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Author contends that the moral arguments supporting money-back guarantees on infertility services are flawed because such services damage the physician-patient relationship and threaten the meaning of parenthood.

As science learns more about how the brain works, and fails to work, the possibility for developing "cognition enhancers" becomes more plausible. And the demand for drugs that can help us think faster, remember more, and focus more keenly has already been demonstrated by the market success of drugs like Ritalin, which tames the attention span, and Prozac, which ups the competitive edge. The new drug Aricept, which improves memory, most likely will join them. Whether such drugs are good for individuals, or for society, is an open question, one that demands far more public discussion.

Objective: Primary caregivers should be aware of recent progress in the genetics of Alzheimer disease (AD) and of the clinical and ethical considerations raised regarding the introduction of genetic testing for purposes of disease prediction and susceptibility (risk) analysis in asymptomatic individuals and diagnosis in patients who present clinically with dementia. This statement addresses arguments for and against clinical genetic testing., Participants: The 20 participants were selected by the investigators (S.G.P., T.H.M., A.B.Z., and P.J.W.) to achieve balance in the areas of genetics, counseling, ethics, and public policy, and to include leadership from related consensus projects. The consensus group met twice in closed meetings and carried on extensive correspondence over 2 years (1995-1997). The project was supported by the National Human Genome Research Institute of the National Institutes of Health., Evidence: All 4 involved chromosomes were discussed in group meetings against a background of information from several focus group sessions with AD-affected families. The focus groups comprised volunteers identified by the Cleveland Area Chapter of the Alzheimer's Disease and Related Disorders Association and represented a variety of ethnic populations., Consensus Process: The first draft was written in April 1996 by the principal investigator (S.G.P.) after the consensus group had met twice. The draft was mailed to all consensus group members 3 times over 6 months for extensive response and redrafting by the principal investigator until all members were satisfied., Conclusions: Except for autosomal dominant early-onset families, genetic testing in asymptomatic individuals is unwarranted. Use of APOE genetic testing as a diagnostic adjunct in patients already presenting with dementia may prove useful but it remains under investigation. The premature introduction of genetic testing and possible adverse consequences are to be avoided.

Drug control has become an important component of Olympic sport. At the Atlanta Centennial Olympic Games, urine samples will be tested for prohibited substances, including stimulants, narcotics, anabolic agents, diuretics, peptides, and glycoprotein hormones as well as prohibited methods of enhancing performance, including blood doping and pharmacological, chemical, and physical manipulation of the urine. Drug testing programs must address short-acting stimulants, beta-blockers, and diuretics; training drugs such as anabolic steroids; and drugs affecting the detectability of other drugs. Programs include short- or no-notice testing during training periods, testing at qualifying competitions, and testing at the Olympic Games. Procedures and disposition that occur when a prohibited substance is found in an athlete competing in an Olympic sport are discussed. An analysis of the ethics of the use of performance-enhancing drugs in sports and of drug control in terms of fair competition and the impact of enhancement technologies of the meaning of sports also is presented.

This article explores some of the potential moral and social ramifications of the Human Genome Project. Research on the human genome is generating important ethical and social questions of at least three distinct kinds. First, what genetic information should be generated, and who should control its dissemination and use? Improved diagnostic techniques such as presymptomatic testing, carrier screening, and prenatal screening can provide information that poses significant ethical problems for individuals, employers and insurance companies, and the medical and counseling professions. Second, what genetic procedures should be employed? The burgeoning ability to manipulate human genotypes and phenotypes through procedures such as gene therapy and enzyme therapy are leading to difficult questions about which manipulations should be permitted and which should be prohibited. Third, how will this new information change lives? Increasing claims about the relationship of genetics to ethically and politically significant traits and behaviors are challenging human self-understanding and the capacity of social institutions to respond adequately.

As we identify genes predictive of diseases such as heart disease, stroke, or cancer, we may unwittingly deprive individuals and families at risk of such diseases from access to health care. This is a problem in distributive justice. Commercial health insurance is built along lines similar to other forms of commercial insurance in which the notion of "actuarial fairness" plays a key role. Actuarial fairness contends that parties seeking insurance ought to pay according to their respective risks of filing a claim. Underwriting is the process by which insurers estimate the likelihood that an applicant would be making a claim. The human genome project has brought the latent ethical problems in commercial health insurance to the surface. In the scenario feared by insurers, predictive genetic tests will filter into general medical practice. Individuals who learn that they are at increased risk of such disease are more likely to purchase insurance. Such behavior is known as "adverse selection" by the insurance industry. Individual companies, in an effort to avoid adverse selection, may seek genetic information about their prospective customers, and other companies may follow suit. Such a scenario has led to the establishment of a national Task Force on Genetic Information and Insurance under the aegis of the human genome project. The Task Force seeks to clarify the empirical and moral components of the controversy. Key questions include the social purpose of health insurance, whether adverse selection is a genuine concern in the context of genetic testing, and the appropriateness of risk underwriting for access to health care.(ABSTRACT TRUNCATED AT 250 WORDS)

Scholarly thinking about morality has been deeply affected by the confrontation with practical moral problems epitomized by bioethics. Attention to social context is increasingly seen as vital to sound moral reasoning. The dominant model in bioethics assumes that moral reasoning proceeds downward, from fundamental principles to specific cases. This top-down model, deductivism, is flawed both as a description of moral reasoning, and as a prescription for how moral reasoning should be done. In recent years, another model known as casuistry and based on case-centered moral reasoning has emerged to challenge deductivism. Casuistry suggests new lines of empirical and conceptual research into the history of moral disputes and the practice of moral reasoning and debate.

