees has taken possession of the bioethical conscience of the world, providing the foundations for an international health policy. Across the world bioethicists invoke a quarternity of principles and an American understanding of autonomy is brought to the physician-patient relationship across the globe. Yet a closer examination of the contemporary state of affairs reveals not only moral diversity internationally, but foundational moral disagreements in North American bioethics itself. Far from appeals to moral principles, moral casuistry or the balancing of moral claims resolving controversies regarding the character of just health care distributions, the moral significance of the human genome, the probity of abortion, or the acceptability of physician-assisted suicide, there are deep and persisting controversies concerning these and other moral issues. The character of moral argument is such that the resolution of moral controversies always presupposes a particular ranking of values, a particular ordering of moral principles, a special moral sense, a concrete moral understanding of nature, or a particular thin theory of the good and the right. Even if one does not succumb to a metaphysical skepticism one is lodged in a moral epistemic condition which makes impossible the resolution of many substantive moral controversies by sound rational argument. With different understandings of autonomy and justice, appeals to such principles divide rather than unite. There is not one content-full moral narrative available to direct moral decisions and justify health care policy. There is a de facto moral diversity that need not lead to a de jure moral relativism. A moral pluralism can be recognized within very general and abstract moral constraints, leaving considerable room for substantially different, content-rich approaches to bioethics and health care policy, including Asian approaches to bioethics. A canonical, content-rich, secular global bioethics cannot be justified. Its international imposition would be immoral.

David J. Rothman and Sheila M. Rothman, Columbia College of Physicians and Surgeons, New York, USA

This paper will present the conclusions of the Task Force with a focus on the ethical and social issues raised by the sale of organs and the use of organs from executed prisoners. It will present the positions of international medical societies, explore the gaps in their policies, and analyze the ethical and social dimensions of the practices that have heretofore been neglected. It will conclude with recommendations for change in policies and practices that the Bellagio Task Force endorsed.

in Brazil and South Africa

Nancy Scheper-Hughes, University of California - Berkeley, USA

This presentation will be based on field work in the two countries that has just been conducted. It will focus on the gap between law and practice, the role played by individual physicians and transplant teams, and the place of transplant in the public imagination.

India

Lawrence Cohen, University of California - Berkeley, USA

This presentation will be based on field work that has recently been carried out in India. It will explore the impact of the new Indian legislation on organ donation; it will also examine in depth the motives and fate of those who continue to sell their organs and those who purchase them.

In the United States, the individual state's interest in protecting a fetus is superseding a woman's autonomous rights to control over her own body, State laws will have to be challenged at the Supreme Court level to guarantee a pregnant woman the right of full citizenship.

In October of 1997, the South Carolina Supreme Court ruled in Whitner v. South Carolina that a woman may be held criminally liable for actions taken during pregnancy. This ruling was the first time that a state high court upheld the criminal prosecution of pregnant women addicted to drugs for child abuse. Its decision also affirms the status of the fetus as a person entitled to full civil rights Nationwide at least thirty other states have used various criminal statues to bring charges of child abuse against pregnant women who use illegal drugs or alcohol. By pursuing punitive measures including imprisonment, custody deprivation, and special criminal laws aimed exclusively at pregnant women, courts, legislators and prosecutors hope to reassert the state's power to regulate reproductive rights. And they may succeed. The vagueness and ambiguity of the Supreme Court's opinions on privacy and fetal personhood clear a space for argument. Specifically, the South Carolina case reinstated an eight-year prison sentence given to Cornelia Whither whose baby tested positive for cocaine use after he was born. Stating that "South Carolina law has long recognized that viable fetuses are persons holding certain legal rights and privileges." the court held that "prenatal injuries tortuously inflicted on such a child are actionable..." Whither (whose son is now a healthy eight-year old) was sent to prison. In explaining its decision, the Carolina court cited the US Supreme Court's aforementioned decisions in Roe v. Wade (1973), Planned Parenthood v. Casey (1992), and Webster v. Reproductive Health Services (1989). By reasoning that the "personhood" of the fetus plus the "compelling interest" standard of the state trumped the liberty rights of the pregnant women, the court staked out an authoritative claim for its encroachment on the mother's privacy and its subsequent punitive measures.

Has the state infringed upon a woman's constitutional rights to privacy, equal protection and due process? Has the state applied different standards to a pregnant woman that do not apply to non-pregnant women or men? Does the Roe decision apply only to the power to restrict abortion or does it give the state power to regulate pregnancies to term? What are the rights of a third party? Should the court be able to lay claim to babies in utero? In short, to what extent must women's reproductive status qualify or undermine her right to self-determination and full citizenship?

Serap Sahinoglu Pelin, University of Ankara, Turkey

Pre-marital sex for a woman is regarded as wrong in my country. As a result, it is socially forbidden for a woman to engage in this act. In order to present a woman as a virgin on her marriage day, she is subjected to pressure, and put under control both by her family and societal norms. A woman found to be a virgin on her first night of marriage is seen as a normal person while the one suspected to have lost her virginity is made to undergo series of medical examinations to bring clarity to her situation. the hymen examination made by a physician in order to find out if a woman is having sexual intercourse with a man for the very first time, in known as "hymen examination". this practice can be seen as exercising a certain control over a woman's sexuality. In our country women have various medical ethics problems: among these being abortion, psychiatry, sex' selection etc. In this sense, unlike countries, the demand for hymen examination comes out as an important problem in medical ethics. In this presentation, I'd like to talk about hymen examination, or rather "perineum examination" as it is known in forensic medicine, which is a very important social cultural subject with tragic ethical problems in Turkey.

Hajime Mizoguchi, Rissho University, Japan

Recently, it has been reported that the ethical committee of Saitama Medical College permitted a professor of plastic surgery to perform the transsexual operation from female to male on the patient with gender identity disorder. That trans-sexual operation is thought to be a kind of object of medical care. This is the first such judgment in Japan. In this study, I discuss the bioethical aspects of gender identity disorder and transsexual operation. It contains the relationship between the loss of reproductive ability, the seeking for self-fulfillment, and legal problems.

