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For all its apparent debate bioethical discourse is in fact very narrow. The discussion that occurs is typically within limited parameters, rarely fundamental. Nor does it accommodate divergent perspectives with ease. The reason lies in its ideology and the political and economic perspectives that ideology promotes. Here the ideology of bioethics' fundamental axioms is critiqued as arbitrary and exclusive rather than necessary and inclusive. The result unpacks the ideological and political underpinnings of bioethical thinking and suggests new avenues for a broader debate over fundamentals, and a different approach to bioethical debate.

For the philosophy of medicine, there are two things of interest about the stoic account of moral norms, quite apart from whether the rest of stoic ethical theory is compelling. One is the stoic version of naturalism: its account of practical reasoning, its solution to the is/ought problem, and its contention that norms for creating, sustaining, or restoring human health are tantamount to moral norms. The other is the stoic account of human agency: its description of the intimate connections between human health, rational agency, and moral norms. There is practical guidance to be gained from exploring those connections, whether or not one is ready to follow stoic moral theory all the way to its austere end.

One of the most important developments in international medicine over the past two decades has been a turn to the market as a way of coping with rising costs and responding to calls for more freedom from government control. A full moral evaluation of the relationship of medicine and the market requires asking a wide range of questions bearing on the meaning and impact of market strategies on the economics of health care and on the clinical and public health outcomes of those strategies. A number of the leading questions are presented and some provisional answers offered.

News media accounts of issues in bioethics gain significance to the extent that the media influence public policy and inform personal decision making. The increasingly frequent appearance of bioethics in the news thus imposes responsibilities on journalists and their sources. These responsibilities are identified and discussed, as is (i) the concept of "news-worthiness" as applied to bioethics, (ii) the variable quality of bioethics reportage and (iii) journalists' reliance on ethicists to pass judgment. Because of the potential social and other benefits of high quality reporting on ethical issues, it is argued that journalists and their bioethics sources should explore and accommodate more productive relationships. An optimal journalism-ethics relationship will be one characterized by "para-ethics," in which journalistic constraints are noted but also in which issues and arguments are presented without oversimplification and credible disagreement is given appropriate attention.

The practice of critical care medicine has long been a difficult task for most critical care physicians in the densely populated city of Hong Kong, where we face limited resources and a limited number of intensive care beds. Our triage decisions are largely based on the potential of functional reversibility of the patients. Provision of graded care beds may help to relieve some of the demands on the intensive care beds. Decisions to forego futile medical treatment are frequently physician-guided family-based decisions, which is quite contrary to the Western focus on patient autonomy. However, as people acquire knowledge about health care and they become more aware of individual rights, our critical care doctors will be able to narrow the gaps between the different concepts of medical ethics among our professionals as well as in our society. An open and caring attitude from our intensivists will be important in minimizing the cross-cultural conflict on the complex issue of medical futility.

Practical medical decisions are closely integrated with ethical and religious beliefs in the Philippines. This is shown in a survey of Filipino physicians' attitudes towards severely compromised neonates. This is also the reason why the ethical analysis of critical care practices must be situated within the context of local culture. Kagandahang loob and kusang loob are indigenous Filipino ethical concepts that provide a framework for the analysis of several critical care practices. The practice of taking-from-the-rich-to-give-to-the-poor in public hospitals is not compatible with these concepts. The legislated definition of death and other aspects of the Philippine Law on Organ Transplants also fail to be compatible with these concepts. Many ethical issues that arise in a critical care setting have their roots outside the seemingly isolated clinical setting. Critical care need not apply only to individuals in a serious clinical condition. Vulnerable populations require critical attention because potent threats to their lives exist in the water that they drink and the air that they breathe. We cannot ignore these threats even as we move inevitably towards a technologically dependent, highly commercialized approach to health management.

