For all of the emphasis on quality improvement—as well as the acknowledged overlap between assessment of the quality of healthcare services and clinical ethics—the quality of clinical ethics consultation has received scant attention, especially in terms of empirical measurement. Recognizing this need, the second edition of Core Competencies for Health Care Ethics Consultation identified four domains of ethics quality: (1) ethicality, (2) stakeholders’ satisfaction, (3) resolution of the presenting conflict/dilemma, and (4) education that translates into knowledge. This study is the (...) first, to our knowledge, to directly measure all of these domains. Here we describe the quality improvement process undertaken at a tertiary care academic medical center, as well as the tools developed to measure the quality of ethics consultation, which include post-consultation satisfaction surveys and weekly case conferences. The information gained through these tools helps to improve not only the process of ethics consultation, but also the measurement and assurance of quality. (shrink)

In considering how to best deploy robotic systems in public and private sectors, we must consider what individuals will expect from the robots with which they interact. Public awareness of robotics—as both military machines and domestic helpers—emerges out of a braided stream composed of science fiction and popular science. These two genres influence news media, government and corporate spending, and public expectations. In the Euro-American West, both science fiction and popular science are ambivalent about the military applications for robotics, and (...) thus we can expect their readers to fear the dangers posed by advanced robotics while still eagerly anticipating the benefits to be accrued through them. The chief pop science authors in robotics and artificial intelligence have a decidedly apocalyptic bent and have thus been described as leaders in a social movement called "Apocalyptic AI." In one form or another, such authors look forward to a transcendent future in which machine life succeeds human life, thanks to the march of evolutionary progress. The apocalyptic promises of popular robotics presume that presently exponential growth in computing will continue indefinitely, producing a "Singularity." During the Singularity, technological progress will be so rapid that undreamt of changes will take place on earth, the most important of which will be the evolutionary succession of human beings by massively intelligent robots and the "uploading" of human consciousness into computer bodies. This supposedly inevitable transition into post-biological life looms across the entire scope of pop robotics and artificial intelligence, and it is from beneath that shadow that all popular books engage the military and the ethics of warfare. Creating a just future will require that we transcend the apocalyptic discourse of pop science and establish an ethical approach to researching and deploying robots, one that emphasizes human rather than robot welfare; doing so will require the collaboration of social scientists, humanists, and scientists. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Place of the Money Bag in the Secular-Mendicant Controversy at ParisRobert J. Karris O.F.M. (bio)Money bag, money bag. So many Bible-reading Christians don't know of your existence. In their defense I note that you are only mentioned twice in the entire New Testament: John 12:6 and 13:29. If faithful Bible-reading Christians don't know of your existence, what is your fate among the faithful who are less than faithful?! (...) Is ignorance truly bliss?New Testament ScholarsMoney bag, money bag. Perhaps, New Testament scholars are the reason why you are almost unknown among Christians.1 Commentators on John's Gospel give you a passing notice, if that.2 Even when they make mention of you, they [End Page 21] generally don't integrate your existence with other features of John's theology or life situation.3 As for the Jesus Seminar, its members sweep you into the dustbin of history along with 99.9% of John's Gospel.4 You see, you are deemed unhistorical. A couple of scholars involved in the quest for the historical Jesus say "Hi!" to you, but then go on with more important matters.5 Other scholars involved in the application [End Page 22] of social science methodology to the study of the New Testament opine that you were kept as a security measure and contained money to pay for the annual temple tax and such like obligations, but then they hold their peace.6Money bag, money bag. Scholars who have investigated the theme of rich and poor in the New Testament hardly give [End Page 23] you a second glance. You do not play a leading role in their general conclusions.7So, money bag, we have to take leave of New Testament scholarship if we are going to make your acquaintance on a serious level.The Middle AgesFrancis of AssisiAs we move into the Middle Ages, we ask: Did St. Francis of Assisi provide us with guidance on how to treat you with the respect that you, O money bag, so richly deserve? You see, some scholars maintain that John's Gospel was most important to Francis's worldview.8 However, Francis doesn't seem to see the problem you created for his all-consuming embrace of Jesus' missionary command of traveling with no money.9 [End Page 24] Surely Francis knows of your existence, for he refers to you in his Fourth Admonition n. 3:And the more they (superiors) are perturbed about their superiorship being taken from them than they would be over the loss of the office of washing feet, so much the more do they collect for themselves a money bag (John 12:6; 13:29) to the peril of their souls.10Francis is heir to a Benedictine spiritualization of the money bag. See how Roger the Abbot in his Sermo in ultima cena employs the money bag:Woe, how many money bags, woe, how many purses are in the monasteries of St. Benedict! Woe, how many cowls, which cover the ears of the tonsured, enclose private supplies of the mind, the money bag of one's own will, the purse of murmuring, detraction, idleness, pride, envy, jealousy, and bad will! But remember, most beloved brothers, that those who do such things follow Judas the traitor. And therefore, unless you amend your lives, you will not possess the kingdom of God.11O money bag, so Francis goes his merry way, apparently ignorant of your true meaning and leaves the problems created by your existence to his learned followers such as Bonaventure of Bagnoregio. To Bonaventure we now turn, but do so through his responses to his secular opponents, William of Saint-Amour and Gerard of Abbeville. First let's hear from the secular masters. [End Page 25]William of Saint-Amour and Gerard of AbbevilleWilliam of Saint-Amour comments on John 12:6 and argues that it does not permit begging and is the basis for the normative view that the apostles and their successors should have a money bag. He writes:Augustine, 'the Lord had a purse to keep the offerings... (shrink)