52C1. Ethical issues in routine psychiatric practice in Taiwan: from the perspective of medical students

Ming-Jen Yang*^{1, 2, 3}, Yung-Chieh Yen¹, Cheng-Chung Chen^{1, 2, 3}, Mian-Yoon Chong^{1, 2}

1 Department of Psychiatry; 2 Institute of Behavioral Science; 3 School of Medical Sociology, Kaohsiung Medical College, Taiwan; *Department of Psychiatry, Chang Gung Memorial Hospital Kaohsiung, and Chang Geng University, Taiwan

The purpose of this paper is to address everyday ethical issues encountered within the psychiatric setting in Taiwan. Specifically, Taiwanese ethics constituent elements and conflict of interaction concerning traditional attitudes toward doctoring in a modern western-style medical context will be explored and discussed.

In the 1997-1998 academic year, rotation clerks in the Psychiatric Department of a Medical College Hospital, totally 195 medical students, were recruited for this study. The participants were requested to note ethical problems they encountered in the course of their psychiatric practices. A short essay of their reflections on ethical issues encountered was required of them at the end of their rotation course. Thereafter, based on these reflections, we applied the technique of content analysis to determine the construct and substance of everyday ethics in the field of psychiatry in Taiwan.

The results of this preliminary analysis revealed that the construct of medical ethics envisaged by the medical students was not as broad as that found in western medical literature. The focus of concern was mainly on the doctor-patient relationship and the morals of the physicians. However, the relationship between the physicians and other professional groups was seldom mentioned. In addition, it is noteworthy that the content was rich in culturally relevant materials, such as the traditional red envelope - monetary gift, the role of families involved in the process of health care, and so forth. Overall, this research identifies the everyday ethics of clinical psychiatric service in Taiwan. The details of the results will be interpreted in a cultural context and discussed during the conference.

52C2. Is it wrong to deliberately conceive or give birth to a child with mental retardation?

Simo Vehmas, University of Jyvaskyla, Finland

In this presentation I analyze the moral status of future people and the obligations of moral agents to them. I discuss this problem by criticizing a utilitarian argument, namely, that one should act in a way that results in less suffering and less limited opportunity in the world as well as a position which emphasizes that parents should act in a way that ensures that their child is able to have the average health status of its birth cohort. Both of these accounts are questioned in this paper. I will argue that the essential point in the discussion of how we should act when what we do affects the well-being of future children is the moral responsibility of parents to commit themselves to the good of their present or future children. Also, there are morally significant differences between 'selective contraception' and selective abortion.

Chirita Vasille and Roxana Chirita, University Psychiatric Hospital "Socola", Romania

Romania has passing these years a so-called period of transition which is marked yet by post-totalitarian features. The Romanian society is confronting with severe economical crisis, as well as a "moral crisis". It is a matter of common knowledge that in Eastern Europe the official philosophy, which was Marxism, denied the existence of universal ethical principles, as well as the existence of autonomous professional ethics. Nowadays, in these countries, the evaluation of ethical implication in psychiatric care is difficult, contradictory and controversial. Romanian psychiatry has experienced great hardships due to the denial of the right to free conceptual commitment and of the right to express alternative options for the theories or concepts that were not in accordance with the communist morals. The process of replacing a communist regime by democratic structures has created the necessary circumstances for the uncensored circulation of information and opinions. In its turn, this fact has made some things possible, such as the debate of some aspects pertaining to psychiatric abuse, coercive psychiatric care and the access to health care in general. One may say that, the acquisition of ethics by all the people involved in the medical profession, as well as the development of their propensity towards ethical reflection are essential for a post-totalitarian society.

Taking into account the fact that the legislation of our country is undergoing a process of transformation, in psychiatry the interest is particularly focused on the ethico-legislative aspects pertaining to involuntary hospitalization, the compulsive treatment and the limits of confidentiality. We are not allowed to disregard the fact that the scarcity of health care budgetary resources obviously influences upon the quality of psychiatric care. Furthermore, the drugs shortage makes it necessary to adopt a rapid way of treating the patients with the risk of a paternalistic attitude. In addition to that, we can count the general attitude of dependency on centralized decision-making, which persist among Romanians. Under the circumstances present in Romania, new adjustments of psychiatric care are highly necessary, both at the medical and the community level and at the legislative one.

Roxana Chirita and Chirita Vasille, University Psychiatric Hospital "Socola", Romania

A historical survey of the social, moral and philosophical dimensions of medical ethics will bring out its deep implications in contemporary Romanian psychiatry. Considering the fact that it entails the acquisition of a personal system of moral values on the part of the individual, one can with good reason question the extent to which it is possible to influence moral reflection after a fifty years long acquisition of communist moral values. Even if we exclude the economical and political aspects, inducing a correct perception of the ethical problems with the population presents a difficult issue. If we take into account the existing possibilities, we wonder whether ethics should be presented as a virtue or as an obligation. The idea of virtue involves moral life and integrity. For fifty years communism endeavored to impose a set of false moral values, many of them utterly inconsistent with the cultural tradition of our people. The rejection of religion and the encouragement of agnosticism were probably the most twisted of all the pseudo-moral coordinates outlined by the communist system. In the beginning, the population was almost unanimous in opposing the new principles. Little by little, opposition turned passive and people gradually learned how to dissimulate their real beliefs.

The problem of suicide, although the existing statistics do not show alarming levels of the phenomenon, has caught the attention of specialists from various fields (medicine, sociology, philosophy, theology). The current concern with this topic might well be the consequence of the fact that it used to be taboo, very much like the problem of AIDS. A genuine member of the socialist society would not resort to suicide. What reasons could one have had to be disappointed or desperate? Still, if one attempted or committed suicide, it had to be that the person was mentally ill. On the other hand, Orthodox Christianity which constituted a refuge during communism, and under whose sway the Romanian people have evolved, has greatly influenced folklore, moral consciousness, inter-human and social relationships and the way of life of the ordinary people.

The attitude of the community towards a person who has committed a suicidal act is not rigid, repudiator or unforgiving, but a compassionate and understanding one. However, the idea of making a rational choice between life and death is strongly rejected . Granting people a "convalescence period", the necessary time for regaining the traditional values would therefore be far more preferable than imposing new obligations and norms, even if they are ethical ones.