This paper deals with a problem which has received a great deal of attention in the ethical literature, but about which very little is known empirically: the selection of recipients for organs in transplant medicine. Based on a larger study, it is shown how this problem is practically resolved in one European country, Germany. It is demonstrated that most of the criteria used to determine recipients are non-medical in nature, even though they generally tend to be rationalized in medical terms. Moreover, the choice of criteria depends as much on prognostic considerations as on personal indiosyncrasies and values held by individual physicians who are in charge at the various programs. Several examples of the extremely diverse policies in which this results are presented.

Health Savings Accounts have been marginalized in the West. In Singapore, however, they are foundational to the financing of health care. In this brief essay, I shall begin to sketch a justification for Health Savings Accounts. The family has always been thought of as a mere prolegomena to the polis and to be primarily about securing the goods of material life: food, shelter, intimacy. I shall first explore the recent scientific literature on the communal nature of human thriving and follow it with a phenomenological account of human dependency. I shall claim that in securing the material means to sustain life, the family is also involved in the creation of the life-world of the child. That means that the bare necessities of life met in families are not merely about sustaining bodily life but are also part of the meaning-making aspects of life. The family then should have recourse to the material means of life-and-death decisions, because it is in these life-and-death decisions that the families' life-world of values is to be deployed.

The structure of our ethical experience depends, crucially, on a fundamental distinction between what we are responsible for doing or deciding and what is given to us. As such, the boundary between chance and choice is the spine of our conventional morality, and any serious shift in that boundary is thoroughly dislocating. Against this background, I analyze the way in which techniques of prenatal genetic diagnosis (PGD) pose such a fundamental challenge to our conventional ideas of justice and moral responsibility. After a short description of the situation, I first examine the influential luck egalitarian theory of justice, which is based on the distinction between choice and luck or, more specifically, between option luck and brute luck, and the way in which it would approach PGD (section II), followed by an analysis of the conceptual incoherencies (in section III) and moral problems (in section IV) that come with such an approach. Put shortly, the case of PGD shows that the luck egalitarian approach fails to express equal respect for the individual choices of people. The paradox of the matter is that by overemphasizing the fact of choice as such, without regard for the social framework in which they are being made, or for the fundamental and existential nature of particular choices-like choosing to have children and not to undergo PGD or not to abort a handicapped fetus-such choices actually become impossible.

Based on a general thesis regarding the proper resolution of interpersonal conflicts, this paper suggests a normative framework for the distribution of scarce health resources. The proposed thesis includes two basic ideas. First, individual well-being is the fundamental value. Second, interpersonal conflicts affecting well-being should be resolved in light of several conceptions of fairness, reflecting the independent value of persons and the moral significance of responsibility of individuals for the existence of interpersonal conflicts. These ideas are elaborated in several principles that are applied with respect to the distribution of scarce health resources.

The question of the moral status of human nature is today being posed above all under the influence of medical and biotechnological aspects. These facilitate not only an increasing number of, but also increasingly far-reaching interventions and manipulations in humans, so that the perspective of a gradual "technologization" of his physical constitution can no longer be regarded as merely utopian. Some authors are convinced that this disturbing development can only be halted when an inherent value is (once again) ascribed to human nature. After a short description of this situation (I), the following paper first examines the difficulties that arise as regards an adequately precise descriptive definition of human nature (II) and, in a second step, the problems posed by the necessity to define the normative status of human nature (III). It hereby comes to the conclusion that a precise definition of "human nature" is not possible for fundamental reasons, and that only a weak normativity can be warranted.

A basic question of medical ethics is whether the norms governing medical practice should be understood as the application of principles and rules of 'the common morality' to medicine or whether some of these norms are 'internal' or 'proper' to medicine. In this article we describe and defend an evolutionary perspective on 'the internal morality of medicine' that is defined in terms of the goals of clinical medicine and a set of duties that constrain medical practice in pursuit of these goals. This perspective is developed by means of a critical examination of the 'essentialist' conception of the internal morality of medicine advocated by Edmund Pellegrino and the critique of internal morality approaches by Robert Veatch and Tom Beauchamp.