The dead donor rule—that persons must be dead before their organs are taken—is a central part of the moral framework underlying organ procurement. Efforts to increase the pool of transplantable organs have been forced either to redefine death (e.g., anencephaly) or take advantage of ambiguities in the current definition of death (e.g., the Pittsburgh protocol). Society's growing acceptance of circumstances in which health care professionals can hasten a patient's death also may weaken the symbolic importance of the dead donor rule. (...) We consider the implications of these efforts to continually revise the line between life and death and ask whether it would be preferable to abandon the dead donor rule and rely entirely on informed consent as a safeguard against abuse. (shrink)

A model for ethical problem solving -- Values in health and illness -- What is the source of moral judgments? -- Benefiting the patient and others : duty to do good and avoid harm -- Justice : allocation of health resources -- Autonomy -- Veracity : honesty with patients -- Fidelity : promise-keeping, loyalty to patients, and impaired professionals -- Avoidance of killing -- Abortion, sterilization, and contraception -- Genetics, birth, and the biological revolution -- Mental health and behavior control (...) -- Confidentiality : ethical disclosure of medical information -- Organ transplants -- Health insurance, health system planning, and rationing -- Experimentation on human subjects -- Consent and the right to refuse treatment -- Death and dying. (shrink)

"This reviewer had to be restrained from stopping people in the street to urge them to read it: They would learn something of the way science is done,...

This contains an extended and wide ranging bibliography, beginning with the seventeenth century, of works relevant to the problem of miracles and Hume’s essay. It is especially useful for the problem in its historical setting.

Assesses the ethical problems that doctors face every day and advocates a more universal code of medical ethics, one that draws on the traditions of religion and philosophy.

In the Summa Theologiae ‘simplicity’ is treated as pre–eminent among the terms which may properly be used to describe the divine nature. The Question in which Thomas demonstrates that God must be ‘totally and in every way simple’ immediately follows the five proofs of God's existence, preceding the treatment of His other perfections, and being frequently used as the basis for proving them. Then in Question 13 ‘univocal predication' is held to be ‘impossible between God and creatures’ so that at (...) best ‘some things are said of God and creatures analogically’ because of the necessity of using ‘various and multiplied conceptions’ derived from our knowledge of created beings to refer to what in God is simple for ‘the perfections flowing from God to creatures… pre–exist in God unitedly and simply, whereas in creatures they are received divided and multiplied’ . In line with this, in the De Potentia Dei the treatment of analogical predication is integrated into that of ‘the Simplicity of the Divine Essence’ . Moreover, it lies at the root of Thomas's rejection of any possibility of a Trinitarian natural theology such as, for instance, St Anselm or Richard of St Victor had attempted to develop, on the grounds that ‘it is impossible to attain to the knowledge of the Trinity by natural reason’ since ‘we can know what belongs to the unity of the essence, but not what belongs to the distinction of the persons’ . Even modern minds sympathetic to Thomas have clearly found it difficult to understand his concern for the divine simplicity: in his Aquinas Lecture Plantinga speaks for many in stating that it is ‘a mysterious doctrine’ which is ‘exceedingly hard to grasp or construe’ and ‘it is difficult to see why anyone should be inclined to accept it’. Not surprisingly, therefore, some of the most widely read twentieth–century commentators on Aquinas have paid little attention to it. Increased interest has recently been shown in it, but a number of discussions pay insufficient attention to the historical context out of which Thomas's interest in the doctrine emerged, and consequently tend to misconstrue its nature. (shrink)