Zbigniew Szawarski, University of Wales, Swansea, UK

"The patient may well be safer with a physician who is naturally wise rather than one who is artificially learned" said T. Fox, a former editor of The Lancet. I try to explain why it is so. The concept of the art of healing is intrinsically connected with the idea of healing powers. There are at least three possible approaches to that idea and all of them have different implications for the problem of medical wisdom. These are: the idea of the healing powers of nature, the idea of the healing powers of science, and the idea of the healing powers of the physician's personality. Having critically discussed those ideas I sketch an ideal of a wise physician as someone who has a particular kind of knowledge, good judgment, and self-trust. Medical knowledge is certainly a necessary condition of being a wise doctor but it is not the sufficient one. And this is why patients generally prefer to seek the help of "naturally wise physicians".

Bethany Spielman, Southern Illinois University, USA

One of the signs of the expanding influence of bioethics in the US is that courts increasingly use bioethics opinions when deliberating about legal issues. Most frequently, courts have used the opinions of institutional ethics committees, the opinions of the American Medical Association's Council on Ethical and Judicial Affairs, and the opinions of expert bioethicists. The use of institutional ethics committee opinions and opinions from the AMA has rarely been questioned by commentators, while the use of ethics experts is highly controversial. This paper compares these three types of bioethics input into the US legal system, their treatment by the courts, and makes recommendations about how bioethics can appropriately contribute to the development of judge-made law in the future. 

Arthur Zitrin, New York University Medical Center, USA

This paper will deal with medical ethical issues related to the death penalty in the United States, and also world-wide to the extent that data from Amnesty International and other sources are available. A brief history of death penalty legislation in the US will be presented followed by a summary of statistics on capital punishment in the 38 states where it is legal: number of executions and persons awaiting execution, methods employed, races of murders and victims, opinions about the death penalty of the public, law enforcement officers, criminologists, and others. These will be compared with data from other countries in the western world and elsewhere.

The ethical principles enunciated by the American Medical Association and other national and international medical organizations governing physician participation in the death penalty will be presented. The ethical responsibility of the physicians role during the several steps in the judicial process and after a condemned prisoner is on death row will be the major focus of the presentation. The pros and cons of the ethical propriety of 1) psychiatric examination to determine the mental competency of the condemned to be executed and 2) the treatment of a mentally incompetent death row inmate with be discussed. Reference will also be made to recent state laws which have defined physician participation in executions as not being the practice of medicine. Ethical implications of these rulings will be considered .

Bernadette Tobin, Plunkett Centre for Ethics in Health Care, Australia

Article 11 of the Universal Declaration on the Human Genome and Human Rights, which was adopted unanimously and by acclamation by the General Conference of UNESCO at its 29th Session on 11 November 1997, says: 'Practices which are contrary to human dignity, such as reproductive cloning of human beings, shall not be permitted. States and competent international organizations are invited to co-operate in identifying such practices and in taking, at national or international levels, the measures necessary to ensure that the principles set out in this Declaration are respected.

This is only one of several occasions on which the Declaration makes use of the concept of human dignity. It speaks of recognizing everyone's inherent dignity, of everyone having a 'right to respect for their dignity', of the fact that that dignity 'makes it imperative not to reduce individuals to their genetic characteristics and to respect their uniqueness and diversity', that no one should be subjected to discrimination based on genetic characteristics which is intended or has the effect of 'infringing human dignity', that research should not prevail over respect for human dignity, that the benefits of advances in human biology, genetics and medicine concerning the human genome should be made available to all with due regard for human dignity, that states should take appropriate measures to raise social awareness of fundamental issues relating to the defense of human dignity which may be raised by research in biology, in genetics, in medicine and its applications, that the International Bioethics Committee of UNESCO should identify other practices such as germ-line interventions which could be contrary to human dignity, etc.

In the first part of this presentation I shall outline several competing conceptions of what it is to respect someone's dignity as a human being and then see if it is possible to identify the particular conception of human dignity which is at work in the Declaration. In the second part I shall consider the sense in which the reproductive cloning of human beings can be said to be 'contrary to human dignity'. In the third part I shall consider whether all germ-line interventions ought to be considered contrary to human dignity in this same sense.

Robert B Leflar, University of Arkansas School of Law, USA

Since the 1996 publication of my article "Informed Consent and Patients' Rights in Japan," several significant developments have advanced Japan's recognition of patients' rights in ways singular to Japanese culture. These developments include: 1) the Tokyo High Court's 1998 recognition of a Jehovah's Witness's right to truthful information about the surgical team's intention to transfuse her in an emergency; 2) the Diet's enactment of a law permitting recognition of brain death and subsequent organ transplantation in very limited circumstances; and 3) a report from a Ministry of Health and Welfare study committee advocating legal recognition of patients' right of access to their medical records. This paper evaluates the significance of these developments from a cross-cultural legal perspective, with emphasis on the special characteristics of Japanese society that have encouraged unusual variations in the conceptual and practical growth of patients' rights in Japan.

Wolfgang Goetze-Claren, University of Munich, Germany

The objection of the German Government to sign the Convention draft paper on Biomedicine does reveals the "slippery slope" which the profession enters violating the higher standard adopted for the embryo in this country. The representatives of Germany for the European parliament in Strasbourg therefore, have demanded the following added corrections of the draft:

1. to reconsider withdrawal of nutrients and liquids in hopeless cases. 2. to ban the term of "human-like creature" and other things degrading in language, 3. to exclude growth of tissues and organ harvesting from the fetus, unmistakably, 4. to ban consuming and wasteful research on the embryo, 5. to prohibit the patenting of the human gene which will be anticipated as long as eugenic selection is not outlawed, 6. also, intervention on incompetent patients for the benefit of third persons without advantage to the object or donor for research must be ruled out.

The respect for the single individual is paramount and precedes the basic rights for freedom in research and science. For a universal base of the "Ethics 2000" we cannot propose simple morality of science and progress but we ought to wait patiently until social opinion and judgment eases the old traditional boundaries and sensitivity in view of modern life's rapid adaptation to a renaissance of enlightenment mellowing the taboo zones at the beginning of life and it's end.

Derek Morgan, University of Wales, Cardiff, UK

The idea that I might 'own' my body while yet being prevented from doing some things with it has been an important organizing principle in arguments about, the development of modern medical law. Similarly, much recent academic literature proceeds in part on the basis that because an individual is an 'autonomous' being it is not the proper role of the state to interfere in what is done consensually to that person, certainly if there is no harm to others.

Where is the basis for the arguments that I own my body? What purpose or purposes are or might be served by a recognition that my body is my body?