L'A. analyse la nature ethique de la bioethique, les conflits entre les methodologies utilisees par les bioethicistes pour pousuivre leurs investigations, ainsi que les confusions entre les differentes theories de justification

The notion that it is useful to specify norms progressively in order to resolve doubts about what to do, which I developed initially in a 1990 article, has been only partly assimilated by the bioethics literature. The thought is not just that it is helpful to work with relatively specific norms. It is more than that: specification can replace deductive subsumption and balancing. Here I argue against two versions of reliance on balancing that are prominent in recent bioethical discussions. Without meaning to address the substance or the overall merits of either view I criticize, I attack Gert, Culver and Clouser's implicit reliance on some overall dimension of balancing as a basis of resolving conflicts among norms and Beauchamp and Childress's residual acceptance of 'justified balancing'. The former authors' description of resolving conflicts depends upon a type of value commensurability that (as they otherwise seem to admit) does not obtain, while the latter authors' role for justified balancing would be better served by continued specification.

Commodification of health care is a central tenet of managed care as it functions in the United States. As a result, price, cost, quality, availability, and distribution of health care are increasingly left to the workings of the competitive marketplace. This essay examines the conceptual, ethical, and practical implications of commodification, particularly as it affects the healing relationship between health professionals and their patients. It concludes that health care is not a commodity, that treating it as such is deleterious to the ethics of patient care, and that health is a human good that a good society has an obligation to protect from the market ethos.

This article comments on the treatment of critical-care ethics in four preceding articles about critical-care medicine and its ethical challenges in mainland China, Hong Kong, Japan, and the Philippines. These articles show how cultural values can be in both synchrony and conflict in generating these ethical challenges and in the constraints that they place on the response of critical-care ethics to them. To prevent ethical conflict in critical care the author proposes a two-step approach to the ethical justification of critical-care management: (1) the decision to resuscitate and initiate critical-care management, which is based on the obligation to prevent imminent mortality without permanent loss of consciousness; and (2) the decision to continue critical-care management, which is based on the obligation both to prevent imminent death without permanent loss of consciousness and to avoid unnecessary, significant iatrogenic costs to the patient and psychosocial costs to the family when the reduction of mortality risk is marginal. Physicians and hospitals should restore the critical-care physician's authority and power -- against prevailing cultural values, if necessary -- to control when critical-care intervention is offered, when it is recommended to continue, and when it is recommended to be discontinued and the patient allowed to die.

In a recent critique of informed consent, Robert Veatch argues that the practice is in principle unable to attain the goals for which it was developed. We argue that Veatch's focus on the theoretical impossibility of determining patients' best interests is misapplied to the practical discipline of medicine, and that he wrongly assumes that the patient-physician communication fails to provide the knowledge needed to insure the patient's best interests. We further argue that Veatch's suggested alternative, value-based patient-professional pairing, is, on his own terms, impossible to implement. Finally, we reexamine the philosophical and practical justifications for informed consent and conclude that the practice should be retained.

The growing phenomenon of teenage pregnancy introduces the problem of who should serve as surrogate decision makers for the children of adolescent parents. The justifications which sanction society's grant of presumptive decision making authority for adult parents, and the rationales and empirical evidence supporting a central role for adolescents who wish to make medical decisions regarding their own care, together suggest that older adolescent parents should be viewed as the presumptive decision makers for their children. There is, however, empirical evidence that adolescent parents lack the cognitive abilities of childless adolescents of the same age and that many exhibit lower levels of emotional stability, sensitivity to infant needs, and social adjustment. These deficiencies, where present, undermine the very justifications for allowing adolescents to make medical decisions for their children. These findings are strong enough to justify a greater level of watchfulness over the competency and decisions of those adolescents who wish to make decisions for their children, but not definitive enough to conclude that, as a group, they be presumed incapable of making those decisions.

The best-interests standard is a widely used ethical, legal, and social basis for policy and decision-making involving children and other incompetent persons. It is under attack, however, as self-defeating, individualistic, unknowable, vague, dangerous, and open to abuse. The author defends this standard by identifying its employment, first, as a threshold for intervention and judgment (as in child abuse and neglect rulings), second, as an ideal to establish policies or prima facie duties, and, third, as a standard of reasonableness. Criticisms of the best-interests standard are reconsidered after clarifying these different meanings.

