There has been a tremendous increase in interest in bioethics, which has come in direct response to the substantial advances in biomedical research and medical technology over the past 30 years. The more sophisticated medical science and technology becomes, the more sophisticated are questions that are raised: Who has the right to decide whether a medical treatment should be initiated, continued, or stopped? How much information are healthcare professionals required to give to patients? When should a patient's right to confidentiality be violated? When, if ever, is active or passive euthanasia or abortion justified, and who has the right to decide on these issues?

A major facet of the bioethics phenomenon in North America has been the emergence of a new profession on the healthcare turf: a growing number of people calling themselves or being called “bioethicists.” Bioethicists are plying their trade mainly as ethics consultants in hospital settings and as researchers and educators with university affiliations. Other more questionable affiliations can easily be imagined: Bioethicist for a controversial transplant program? For a lobby or advocacy group? For a pharmaceutical company?

The Object of Morality is the title of a book I wrote a good many years ago shortly before I deviated irreversibly into university administration (often an intellectually terminal condition). I do not want to plug that book; nevertheless, it may not be completely irrelevant to say something of what it was about and take a rather rapid trot over its theme.

After the second World War, a cliché was repeated so often as to provoke, I fear, either yawns or giggles: “our moral sense was lagging behind our technical invention,” i.e., science had, as it were, outstripped morality. In those days, of course, the bogey scientists thought to have left morality behind were physicists, especially those who had made possible the nuclear bomb. A wholly new kind of war weapon did indeed seem to have changed the world and to require a new dimension of moral thought and moral philosophy, if we were not all to be destroyed.

Whether ethics is too important to be left to the experts or so important that it must be is an age-old question. The emergence of clinical ethicists raises it again, as a question about professionalism. What role clinical ethicists should play in healthcare decision making – teacher, mediator, or consultant – is a question that has generated considerable debate but no consensus.

Rather than discussing the economic side of competition, the actual shortage of resources, I want to discuss competitiveness itself, the competitive attitude. Certainly good causes must in a sense be in competition; that is, they must share resources. The question is should they actively compete? Should they see themselves as competing?

I want to look at a range of difficulties that seem endemic to controversy as such. Some of the difficulties are psychological, but that does not mean that they are accidental, neurotic oddities of particular disputants. They afflict almost everybody who must argue about something important. Other difficulties are in-trinsic in the nature of human life–clashes between rival values, needs, and ideals, places where no fully satisfactory resolution seems attainable.

Some years ago I received the following letter from a friend who became my patient.

In pursuit of my ultimate objective of being in control of my self-deliverance at the time when my physical condition no longer warrants continuance, I have joined the Hemlock Society of Los Angeles. The Society urges its members to explore with their personal physicians this subject well in advance of the actual moment of necessity, and in particular the problem of acquiring a lethal dose of a drug that will provide a release consistent in quality with the degree of peace and serenity sought in life. It is my hope that we can find a process commensurate with your moral and professional concerns which will allow us to collaborate.

On 10 July 1973, Laurens, our second son, was born in the same Dutch hospital where I worked as an intensive care physician. Two weeks after we brought him. home from the hospital, my wife heard him crying at about 5:45 A.M. Rather than going to him, she decided to wait until his scheduled feeding time. At about 6:10 when she went to Laurens's room to feed him, she saw him. face down in the corner of his crib. He appeared dead. She screamed for me. I ran from upstairs to Laurens's room on the ground floor. I initiated cardio-pulmonary resuscitation and continued the CPR while my wife called our general practitioner. He arrived in about 10 minutes and the ambulance arrived a minute later.

Dutch developments on euthanasia have drawn much attention over the years. Defenders and opponents have been telling very different stories about the practice of euthanasia and the frequency of cases, and the Dutch government has been struggling with the legal and moral problems involved. Concern about the procedures followed by physicians as well as questions on the “real” figures led the government to decide to organize an epidemiological study on the extent and the decision making. The results of the study were published in November 1991 (The End of Life in Medical Practice, 1991). Interpretation of the data may lead to a final settlement of the debate on euthanasia and has inevitably led to a revival of the moral debate of the 1970s. For the moment it has been decided that euthanasia will remain officially illegal under the Penal Code. However, in cases where euthanasia does occur, Attorneys General will continue to check the procedures followed by physicians to ensure no abuses have occurred and to safeguard physicians against prosecution. In this contribution, we discuss the development and intertwinement of legal, medical, and moral aspects of euthanasia in The Netherlands and the effects of the empirical studies of 1991, both on definitions and procedures for medical decisions at the end of life(MDEL)

Last year, the Joint Commission on Accreditation of Healthcare Organizations for the first time included provisions in its Hospital Accreditation Manual requiring institutions to have mechanisms in place to consider ethical issues arising in the care of patients and to educate care givers and patients on bioethical issues. This new requirement is notably vague. There is no indication of what type of mechanisms would be appropriate or how those involved in considering ethical issues should conduct themselves. This vagueness is by no means accidental, but it reflects a recognition that clinical bioethics is still in its formative stages and that there are currently almost as many different mechanisms for dealing with bioethical issues in the healthcare setting as there are institutions that have such mechanisms. The Joint Commission's action, however, also implies that the time for experimentation will soon be over.

There is large, imposing-looking box in a wing of University College, London, that contains the lifelike remains of the English philosopher, Jeremy Bentham. Bentham requested that upon his death, which occurred in 1832, his body should first be used for purposes of a medical lecture and then be place on display. His request was entirely utilitarian in character. For as a famous individual, Bentham could argue that it made less sense to be buried and then have a statue constructed of his likeness than to eliminate the burial by having himself made into a statue. He called the latter an auto-icon.