The thesis of this paper subjects these and related claims to critical examination. It adopts and uses arguments showing both limitations and misunderstandings of Lockean concepts of ownership of property (Hyde) and Kantian notions of autonomy (Kass) to suggest that in a fundamental my body may be mine to use and enjoy but not to 'own.'

If we admit of the notion of body ownership, that is (another) invitation to engage the (further) juridification of social spheres (Teubner), a further twist of the role of law in the 'risk society' (Beck). If, however, we conceive of law's responsibility to defend some myths by which a community chooses to live, that law might act as a community's nomos (Minow, Ryan and Sarat), we may conclude that law might be required to act as a bulwark against the spread of technological rationality (Beck) rather than as at present its alter ego (de Sousa Santos).

Naomi Gale, Ashkelon Regional College, Bar-Ilan University, Israel

What is feminism? Feminism is advocating for equal rights for women in all arenas. But these rights, even it granted, can be exercised on]y in conducive protective environments; thus natural rights for safe, secure and dignified life are prerequisites for the realization of citizen equal rights. This paper highlights the problematic nature and the magnitude of the phenomenon of violence in intimate relationships in Israel, emphasizing the need for human rights for battered women. It argues that this problem is universal and thus societies must deal effectively to rid themselves of it, outlining techniques used to help battered women to achieve their rights and with some suggestions of how to improve the situation. In Israel in 1997 100,000 women have lodged complaints with the police, but most women do not get out of abusive situations because they feel they have nowhere to turn to. The result - every year 15-20 women were killed by their husbands.

It has become fashionable to advocate for human rights for the poor, political prisoners, refugees and terrorists, and recently for abused children. We are shocked when we learn about violence against them, but violence against women was scan as an integral part of life, an intimate problem. The key to the problem is to a large extent the way women are perceived by men and by themselves. In the traditional world, women are viewed as mens' property and thus have limited rights. In the modern world women are viewed as the weaker sex, and thus need the protection of men. In both , women are placed in a subordinate position to men.

In the last few decades, however, there has been growing recognition that battered women is a serious social problem, a notion that is already bringing turmoil and anomic due to conflicts of interests resulting from changing norms, mores. There are two ways to bring change and help battered women to realize their human rights: by societies (governments) and individuals (men and women). (a) On the macro level - by redefining gender relationships, by changing cultural ideologies emphasizing equality as the main theme. This is a long and very gradual task and its success or failure can be felt only after several generations. (b) On the micro level - for change in the immediate future, governments must lake an active pan by legislation - to protect women and make sure these are implemented; by funding programs to rehabilitate the victims as well as the abusive partners so they can, if they choose, continue to live together without violence. There is a growing need to particularly educate battered women to understand their basic human rights for a life free from violence, and be more assertive so they can conduct a dignified and secure life for them and their children. Thus the demand is for active intervention to achieve this goal. Educating all members to take an active part to change their environment, to help change the abusive situation in which battered women live. Thus, there is a need to persuade them that the change will better not only the battered women's situation but will contribute to the betterment of society at large to make it a better place to live in.

Godfrey Tangwa, University of Yaounde, Cameroon

Increasing awareness of the importance of the biodiversity of the whole global biosphere has led to further awareness that the problems which arise in connection with preservation and exploitation of our planet's biodiversity are best tackled from a global perspective. The 'Biodiversity Convention' and the 'Human Genome Project' are some of the concrete attempts at such globalization. But, while these efforts are certainly very good at the intentional level and on paper, there is, at the practical level of implementation, the danger that globalization may simply translate into Westernization, given the Western world's dominance and will to dominate the rest of the globe. How is 'global bioethics' to be possible in a world inhabited by different cultural groups whose material situation, powers, ideas, experiences and attitudes differ rather markedly and who are not, in any case, equally represented in globalization efforts and fora? One index of the pertinence of this question is that talk about biodiversity, biotechnology, biotrade etc. is being increasingly matched by talk about biopiracy, biorade, biocolonialism etc. In this paper I will attempt to explore and develop these and related very general concerns.

Peter Whittaker, National University of Ireland, Ireland

There is, at present a major debate concerning the use of genetically manipulated crop plants. The debate tales place at three levels: 1) Is it ethically acceptable to transfer genes between species? 2) Does the growth of genetically manipulated crops pose a risk to the environment? 3) Are there dangers associated with eating genetically manipulated plants? The first question is clearly an ethical one; the others are scientific questions which, depending on the answers, could have important ethical aspects. The paper will present the contributor's assessment of the considerations involved.

Donald M.Bruce, Society, Religion and Technology Project, Church of Scotland

In Europe, two biotechnology policy decisions have left behind a serious gulf between the public and policy makers - the passing of the EU Directive on biotechnology patenting and the importing of insegregated and unlabelled genetically soya and maize from the USA. The first was a debate conducted over 10 years in which the pressures of industry, political expediency and EC treaties eventually combined to pass legislation which was widely opposed by many ordinary people in Europe, and in the end especially the genetic disease sufferers whose needs the Directive was claimed to be supporting. The Directive leaves unresolved major issues on where (and even if) ethics comes into the development of biotechnological products. In response to such concerns the EC cites the official position of EU Treaties which leave ethical issues to member states. Over genetically modified foods, however, the EC is currently insisting that the commercial agreement to import soya and maize must override the ethical objections of certain member states. Moreover, the current EC labeling legislation addresses only scientifically provable DNA, and so misses the point about what concern of many people's wider anxieties over food modification. In combination these two cases suggest a serious failure in public accountability in the current policies of biotechnology, which the policy makers may live to regret.

Shinichi Shoji & Katsuko Kamiya, University of Tsukuba, Japan

An educational program "Clinical anthrolopology" for humanity and bioethics to undergraduate university students has been carried out. This program was conducted by presentation of a concrete clinical case or scene relating to birth, ageing, illness or death, presentation of typical opinions and necessary information, free discussion in small group, reports of summary of discussion, general discussion, then tutors present their own opinion clearly, describing their own impressions. Student attitudes towards use of advanced medical technology was analysed. Significant differences between medical and non-medical student are found. More medical students are conservative than non-medical students over the use of advanced medical technology. This may be due to the difference in stand point of medical and non-medical students. Medical students always thinks of stand point of not only an user but also an executor of advanced medical technology.