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

The emergence of the “4th Industrial Revolution,” i.e. the convergence of artificial intelligence, the Internet of Things, advanced materials, and bioengineering technologies, could accelerate socioeconomic insecurities and anxieties or provide beneficial alternatives to the status quo. In the post-Covid-19 era, the entities that are best positioned to capitalize on these innovations are large firms, which use digital platforms and big data to orchestrate vast ecosystems of users and extract market share across industry sectors. Nonetheless, these technologies also have the potential (...) to democratize ownership, broaden political-economic participation, and reduce environmental harms. We articulate the potential sociotechnical pathways in this high-stakes crossroads by analyzing cellular agriculture, an exemplary 4th Industrial Revolution technology that synergizes computer science, biopharma, tissue engineering, and food science to grow cultured meat, dairy, and egg products from cultured cells and/or genetically modified yeast. Our exploration of this space involved multi-sited ethnographic research in both the cellular agriculture community and alternative economic organizations devoted to open source licensing, member-owned cooperatives, social financing, and platform business models. Upon discussing how these latter approaches could potentially facilitate alternative sociotechnical pathways in cellular agriculture, we reflect upon the broader implications of this work with respect to the 4th Industrial Revolution and the enduring need for public policy reform. (shrink)

a comprehensive, somewhat Gricean theory of speech acts, including an account of communicative intentions and inferences, a taxonomy of speech acts, and coverage of many topics in pragmatics -/- .

One of our great behavioral scientists, the bestselling author of Behave, plumbs the depths of the science and philosophy of decision-making to mount a devastating case against free will, an argument with profound consequences Robert Sapolsky's Behave, his now classic account of why humans do good and why they do bad, pointed toward an unsettling conclusion: We may not grasp the precise marriage of nature and nurture that creates the physics and chemistry at the base of human behavior, but (...) that doesn't mean it doesn't exist. Now, in Determined, Sapolsky takes his argument all the way, mounting a brilliant (and in his inimitable way, delightful) full-frontal assault on the pleasant fantasy that there is some separate self telling our biology what to do. Determined offers a marvelous synthesis of what we know about how consciousness works-the tight weave between reason and emotion and between stimulus and response in the moment and over a life. One by one, Sapolsky tackles all the major arguments for free will and takes them out, cutting a path through the thickets of chaos and complexity science and quantum physics, as well as touching ground on some of the wilder shores of philosophy. He shows us that the history of medicine is in no small part the history of learning that fewer and fewer things are somebody's "fault"; for example, for centuries we thought seizures were a sign of demonic possession. Yet, as he acknowledges, it's very hard, and at times impossible, to uncouple from our zeal to judge others and to judge ourselves. Sapolsky applies the new understanding of life beyond free will to some of our most essential questions around punishment, morality, and living well together. By the end, Sapolsky argues that while living our daily lives recognizing that we have no free will is going to be monumentally difficult, doing so is not going to result in anarchy, pointlessness, and existential malaise. Instead, it will make for a much more humane world. (shrink)

In celebration of the fortieth anniversary of the publication of Beauchamp and Childress’s Principles of Biomedical Ethics, a review is undertaken to compare the lists of principles in various bioethical theories to determine the extent to which the various lists can be reconciled. Included are the single principle theories of utilitarianism, libertarianism, Hippocratism, and the theories of Pellegrino, Engelhardt, The Belmont Report, Beauchamp and Childress, Ross, Veatch, and Gert. We find theories all offering lists of principles numbering from one to (...) ten. Many of the differences can be reconciled, but some critical differences remain. (shrink)

No one really believes that literally all functions of the entire brain must be lost for an individual to be dead. A better definition of death involves a higher brain orientation.