One of the main concerns in defining health is determining its status in relation to value. The main proposals in this direction generally assume a strict dichotomy between descriptive and evaluative dimensions. This essay argues that such a dichotomy leads to a theoretical inconsistency, which becomes evident once a definition of health is practically operative. A new conceptual framework uniting these two moments is proposed as an alternative, capable of preserving the fundamental insights of both descriptive and evaluative accounts of health, and of avoiding the theoretical inconsistencies on the level of practical application.

The religious justification for male circumcision proffered by Jewish and Islamic parents is frequently overlooked in current secular (medical/hygienic) discussions that (1) challenge the moral justification of this ancient practice, and (2) question the decisions of today's parents who are committed, on the basis of their religious beliefs, to continue this practice. This paper reviews critically these conflicting values and arguments and calls for compromise in the face of potential state intervention to coerce parents to abandon this practice.

This essay comments on the articles by Loretta M. Kopelman and Anita Silvers. It extends their analyses and concludes that consistency and the total absence of conflict may be unavailable when one interprets and applies the Americans with Disabilities Act.

Variants on two approaches to the concept of health have dominated the philosophy of medicine, here referred to as 'reductionist' and 'relativist'. These two approaches share the basic assumption that the concept of health cannot be both based on an empirical biological foundation and be evaluative, and thus adopt either the view that it is 'objective' or evaluative. It is here argued that there are a subset of value concepts that are formed in recognition of certain fundamental facts about living organisms, among which is the concept of health. These are not yet moral concepts, but they are 'normative' or 'evaluative'. The view is defended that health, so understood, is a fundamental concept in the process of medical diagnosis and treatment.

This paper illustrates a role that bioethics should play in developing and criticizing protocols for breast cancer genetic screening. It demonstrates how a critical bioethics, using approaches and reflecting concerns of contemporary philosophy of science and science studies, may critically interrogate the normative and conceptual schemes within which ethical considerations about such screening protocols are framed. By exploring various factors that influence the development of such protocols, including politics, cultural norms, and conceptions of disease, this paper and the critical bioethics' approach it endorses illuminate and critically assess some of the competing worldviews informing protocol development. One of the frequently neglected worldviews in traditional bioethics' treatment of protocols concerning breast care is constituted by women's own views of their breasts and breast cancer, both within the technologically-oriented social practice of American medicine and in light of the social construction of their breasted experience in American society. This paper attempts to redress and critically assess this neglect on the part of traditional bioethics. Finally, in contrast to traditional bioethics, critical bioethics critically interrogates its own normative and conceptual commitments. In this final capacity, a critical bioethics' approach makes a valuable contribution to the evolution of bioethics.

A series of cases have crystallized disputes about when medical treatments are useful or futile, and consequently about the doctor-patient relationship, resource allocation, communication, empathy, relief of suffering, autonomy, undertreatment, overtreatment, paternalism and palliative care. It is helpful to understand that utility and futility are complimentary concepts and that judgments about whether treatments are useful or futile in the contested cases have common features. They are: (1) grounded in medical science, (2) value laden, (3) at or near the threshold of utility, and (4) burdensome. No schema for line-drawing escapes borderline cases and we should focus upon justification of the empirical, ethical and evaluative components underlying these judgments, rather than make an arbitrary decision about whether doctors, patients or societal consensus should be the final arbiter.

This paper evaluates the arguments against physician assisted suicide which contend that it violates the integrity of medicine and the physician-patient relation; i.e. that it contradicts the goal of seeking health and healing, violates an absolute prohibition against killing, and undermines the patient's trust in the physician. These arguments against physician assisted suicide (1) misuse notions of teleology and teleological explanation; (2) rely on inappropriate notions of "ideal medicine", for which death is a defeat; (3) turn on a highly selective reading for the Hippocratic tradition; and (4) are unacceptably paternalistic.