Osamu Kanamori, Japan

Avoiding to repeat some tendencies of pluralization of casuistic comments and of the search for the sophistication of jurisprudential analysis, I will focus upon a more theoretical and principle problem relating to the Bioethics. Particularly, I would like to analyze certain French historical documents and make some comments upon the contemporary works about the philosophy of technology. Doing so, I hope to reconsider or to restate them in the frame of bioethical problems, in order to search some possibilities to open a new kind of approaches for bioethics.

Thijs Visser & Henk Verhoog, Leiden University, Netherlands

In discussions about the ethical aspects of genetically engineering animals it is often said by biotechnologists that genetically modifying animals is permitted because it also occurs in nature. With those who are concerned about the genetic manipulation of animals we can notice that ethical concerns are not only formulated in terms of animal well-being and animal suffering. It is argued for instance that the crossing of species barriers is morally wrong because it is 'unnatural', or damages the 'integrity' of the animals. Intuitively many people that these ale morally relevant concepts.

In our research we focus on the latter kind of argumentation. A key concept in animal ethics is the concept of the intrinsic value/worth of animals. This concept indicates that the value of animals not only depends on their usefulness for human beings (instrumental value). They also have a value or a good of their own, independent of their utility-function. That they have this value can not be proven but it is a basic assumption of any non-anthropocentric approach in animal ethics. One could argue that only wild animals have intrinsic value, because they are fully self-supporting and independent of humans. The moral relevance of naturality would then imply that only 'unspoiled nature', without any human interference would have intrinsic value. This view is rejected by the authors. It is based on a dualism between man and nature (cultural versus natural. the artificial versus the natural).

In the paper it will be argued that we are only allowed to speak about the moral relevance of naturalness when 'nature' is defined as the species-specific character, as the 'essential' characteristics of the animal, allowing us to determine what is the 'good of its own' of a particular animal. Some practical consequences of this conclusion will be outlined.

Bethany Spielman, Southern Illinois University, USA

The widespread adoption of the Uniform Anatomical Gift Act (UAGA) promised legal immunity to professionals who complied with its provisions, virtually ensured that, in the U.S., the details of procurement would not frequently be subjected to the harsh light of litigation. When non heart beating cadaver (NHB) procurement became widespread in the 1990's, however, its legal status was uncertain. The practice did not meet the UAGA requirement for brain death. Thus legal immunity was sacrificed. Additionally, in 1997 the Cleveland Clinic was faced with potential criminal charges for conspiracy to commit murder if its protocol were implemented. Secretary of Health and Human Services Shalala ordered the Institute of Medicine to study the ethics of various organ procurement approaches including NHB, but the resulting report did not face head-on potential conflicts between patients' rights to direct end of life care and families' donation preferences, or what should be done if capable patients wished to terminate life sustaining treatment and donate organs. This paper analyzes three features of the "lack of fit" between NHB and U.S. law and argues that the controversy regarding NHB procurement is far from over because difficult legal issues have not yet been squarely faced: conflict between the UAGA definition of death and definitions used in NHB; between the rights of terminally ill patients and the family-dominated approach of the IOM, and between legal prohibitions on assisted suicide and the capable patient's wish to end life support and become an NHB donor.

Julian Savulescu, Murdoch Institute Rsym Children's Hospital, Australia

This paper will review the current status of fetal tissue transplantation as a medical treatment and the possible contribution human reproductive cloning might make to the enhanced efficacy and efficiency of it. Is it permissible to clone an adult human somatic cell to produce a fetus which will be sacrificed as a source of fetal tissue for transplantation? The paper will examine the moral arguments for and against cloning as they pertain to this particular application of human cloning. It will provide a novel argument in favour of the use of cloning to provide a source of fetal tissue for transplantation based on the right of individuals to determine the fate of their own body parts, including their own cells and tissues. This right extends (under some circumstances) both to the proliferation of cells and to their transmutation into other cell types (the Principle of Tissue Transmutation). This argument is based on two controversial claims which will be defended: (1) a fetus which is the product of the cloning of a person's somatic cell is best described (ontologically) as that person's own tissue up until a certain point in fetal or post-natal development and (ii) that a person has a strong claim that medical technologies be developed and deployed to manipulate that person's own tissues to provide a source of transplantable tissue for treatment of that person's disease. The central claim of this paper is that it is not only permissible to use cloning technologies to create fetuses which will be sacrificed as a source of organs for transplantation, but that it is morally required that we develop and use cloning technologies in this way.

Wolfgang Goetze-Claren, University of Munich, Germany

After ratification of the law on organ-transplantation in November 1997 more than 200 parliamentarians voted against decision-making for explanation by surrogate. Increasing numbers of the 600 law makers rejected the equalization of brain death with the death of man. Despite the great PR-campaign sponsored by the government, organ donation decreases due to the report of the European transplant agency in Leyden (NL) for organ allocation. The altruistic consent of the donor to accept his prolonged dying process-prolatio mortis-docs not represent euthanasia. The patients decision to be treated for dying-dysthanasia-made after full demonstration of his/her path to death covers the constitutional rights. thus, the autonomy of the patient remains the prime rule. does he want to let nature run it's course, or, does he wish to be ready for explanation. the original paper analyses a rationale of future developments for organ substitutes as well as the turn in medical science to demote brain death. then, Sir Eccles' hypothesis on neuron activity in coma effluere will be scrutinized and compared to recently advanced results in neurophysiology of the limbic system and midbrain rest activities during brain death. Should such focal scanning be verified to mediate experiences, then, even so unrecognizable, bioethics cannot ignore the vague neuro-memories outside of our comprehension. We must account for them. certainly, the donor on the operating table will be covered under full anesthesia. It is one mission of IAB4 is to analyze and rule on the irresistible scientific progress and the theory of cognition and last not least to protect the organ giver on his way to death.