Modern historical criticism of the gospels and Christian origins began in the seventeenth century largely as an attempt to debunk the Christian religion as a pious fraud. The gospels were seen as bits of priestcraft and humbug of a piece with the apocryphal Donation of Constantine. In the few centuries since Reimarus and his critical kin, historical criticism has been embraced and assimilated by many Christian scholars who have seen in it the logical extension of the grammatico-historical method of the (...) Reformers. The new views of New Testament exegesis and of early Christian history are important and well known. Many New Testament scholars would now hold with Schweitzer and Bultmann that Jesus was a preacher of the imminent end of the world. He may have secretly considered himself to be the Messiah, or he may have simply sought to pave the way for another, the apocalyptic Son of Man. After his execution, his disciples' experiences of his resurrection forced on them a conclusion already implicit in his teachings and personal piety: that Jesus was indeed, or had become, the Messiah, and was in fact God's Son. They expected he would soon return as the Son of Man he had predicted. (shrink)

Clinicians cannot obtain valid consent to treatment because they cannot guess which treatment option will serve a particular patient's best interests. These guesses could be made more accurately if patients were paired with providers who share their deep values.

Typically, the determination of death by neurological criteria follows a very specific protocol. An apnea test is performed with further confirmation as necessary, and then mechanical ventilation is withdrawn with the consent of the family after they have had an opportunity to “say goodbye,” and at such a time to permit organ retrieval (with authorization of the patient or consent of the next of kin). Such a process maximizes transparency and ensures generalizability. In exceptional circumstances, however, it may be necessary (...) to deviate from this protocol in order to spare family members unnecessary suffering and to reduce moral distress felt by clinical staff. It may also be appropriate, we argue, to refrain from even inquiring about organ donation when the next-of-kin is not only certain to refuse, but lacks the decision-making capacity to potentially consent. The case described in this article calls into question generally reliable assumptions about determination of death by neurological criteria, where the best the clinical team could do for the patient and his family was “the least bad option.”. (shrink)

It is not too great an exaggeration to claim that On the Origin of Species was, along with Das Kapital, one of the two most significant works in the intellectual history of the nineteenth century. As George Henry Lewes wrote in 1868, ‘No work of our time has been so general in its influence’. However, the very generality of the influence of Darwin’s work provides the chief problem for the intellectual historian. Most books and articles on the subject assert the (...) influence but remain very imprecise about its nature. It is very difficult indeed to assess what it was about the Darwinian theory which was so influential and how its influence was felt. This problem in Victorian intellectual history intersects with a related one in the history of science. There has been a tendency on the part of historians of science to isolate Darwin in two related ways. The first is to single him out from the mainstream of nineteenth-century naturalism in Britain and allow ‘Darwinism’ to stand duty for the wider movement of which it was in fact but a part. The second is the tendency to single out his evolutionary theory and to demarcate it sharply from those of his predecessors and contemporaries. According to this interpretation Darwin stood alone as a real, empirical scientist and provided the first genuinely scientific hypothesis for the process by which evolution might have occurred. The theories of the other main evolutionists—Erasmus Darwin, Lamarck, Chambers, Spencer, and Wallace—were more or less besmirched by ideological, anthropomorphic, or other ‘non-scientific’ factors or by the uses to which they were put by their authors. Charles Darwin is thus made to stand out as a figure of comparatively unalloyed scientific status and is treated in relative isolation from the social and intellectual context in which he worked and into which his theory was received. (shrink)