In an article titled, "Who Shall Live When Not All Can?", James Childress proposes a system for allocating scarce lifesaving medical resources based on random selection procedures. Childress writes of random selection procedures, [They] "cannot be dismissed as a 'non-rational' and 'non-human' ...without an inquiry into the reasons, including human values which might justify it." My thesis is that once we concentrate on determining the rationality of random selection procedures, we will see that Childress's claim that we cannot dismiss such procedures as 'non-rational' is open to question. My claim will be that while both random selection and social worth procedures are rationally defensible systems, random selection procedures easily lead to specific choices that are objectively irrational, apart from the limited perspective of the random selection process itself.

The Catholic Church in the United States provides extensive health care service through its more than 600 health facilities. The Church, on the basis of its moral teaching, sees health care as a basic human right and supports universal coverage. At the same time, the Church considers abortion morally wrong and opposes coverage of abortion as a health service in a national health plan. Mandated coverage of abortion would violate the moral commitments of Catholic hospitals and the consciences of Catholics who would be required to financially support provision of abortion services.

Centralized, democratic rules are often asserted as a superior basis for rationing than individualized physician discretion. This article counters this prevailing wisdom by exploring the deficiencies of rule-based rationing. Rules are too imprecise to accurately reflect all the nuances of physical and mental impairment and the complexity of medical science, particularly considering the widely varying personal values that different patients attach to medical risk and benefit. Rule-based rationing also suffers from the biasing effects of interest group pressure on political processes and the tendency to absolve physicians from any moral responsibility for the rationing decisions they implement. Internalizing cost constraints is a more socially and professionally acceptable means of rationing and, in any event, it is inevitable since even a preponderance of rule-based rationing will leave considerable areas of discretion for physician judgment in the implementation and interpretation of the rules. As a consequence, despite the flaws of bedside rationing, it is foolhardy to dispense with it entirely in favor of an exclusively rule-based system.

The work of H. Tristram Engelhardt provides an important set of reflections for bioethics in a secular context. Taking Engelhardt's work as its point of departure this article explores the challenges that Jewish ethicists face in contributing to bioethics in a secular context. The article explores how the Jewish tradition can address issues in bioethics in ways that are true to its tradition and at the same time accessible and relevant to "moral strangers" in a secular society.

La bioethique en tant que discipline a part entiere decoule des aspirations de la philosophie morale moderne. Faire une synthese d'un grand nombre de points de vue, synthese qui ferait l'unanimite

There is a growing interest in comparison of international health care data with the hope that such studies will enable individual systems to learn from other systems. Such comparisons, however, presuppose that there exist common criteria for evaluating health care systems. The main thesis of this paper is that these comparative studies are misleading because they employ inappropriate operationalizations of these criteria because the operationalizations are based upon mistaken global conceptualizations of the criteria in question. The essay provides a methodological critique of what has been done and sets a new agenda for future research.

Defenders of patient autonomy have successfully supported the legal adoption of advance directives. More recently, some defenders of patient autonomy have also supported the legalization of voluntary active euthanasia. This paper explores the wisdom of combining both practices. If euthanasia were to become legal, should it be permitted by advance directives? The paper juxtaposes the most significant doubts about advance directives, with the most significant doubts about euthanasia. It argues that the doubts together raise more concern about the combined practices than about either euthanasia or advance directives separately. Not all cases of voluntary euthanasia by advance directive are equally problematic, however. Advance directives can help in the defense of euthanasia for patients who make the request in advance and reaffirm it under circumstances of severe suffering.

Practices such as physician assisted suicide, even if legal, engender a range of moral conflicts to which many are oblivious. A recent proposal for physician assisted suicide provides an example by calling upon physicians opposed to suicide to refer patients to other, more sympathetic, physicians. However, the proposal does not address the moral concerns of those physicians for whom such referral would be morally objectionable.