Tsuyoshi Awaya, Tokuyama University, Japan

The sale of human organs is generally considered ethically unacceptable. It is prohibited in most countries. Despite this, the whole human body is gradually becoming a commodity. Most kinds of human tissues for transplant, for example, bones, skin, cardiac valves, tendons, blood vessels, etc. have already, in substance, become a commodity. These tissues have price tags in the name of "processing fees." Human cells and genes for research and educational purposes have already become commodities. They are openly sold by catalog and on the Internet, listed in the same way as a rat or a guinea pig. How about organs? They are halfway to becoming commodities. For example, the cornea, which is usually categorized as an organ, has become one in substance. In a market economy, everything on earth has the potential to become a salable commodity; human organs, tissues, cells and genes are no exception. Both the development of technology, especially medical technology, and the progress of the market economy cause the commodification of the human body. °°We are entering a new era in which human body parts are becoming commodities available for distribution. How should we respond to this? It seems that almost the only response available is to calmly recognize this new reality. This means that we need new societal values and morals. From a legal aspect, it is inevitable that current legislation prohibiting organ sales in the world will be reconsidered in the future. It seems that it is necessary to make worldwide uniform regulations to encompass the commodification of the human body and the sale of organs.

T. A. Cavanaugh, University of San Francisco, USA

Conceptual and ethical issues arise from a current U.S. movement to improve care by learning from errors. E.g., do errors differ from adverse events or complications? I argue that errors differ from adverse events insofar as adverse events are known specific identifiable possibilities before the medical intervention while the ways of error are myriad. Moreover, I argue that a physician cannot be said to err if there was no way to avoid the bad effect -- or the only way of avoiding such an outcome would be regarded by all as impractical, say by testing everyone for rare allergies. I argue that error, by definition, concerns outcomes that are practically avoidable. For example, if one discovers that a drug has an interaction that one could not have known of or that one could not have known of without rendering the practice of medicine impractical, then one has not erred insofar as one has not strayed from a path that one could or should have followed.

These conceptual clarifications have ethical implications. For example, it is appropriate for a physician to apologize for a harmful error and to ask the patient's forgiveness insofar as personal inadvertence caused harm. In the case of an unavoidable bad outcome, however, while it would be humane to say "I am sorry", it is mistaken to ask for forgiveness, for one has not gone astray. In both cases it is right to compensate the patient for serious harm while still significantly distinguishing the two cases.

Yutaka Tejima, University of Tsukuba, Japan

Malpractice is one of the important reasons in Japan that medical personnel have to encounter law and the legal framework, as it is in so many countries. As for the number of malpractice suits in Japan, approximately 500 cases have been filed every year recently. In addition, the number of cases is now increasing every year, and the situation surrounding medical personnel is getting worse than before. Various causes have been pointed out already for these increases in Japan, but one of the principal reasons is that many Japanese think the right to receive medical treatment is a matter of course, because a fairly long period has passed since the national medical insurance system was established. In this context, equality in medicine is strongly supported in Japanese society.

However, it is a very recent topic in Japan that people began to allege the rights of patients in the practical aspects of medicine. Therefore, the awareness of rights is very much different from persons to persons, or institutions to institutions. Nevertheless, the rights of patients in Japan began to expand steadily through many cases, consumer protection activities, information disclosures on the aspects of medical affairs in response to recent trends of deregulation, and so on. Patients' rights in Japan are now in the process of drastic change. Malpractice must be seen as a severe infringement of patients' rights, and it is necessary to cope with and adjust to such a serious breach of rights.

This report first describes the legal framework and trends to malpractice in Japan as a premise, then introduces the difficulties and problems that hold under the present system. After examining some foreign systems against medical injuries, I assert that the construction of a new legal system related to medical accidents should be considered seriously in Japan. Some discussion will be added about whether such a new system construction may cause side effects to the present activities of expanding patients' rights in Japan.

Tamayo Okamoto, Hiroshima Prefectural College, Japan

Informed consent has become a well-known concept in the practice of modern medical ethics. It has provided a tremendous impact on the physician-patient relationship even in this country where benevolent paternalism has been the norm for centuries. Although cancer disclosure still remains at the level of about 309%, citizen's actions are increasing to make the medical relationship and information dissemination as democratic as possible.

However, it seems that the practice of informed consent is not very well established when the team approach is used. In this case not only physicians but also professionals of health-related disciplines, such as nurses, therapists, medical technicians and social workers participate. Who provides the patient with the team's decisions is not clear. Information sharing among the team members is not completely open.

I would like to point out some on-going issues and problems surrounding the team approach. 1) The relationship of an attending physician with other team members. Is the physician placed at the center or the hub of the circle surrounded by allied-health professionals? Then where is the patient for whose very care the circle is formed? 2) If the patient is at the center with the physician being one of the circling party, then what is an appropriate relationship between the physician and other health professionals? 3) What is the proper practice of informed consent in these relationships?

Tanida Noritoshi, Hyogo College of Medicine, Japan

Whether truth disclosure would harm patients was studied using the Functional Living Index-Cancer (FLIC questionnaire in cancer patients, Methods: Truth-disclosed patients with cancer (TD group) and truth-concealed patients (TC group) were asked to answer 22 FLIC questions. Results were compared with those with irritable bowel syndrome (IBS group) and other gastrointestinal diseases (OGD group). Results: Average FLIC scores were the same between the TD and IBS group and between the TC and OGD group. Statistically significant difference was found in 4 FLIC items: "Discouraged about life", "Uncomfortable today" "'Pain disrupts activity" and "How much nausea". The IBS group showed the worst FLIC scores among the former 3 items. The TD group was more likely to think that their daily activities were disrupted via pain or discomfort than the TC group. On the other hand, incurability of cancer worsened 10 FLIC items, among which incurability was independently associated with the deterioration of FLIC in "Family disruption and Cancer-related pain". The incurability of cancer, and lack of truth disclosure, negatively affects the quality of life of patients. Thus, truth disclosure could be performed without fear of being cruel or harming patients.

James Dwyer, New York University, USA

Do doctors and societies have an ethical obligation to provide health care for illegal immigrants? Do they have an ethical obligation to provide health care for medical travelers - people who travel to another country for the sole purpose of getting medical treatment? In my paper I try to discuss these questions in a critical way.

To begin, I give examples from the United States, France, and Japan; and I try to place these examples in the context of recent economic and political developments. I then consider the arguments that have been advanced in favor of restricting access to non emergent medical care for illegal immigrants. I criticize the discourse and the framework of these arguments. But I also criticize those arguments, in favor of providing care, that are based on appeals to physicians' ethics and human rights. In particular, I argue that the discourse of human rights obscures important issues and conflates cases that should be distinguished.