When a new, brain-based definition of death was proposed fifty years ago, no one realized that the issue would remain unresolved for so long. Recently, six new controversies have added to the debate: whether there is a right to refuse apnea testing, which set of criteria should be chosen to measure the death of the brain, how the problem of erroneous testing should be handled, whether any of the current criteria sets accurately measures the death of the brain, whether standard (...) criteria include measurements of all brain functions, and how minorities who reject whole-brain-based definitions should be accommodated. These controversies leave little hope of consensus on how to define death for social and public policy purposes. Rather, there is persistent disagreement among proponents of three major groups of definitions of death: whole-brain, cardiocirculatory or somatic, and higher-brain. Given the persistence and reasonableness of each of these groups of definitions, public policy should permit individuals and their valid surrogates to choose among them. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Back to the Future:Obtaining Organs from Non-Heart-Beating CadaversRobert M. Arnold (bio) and Stuart J. Youngner (bio)Organ Transplantation requires viable donor organs. This simple fact has become the Achilles' heel of transplantation programs. Progress in immunology and transplant surgery has outstripped the supply of available organs. Between 1988 and 1991, for example, the number of transplant candidates on waiting lists increased by about 55 percent, while the number of donors (...) increased only about 16 percent.1 By the end of March 1993, more than 30,000 potential recipients awaited transplantation (United Network for Organ Sharing Database (UNOS) 1993). Every day six of these patients die prior to receiving a heart or liver transplant, while patients needing kidney transplants must tolerate a lower quality of life on dialysis (Grenvik 1992; Evans, Orians, and Ascher 1992).This scarcity is likely to get worse. As transplantation becomes more successful, it is being offered to sicker and older patients. Attempts to transplant other solid organs, such as small bowel and pancreas, will only fuel the demand for donors. However, the current source of organs is unlikely to grow. Most organs come from patients who have been declared dead by neurologic criteria (commonly referred to as "brain dead" or heart-beating cadaver donors (HBCDs) because their hearts are beating at the time of procurement). Estimates of the potential pool of HBCDs have been revised downward from 20,000-27,000 to roughly 10,000-12,000 (Nathan et al. 1991). Improvements in automobile safety and handgun legislation will likely lead to further reductions. Moreover, the rate of procurement from HBCDs has remained relatively flat despite extensive public awareness campaigns and legislation requiring hospitals to routinely request donation from families of dead patients (Caplan et al. 1992).If organ transplantation is going to continue to flourish, alternative [End Page 103] sources of organs must be found. Recently the University of Pittsburgh Medical Center (UPMC) proposed procuring organs from patients who have been declared dead by traditional cardiopulmonary rather than brain-oriented criteria after they or their families have decided to forgo life-sustaining treatment—hereafter referred to as the Pittsburgh protocol (UPMC Policy 1993). These patients are typically referred to as non-heart-beating cadaver donors (NHBCDs) because their hearts are no longer beating at the time of organ procurement.Although NHBCDs were a major source of transplantable kidneys prior to the institution of death by neurologic criteria, their usefulness was limited by "warm ischemia time." This term refers to the injury to tissues that occurs when the blood supply is interrupted and before the organs are cooled and reperfused. Under the Pittsburgh protocol, therapy is withdrawn in the operating room where a waiting surgical team removes organs immediately after death is declared. By controlling the place and time of death, it has been possible to minimize warm ischemia time and thus solve the technical problems previously associated with procurement from NHBCDs.The potential contribution of NHBCD organs is significant. Nathan (1992), using data from Delaware Valley Transplant Program, concludes that the use of severely brain injured, but not "brain dead" patients, would increase the donor pool by 20-25 percent. Moreover, unpublished data from the Pittsburgh organ procurement organization, the Center for Organ Recovery and Education (CORE), suggests that these organs, particularly kidneys, function as well as those procured from HBCDs (Broznick 1993).This volume is devoted to the ethical, psychosocial, and public policy implications of procuring organs from non-heart-beating cadaver donors after a discussion to forgo life-sustaining treatment. The genesis of this volume was a project in which we invited leading experts in transplantation, ethics, and public policy to use the Pittsburgh protocol as a starting point for exploring a broad range of issues associated with attempts to procure organs from NHBCDs. The issues raised by NHBCDs turned out to have important implications about the fundamental conceptual and moral assumptions underlying organ procurement.Although each of the papers in this volume can be read separately, we intend the volume to be read as a whole. Many of the latter pieces on the ethical implications of the policy are best understood in light of the earlier background papers... (shrink)

Currently the Enlightenment tradition is under such intense attack that Richard Bernstein calls the present mood a “rage against the enlightenment.” The purpose of this essay is to defend the deep spirit of the Enlightenment, the position that no idea, proposition, or principle should be beyond critical assessment. The defense involves an examination of and a response to two criticisms of the Enlightenment: first that the Enlightenment disdainfully rejects religion, particularly Christianity, and second that Enlightenment thinkers had a misguided confidence (...) in the powers of a-historical reason, i. e. the notion that humans have a rational capacity, unaffected by context or historical circumstance, to arrive at truth. (shrink)