The U.S. has a wide range of options in choosing a health care system. Rational choice of a system depends on analysis and prioritization of the basic moral goals of equitable access to all citizens, the just sharing of financial costs between well and ill, respect for the values and choices of subscribers and patients, and efficiency in the delivery of costworthy care. These moral goals themselves, however, tell us little about what health care system the United States should have. Equitable access does not demand a level and scope of care for the poor equal to that rationally chosen by the middle class, and there are ways within mixed systems, though not easy ways, to achieve a fair distribution of costs between well and ill. Despite pluralistic systems' apparent advantage in allowing subscribers to choose their own forms of rationing, problems in translating serious long-term subscriber choices into actual medical practice may be greater in pluralistic than in unitary systems. Final choice of a system hinges primarily on peculiar historical facts about U.S. political culture, not on moral principle.

For years analysts have recognized the error of assuming that experts in medical science are also experts in deciding the clinically correct course for patients. This paper extends the analysis of the use of the consensus of experts to their use in public policy groups such as NIH Consensus Development panels. After arguing that technical experts cannot be expected to be expert on public policy decisions, the author extends the criticism to the use of the consensus of experts in estimating facts to provide a basis for policy decisions. It is argued that to the extent that (a) experts' views regarding a body of facts can be expected to correlate with their values relevant to those facts; and (b) the values of experts differ from the values of lay people, even the estimates of the facts given by the consensus of expert panels can be expected to differ from the estimates lay people would have given had they had the relevant scientific expertise.

The essays in this issue of the Journal highlight the types of insights that nursing ethics brings to health care ethics, in general, and attempt to address questions about the adequacy of the conceptual and theoretical foundations of bioethics for a practice discipline like nursing. The essays are written by nurses and non-nurses and bring a surprising balance to the discussion of important issues in nursing ethics from several perspectives. The essays do not represent the full scope of philosophical thought and normative judgements in nursing ethics at the present time, but they do provide a view of nursing ethics through the lens of nursing ethics research, past and present. [Introductions follow to essays by Joy H. Penticuff, Joan Liaschenko and Anne J. Davis, Nancy S. Jecker and Donnie J. Self, Betty J. Winslow and Gerald R. Winslow, Robert J. Connelly, Patricia A. Roth and Janet K. Harrison, and Kevin Wildes].

Nurses are often caught in the middle of what appear to be intractable moral conflicts. For such times, the function and limits of moral compromise need to be explored. Compromise is compatible with moral integrity if a number of conditions are met. Among these are the sharing of a moral language, mutual respect on the part of those who differ, acknowledgement of factual and moral complexities, and recognition of limits to compromise. Nurses are in a position uniquely suited to leadership in fostering an environment that makes compromise with integrity possible.

Euthanasia in China is gaining increasing acceptance among physicians, intellectuals, and even the people. This paper surveys current attitudes towards euthanasia and suggests why it should be legalized.

Formal training in clinical ethics must become a central part of residency curricula to prepare practitioners to manage the ethical dimensions of patient care. Residency educators must ground their teaching in an understanding of the conceptual, biomedical, and psychosocial aspects of the important ethical issues that arise in that field of practice. Four aspects of professional competence in clinical ethics provide a useful framework for curricular planning. The physician should learn to: (1) recognize ethical issues as they arise in clinical care and identify hidden values and unacknowledged conflicts; (2) think clearly and critically about these issues in ways that lead to ethically justifiable courses of action; (3) apply those practical skills needed to implement an ethically justifiably course of action; and (4) judge when the management of a clinical situation requires consultation with individuals or institutional bodies with additional expertise or authority. We argue that these practical goals can be accomplished with a relatively modest emphasis on the theoretical aspects of medical ethics.

The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an 'appropriate' framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions.The literature on bioethics is diverse and confusing in its treatment of appropriate components for decision making. As a result, the literature on teaching bioethics is also confusing, even contradictory, in presenting an 'appropriate' framework within which learners may come to understand the nature and process of bioethics. The article sets out five decision components which are seen as common to all decision making. These components are then shown to have a significant influence both on bioethics decision making and on bioethics teaching. They are also shown to play a role in breaking down the separatism evidenced in contemporary bioethics literature aimed at individual professions.