I try to show why the issue of medical care for illegal immigrants should be considered in terms of the role of public institutions in community life. I argue that illegal immigrants are moral members of the communities in which they reside and should be in included in the scope of public institutions. But I suggest that the issue of providing care for medical travelers is different and requires a different discourse and framework. 

Jozef Glasa, J. Bielik, J. Dacok, M. Mojzesova, J. Porubsky, A. Stefko - Institute Medical Ethics, Slovakia

Bioethics in Slovakia was born after the so-called Velvet Revolution of November 1989. The fall of a totalitarian regime and the ideological despotism of 'Marxism-Leninism' opened the door for a new freedom and exciting possibilities of progress and development. The need of a profound reform of the economical, social, cultural, and scientific life of the country was felt as an indispensable prerequisite of a prosperous rise of the society. In the field of medicine and health care this transition was marked by an unprecedented interest in the old and novel ethical problems, brought in by the development of medicine itself, and by the necessary reforms of the national health care system (HCS).

Interestingly, the development of bioethics in SR, since the very beginning, was marked by some connection and input to the process of HCS reform (especially via the Central Ethics Committee established at the Ministry of Health SR in 1990). This included also an ethical review of proposals of the new health legislation. The connection became less prominent after the year 1993.

Different traditions of the medical ethical thought were present in the SR 'bioethics field', contributing to its marked pluralism and (sometimes) to the heat of certain public health care ethics debates. The biggest group of 'bioethicists' consisted of the intellectuals engaged in the former 'underground' (among them the members of various Christian denominations, 'humanists', 'democrats', 'liberals', 'conservatives', 'neo-conservatives', etc.). The other group were the university teachers in humanities - former Marxists-Leninists, trying to transform themselves into 'democrats', 'liberals', or 'Christians'. The proponents of some 'ultra-modern' or 'ultra-conservative' views and ideologies, mostly coming or being considerably backed from abroad, completed the scene. It was further enriched and cultivated by the intellectual input of the 'western' philosophical thought, mutual scientific and information exchange, increasing scientific and educational collaboration, and, with some delay, gradual developments in the systemic legal harmonization (towards the legislation of the European Union). Soon on, the original input of the research and study efforts in the field, as well as the work of national research institutions and various professional and scientific organizations became visible.

It might be concluded, that bioethics in Slovakia - developing gradually its educational and research facilities (e.g. Institute of Medical Ethics and Bioethics in Bratislava); own and shared communication channels (e.g. journal Medical Ethics & Bioethics; growing inputs to the professional and general media information space); and its 'working institutions' (i.e. ethics committees) - has established a specific, non-negligible position within the contemporary transformation processes of medicine and the national health care system.

Frank J. Leavitt, Be Gurion University of the Negev, Israel

Are decisions to lower the lower the age of women for whom to perform pre-natal testing for genetic syndromes ethical decisions or economic decisions? Are the considerations behind policies on living wills and DNR ethical or economic? Can medicine be ethical if one patient receives better treatment than the other simply because the former has more money to pay? This paper will examine current trends towards privatization in health care, and the philosophy of free-market medicine, asking whether economic considerations in clinical decision making are compatible with ethics.

Li Jining, Guengxi College for Health Administrative Cadres, China

The unfair allocation and low effectiveness of health resources are global problems. The main reasons for these are as follows: 1) Medical treatment is prescribed as a means of making money, 2) The existing medical management mode is deficient 3) The aging of population 4) The change of disease patterns and 5) The abuse of high technology. the following steps must be taken so that the phenomenon of the unfair allocation and extravagance of health resources could b abolished: 1) Changing the traditional sense of health care, 2) The health policies shall be based on fairness and high effectiveness, 3) The unreasonable health security system shall be reformed and 4) The self-health-care system shall be further improved.

R.N. Sharma, National Chemical Laboratory, India

Idealistic and affluent sociologists and politicians, as also sometimes errant economists, well meaning or otherwise, often praise the virtues of poverty. The phenomenon recurs continuously in developing societies and workers' paradises, and seems to have some kind of spiritual connotation and blessing of various religions, cutting across ethnic and geographical barriers. Culturally as well as biologically, however, merits of fortitude in bearing vicissitudes of deprivation seem few. Acquiescence in inescapable, forced poverty may be condonable. Voluntary hardships, except for individual spiritual or medical uplift, cannot be justified, most certainly not on ideological or (pseudo) intellectual grounds. Ecstasy, and Ethics ascribed to poverty, are myths emerging from misperceptions by ill informed, albeit perhaps well meaning spiritual or sociological workers. The best commentators, and judges of poverty are the poverty stricken themselves, not unconcerned, or at least not directly affected, aloof observers with romantic notions of fortitude.

Shinryo N. Shinagawa, Hirosaki University, Japan

After a short introduction of population policy in Japan, five topics will be presented focusing on bioethical issues. They are: 1) Legalization of induced abortion and its consequences in Japan. 2) Human rights, mother's rights and embryo rights in Japan. 3) Reproductive medicine and ART (assisted reproductive technologies) in Japan with special attention to IVF (in vitro fertilization) and AID (artificial insemination by donor's semen) in Japan. 4) Contraception in Japan with particular comments to Dr. Ogino and oral contraceptive pills. 5) Characteristics in decision-makings, especially relating to health issues, among Japanese people: phenomenally Euro-American but essentially and/or genetically family-centered and communal.

Alison Brookes, Deakin University, Australia

Drawing on qualitative research projects exploring women's experience of prenatal ultrasound and prenatal genetic screening (PGS), the paper explores the way that ultrasound as an obstetric rite of passage obscures women's lack of information regarding the test. The research compares the popular image of ultrasound examinations with the medical and ethical questions raised by both the test and current practice procedures. In the paper I will compare the changing historical role of prenatal ultrasound to its current routine obstetric practice with the implementation of other PGS testing, and draw out the implications of this for participants in the programs.

In interviews with women undertaking prenatal ultrasound, amniocentesis, chorionic villi sampling and maternal serum alpha-fetoprotein testing, the need for information which is inclusive of both medical and ethical issues became apparent. The way that women make choices about testing is severely restricted by a lack of easily accessible information. For testing to continue to be justified on the basis of increasing women's choices, women's experiences and expectations of testing must be more adequately accommodated and lack of access to information remedied.