After distinguishing two different meanings of the notion of a morality internal to medicine and considering a hypothetical case of a society that relied on its surgeons to eunuchize priest/cantors to permit them to play an important religious/cultural role, this paper examines three reasons why morality cannot be derived from reflection on the ends of the practice of medicine: (1) there exist many medical roles and these have different ends or purposes, (2) even within any given medical role, there exists (...) multiple, sometimes conflicting ends, and, most critically, (3) the ends of any practice such as medicine must come from outside the practice, that is, from the basic ends or purposes of human living. The paper concludes by considering whether these ends external to medicine are universally part of the moral reality or whether they are socially constructed. The paper argues that, even if various cultural accounts of the common, universal morality are socially constructed, they may, nevertheless, be reflections, however, imperfect, of a more universal common morality that should be thought of as real. Therefore, the morality of medicine must come from a more fundamental morality external to medicine. That external morality will be socially constructed, but may nevertheless reflect an underlying common morality. (shrink)

In its October 2001 issue, this journal published a series of articles questioning the Whole-Brain-based definition of death. Much of the concern focused on whether somatic integration - a commonly understood basis for the whole-brain death view - can survive the brain's death. The present article accepts that there are insurmountable problems with whole-brain death views, but challenges the assumption that loss of somatic integration is the proper basis for pronouncing death. It examines three major themes. First, it accepts the (...) claim of the "disaggregators" that some behaviors traditionally associated with death can be unbundled, but argues that other behaviors (including organ procurement) must continue to be associated. Second, it rejects the claims of the "somaticists," that the integration of the body is critical, arguing instead for equating death with the irreversible loss of "embodied consciousness," that is, the loss of integration of bodily and mental function. Third, it defends higher-brain views against the charge that they are necessarily "mentalist," that is, that they equate death with losing some mental function such as consciousness or personhood. It argues, instead, for the integration of bodily and mental function as the critical feature of human life and that its irreversible loss constitutes death. (shrink)

The dead donor rule (DDR) governs procuring life-prolonging organs. They should be taken only from deceased donors. Miller and Truog have proposed abandoning the rule when patients have decided to forgo life-sustaining treatment and have consented to procurement. Organs could then be procured from living patients, thus killing them by organ procurement. This proposal warrants careful examination. They convincingly argue that current brain or circulatory death pronouncement misidentifies the biologically dead. After arguing convincingly that physicians already cause death by withdrawing (...) treatment, they claim no bright-line differences preclude organ removal from the living. The argument fails for those who accept the double effect doctrine or other grounds for distinguishing forgoing life support from active, intentional killing. If the goal is determining irreversible loss of somatic function, they correctly label current death pronouncement a “legal fiction.” Recognizing a second, public policy meaning of the term death provides grounds for maintaining the DDR without jeopardizing procurement. (shrink)

While twentieth-century medical ethics has focused on the duty of physicians to benefit their patients, the next century will see that duty challenged in three ways. First, we will increasingly recognize that it is unrealistic to expect physicians to be able to determine what will benefit their patients. Either they limit their attention to medical well-being when total well-being is the proper end of the patient or they strive for total well-being, which takes them beyond their expertise. Even within the (...) medical sphere, they have no basis for choosing among the proper medical goals for medicine. Also, there are many plausible strategies for relating predicted benefits to harms, and physicians cannot be expert in picking among these strategies. Second, increasingly plausible ethical systems recognize that in some cases, patient benefit must be sacrificed to protect patient rights including the right to the truth, to have promises kept, to have autonomy respected, and to not be killed. Third, ethics of the next century will increasingly recognize that some patient benefits must be sacrificed to fulfill duties to others - either the duty to serve the interests of others or other duties such as keeping promises, telling the truth, and, particularly, promoting justice. Physicians in the twenty-first century will be seen as having a new, more limited duty to assist the patient in pursuing the patient's understanding of the patient's interest within the constraints of deontological ethical principles and externally imposed duties to promote justice. The result will be a duty to be loyal to the consumer of health care with the recognition that often this will mean that the physician is not permitted to pursue the physician's understanding of the patient's well-being. (shrink)