Deciding whether genetic differences among individuals are morally relevant to health insurance requires us to ask, What kind of good is health care? and, What principles should govern its distribution? There are good reasons to doubt that "actuarial fairness" is an adequate description of genuine fairness in health insurance.

In addition to provocative questions about science policy, research on the human genome will generate important ethical questions in at least three categories. First, the possibility of greatly increased genetic information about individuals and populations will require choices to be made about what that information should be and about who should control the generation and dissemination of genetic information. Presymptomatic testing, carrier screening, workplace genetic screening, and testing by insurance companies pose significant ethical problems. Second, the burgeoning ability to manipulate human genotypes and phenotypes raises a number of important ethical questions. Third, increasing knowledge about genetic contributions to ethically and politically significant traits and behaviors will challenge our self-understanding and social institutions.

The public's involvement in the debate over human gene therapy is used to illustrate two points. First, complex bioethical issues often come to the public's attention because of a scandal, in this case the Cline episode; enlightened discussion and public understanding are difficult to achieve under these conditions. Second, even with unfavorable circumstances at the outset, the debate can become channeled into politically responsible institutions which then can develop effective public policy. For gene therapy, four significant forums emerged: the President's Commission's Report Splicing Life, the 1982 Congressional Hearings, the OTA Report, and the RAC's Points to Consider document.

The identification of Acquired Immune Deficiency syndrome (AIDS) three years ago has created a crisis of confidence. Persons with AIDS and others who might be research subjects recognize that research is essential to understand, treat, and prevent this devastating disease, yet they are concerned that information divulged for research purposes might be used in ways detrimental to their interests. Unless they have confidence in the system designed to protect their privacy and in the people to whom personal information is entrusted they may provide invalid or incomplete data. The problem, then, is: What procedures and policies will both protect the privacy interests of research subjects and enable research to proceed expeditiously? Now that major research efforts are being undertaken to tackle the many puzzling aspects of AIDS, this question has become an urgent one. These guidelines, developed by a multidisciplinary group representing diverse professional, public and social interests, are designed to provide the basis for the cooperation of the research community and the subjects of AIDS research. Addressed to research institutions, individual researchers, institutional review boards and public health departments, the recommendations seek changes deemed necessary to afford the fullest degree of protection for confidentiality compatible with sound scientific research.

Three issues addressed in Robert Weir's book Selective Nontreatment of Handicapped Newborns raise important questions about the social and political context of moral judgment, and the relation of moral judgment to moral theory. Arguments to the effect that infants are not moral "persons" as we normally understand the concept of personhood, illuminate the dialectical relationship between sound, confident moral judgments and moral theories. The way we describe and label decisions to offer or not to offer particular treatments to specific individuals has political and moral consequences. In general, we should opt for descriptions that display, rather than conceal, the problematic and controversial aspects of our decisions. The active killing of patients can only be defended from the narrowest viewpoint of minimizing that individual's suffering. It ignores the requirements made of other moral actors, and it fails to acknowledge a number of important facts about social institutions. Workable solutions must be attentive to the political and social context of moral dilemmas.

The fetus destined to be born rather than aborted has become increasingly an object of medical and moral concern. With considerable justification, women view this concern--which they share to a great degree--with suspicion that it will serve as a pretext for denying them social and economic equality with men. This article attempts to show that practical moral judgments about our obligations to not-yet-born children can be made without falling into the abyss of controversy surrounding abortion. By stressing the similarities in fathers' duties to their born children, we can also counter a measure of our historical propensity to view women's moral duties to their not-yet-born children as the overwhelmingly important feature of their moral lives, and resist the temptation to impose coercive public policies.

An examination of the notion of divided loyalties dilemmas in medicine, situated within their social contexts, yields insight into the contemporary social and moral position of medicine in the United States. In a review of the literature, the author identifies four concepts important to gaining an understanding of the position that divided loyalties play in medicine and the physician-patient relationship. After describing some of the situations in which these dilemmas affect physicians' responses to patients' health care needs, interests, and choices, the author argues that divided loyalties dilemmas are not rare, and will probably increase with the changes in U.S. medicine. Candor and awareness of the importance of the public belief in physician loyalty are seen as necessary in preventing these changes from becoming destructive of the physician-patient relationship.

Relationships governed by markets keep moral and social dimensions to a bare minimum. Gifts, by their open-endedness, defy such minimalization. Impersonal gifts such as blood or body parts or charity may not regulate relationships between specific individuals, but they serve other functions by regulating larger relationships and honoring important human values, precisely those threatened by massive and impersonal bureaucracies.