The research projects found women's relationship to prenatal ultrasound and other PGS testing far more multi-faceted than that commonly presented in either medical or bioethical literature. Exclusion of women from the medical and bioethical debates surrounding prenatal ultrasound and PGS impacts on the ethical validity of the programs and restricts women's autonomous reproductive decision-making.

Sjef Gevers, University of Amsterdam, Netherlands

Termination of pregnancy is a matter of controversy in many, if not all countries. In most of them, legislation in this field has only been adopted after extensive public debate and political struggle between 'pro life' and 'pro choice' positions. The delicate compromise laid down in most abortion laws may be at risk due to the increasing possibilities to detect untreatable fetal abnormalities, in particular when such conditions are detected (for instance by means of ultrasound) in a later stage of pregnancy. While under varying restrictions most laws leave at least some room for termination in the first, and sometimes also the second trimester of pregnancy, third trimester abortion -when the fetus is considered viable - is usually prohibited. Nevertheless, the detection of structural, incurable abnormalities after 24 weeks may be a reason for some women to request termination of their pregnancy. The knowledge of carrying a baby which will fail to survive after birth (or which will survive for a shorter or longer period with serious and lasting handicaps) can be an unbearable burden. Should these women be forced to continue their pregnancy and to carry their baby to term? Or should doctors be allowed to act upon the woman's request in such a situation? This paper discusses the recent advice of a Dutch government appointed commission. In its report, the commission deals with the ethical and legal aspects of the issue; it proposes that the existing criminal prohibition of third trimester abortion be kept in place, but elaborates rules of careful medical practice which would allow for such termination in a limited number of cases without the threat of criminal prosecution.

Lourdesita Sobrevega-Chan & Rosena D. Sanchez, Ateneo-Social Research Office, The Philippines - Ethical Issues that Emerged in the Study on Abortion and Reproductive Health Among Filipino Women

Ken Daniels, University of Canterbury, New Zealand

Third party reproduction is dependent on gametes (semen or oocytes) being available. Almost all clinics providing services report difficulty in recruiting sufficient numbers of men and women who are prepared to provide their gametes for other, usually infertile, couples. Professionals in many clinics frequently argue that it is essential to provide financial recompense as an incentive to recruitment and in a number of countries this has been the practice for some years. Recently the British and Canadian Governments have moved to ban the system of payment for gametes. This has lead to heated debate between the policy makers and the practitioners.

Practitioners usually argue for a "market" or pragmatic approach to issues of supply and demand and if the demand outstrips the supply then you encourage the supply by offering more money as a reward. Policy makers in Britain and Canada are challenging this position. In New Zealand most clinics have been recruiting semen donors without payment for some years. This paper will explore the reasoning being used by policy makers and seek to clarify the extent to which ethical considerations are playing a part in these deliberations.

Minakshi and Jayapaul Azariah, University of Madras, India

A questionnaire was prepared with 30 statements/issue based questions and opinions covering the following areas of interest: (i) general (ii) Human (Natural) resources (iii) Commercial (iv) Reproduction and infertility (v) Medical research for (a) individual organs and genes (b) for individual organ (c) cloning and diseases and (d) for organ transplantation (6) surrogacy (7) Personal and (8) ethical.

The Indian community, and the Tamilian community in particular, considers that "Birth of a Woman" is the natural and preferable method of human reproduction. Cloning is considered to be an artificial mode of reproduction. The paper distinguishes the meaning of various terms like " natural ", "artificial" ," normal" and " preferable", and discusses the validity of describing cloning as "asexual". In accordance with the paradigm shift in cloning ethics, a new generic term namely "non-sexually sexual" has been introduced, taking into consideration the involvement of both differentiated somatic cell and gamete.

The educated respondents (ER) were aware of cloning techniques and displayed consistency of opinion in regarding a cloned human being as an artificial human being. They also opted to consider surrogate motherhood as not normal and also as procreating a human being by cloning. However, it is interesting to note that the group is willing to consider a person as normal if he/she is born of a surrogate mother. The survey found that this notion has gone deep in the minds of the ER. Such an impression may have originated from the universal use of the term "artificial insemination" with regards to IVF technique. Paradoxical situations have arisen in their minds with regard to social issues such as family ties between a clone and his family and marriage of cloned persons. Before bioethics education 74%. of the ER was opposed (32% disagree and 43%, strongly disagree) to marrying a cloned person. Survey revealed that education is a necessary tool to alter, if possible, such world views.

The survey also revealed that education is needed to bring a change of opinion with regard to the fact that fetal/womb conditions and external environment and culture of a given time will play an important role in bringing a different personality in a cloned person. ER are ignorant or unable to decide 13 of the 30 questions (43%). In these areas it is suggested that strong emphasis in curriculum must be given. Although, the ER agreed for medical cloning and not for reproductive purposes, they were inclined to be commercial if cloning is allowed to be performed. Religious considerations were also dominant in guiding their responses. The paper concludes with a strong plea for developing a global bioethics education to address scientific cultural needs and growing global social complexities. The paper also compares the responses of a similar survey carried out among the general public and students.

David M. Kaplan, University of Toronto, Canada

Canada and the United States of America adopted different policies of intervention vis-‡-vis human embryo research. Why? One explanation may rest in an examination of the history and the values expressed in the respective landmark abortion decisions. A comparative analysis of the abortion law jurisprudence has accounted for these differences in American and Canadian policy.

Before explicating the benefits of conducting research on embryos and the concerns that such research elicits, the moral status of the pre-embryo and its biological development were outlined. The relevant cases and policy documents were analyzed by wedding a neo-institutional approach to policy analysis with DworkinÇs theory of judicial review. This framework provided sufficient leverage for supporting this exploratory investigation. Both the American and Canadian landmark abortion decisions, R. v. Morgentaler (1988) 1 S.C.R. 30 and Roe v. Wade (1973) 410 U.S. 113, underwent substantive examination. Using ideological discourse analysis, the values to which the respective judiciaries appealed were identified. The relevant, subsequent case law collected through legal databases was used to fine-tuneÇ the values identified in R. v. Morgentaler and Roe v. Wade. While a right to abortion exists in United States, the Canadian judiciary has not identified such a right. Moreover, while protection of (potential) human lifeÇ was found to be a highly institutionalized value in both countries, protection of reproductive healthÇ was not as highly institutionalized. By institutionalizing these different valences, the respective legal systems differentially constrained the North American policy makers who examined how the state should regulate human embryo research.