Moral evaluations of medical research and care focus on different issues, e.g., clinical choices, public policy and cultural values. Technical ethical concepts and arguments do not suffice for all issues. Analysis of the literature suggests that, in addition to ethical discourse, prophetic, narrative, and policy discourse function morally. The article characterizes each of these forms, and suggests the insufficiency of each if it is taken to be the only mode of analysis.

Diagnosis is widely regarded to be governed by logical rules, but constructing a rational treatment plan has received less philosophical attention. I examine such treatment plans under three senses of the term "rational": consensual, scientific, and ethical. My thesis is that treatment plans, even those based on medical indications alone, are inherently consensual and are governed by a logic of proportionality.The notion of rationality in medicine is examined in its scientific, consensual, and moral senses. A "rational" treatment plan is held to be a conglomerate of appropriate judgments based on scientific facts, statistical data, standards of medical care about which there is a collegial consensus, preferential indications made by patients or their guardians, the relationship between preferential indications and medical indications, the burdens/benefits calculus, and the ethical principle of beneficence.

Rather than eliminate the terms "mental health and illness" because of the grave moral consequences of psychiatric labeling, conservative definitions are proposed and defended. Mental health is rational autonomy, and mental illness is the sustained loss of such. Key terms are explained, advantages are explored, and alternative concepts are criticized. The value and descriptive components of all such definitions are consciously acknowledged. Where rational autonomy is intact, mental hospitals and psychotherapists should not think of themselves as treating an illness. Instead, they are functioning as applied axiologists, moral educators, spiritual mentors, etc. They deal with what Szasz has called "personal, social, and ethical problems in living." But mental illness is real.

It is argued that human needs are not facts (properties, states, processes, relations) about people, but are values. The reasons presented for this position are (1) that needs are goal oriented and goals are things people value, (2) that 'need' functions as a basic motivational term, and (3) that disagreements about what people need are disagreements in attitude toward, and emotional attachment to, things variously considered to be valuable. If human needs are not facts, then, of course, health or medical needs are not. Viewing health or medical needs as discoverable facts, rather than values, engenders certain difficulties in the following areas of concern: (a) Deciding when surgery is necessary and when unnecessary; (b) Defining the concepts of health and disease; (c) Evaluating some consequences of the development of medical science and technology; and (d) Understanding the alleged conflict between patients' health needs and their human rights.

Technology has been developed in order to protect and safeguard human dignity; however, technology may also threaten it. The principle of human dignity plays an important role in assessing medical technology and medical practices.

The study of professional ethics has a long tradition in the Soviet Union; medical ethics is a code of conduct as well as an academic discipline. The paper discusses the ethical issues in intensive care, the definition of death, abortion, euthanasia, and the moral aspects of medical mistakes.

Medical practice is animated by the intention to cure; it aims to relieve the immense variety of sufferings to which human beings are subject in virtue of the conditions of their embodied existence. My purpose here is to demonstrate how a philosophical analysis of the formal structures and kinds of human suffering provides an essential foundation for determining certain ethical dimensions of the physician's relation to his suffering patient. Can paternalism in medical practice be justified by the aim of relieving suffering? What are the scope and limits of the patient's responsibility for his suffering, and what difference does this make in the physician's response to it? How is the suffering that medical treatment itself exacts in the name of cure to be justified? Such questions can be answered only by an analysis of the sense or value of suffering in human life.Rawlinson provides a philosophical analysis of the structure and kinds of human suffering as a foundation for considering certain moral dimensions of the physician's relation to the suffering patient. One traditional analysis asserts that suffering may be comprehended in the relation between the individual soul and an ideal order. Other thinkers, however, focus on the distinction between redemptive and non-redemptive suffering, holding that the relation that is threatened or disrupted in suffering is that of the subject to himself, between his immediate condition and his own ends. Suffering may not be an evil to be effaced but may be essential to the growth and development of persons and to the production of autonomy. The author maintains that intervention is unjustified and violates the autonomy of the patient when the sufferer resists assistance and is capable of evaluating his or her life in relation to those values within which his or her identity is established.