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ILAR Journal V31(4) 1989
Perspectives on Animal Use

A Medical Ethics Primer
J. Wesley Robb
J. Wesley Robb is adjunct professor of bioethics, School of Medicine, and professor emeritus, School of Religion, at the University of Southern California in Los Angeles. He is a member of the ILAR Council.


During the past several years, the ILAR Council has become increasingly involved in issues regarding the ethical use of animals. Council recognized that the terminology used by philosophers is often unfamiliar to scientists, who, unaccustomed to its use, rarely engage in debates on ethical issues. As a result, Council invited one of its members, Dr. J. Wesley Robb to present to Council a "Primer on Medical Ethics." Following this presentation on January 10, 1989, the Council urged Dr. Robb to prepare a manuscript, on the same subject, for publication in ILAR News. Although the article does not directly address ethical concerns for the use of animals in research, Council recognized that the principles used in making ethical judgments are the same whether they concern medical practice, research, or public policy. We hope you find this article both useful and informative.
ILAR News Editorial Panel

Introduction

Ethical issues are high on the agenda of almost all levels of society. Watergate, Pentagongate, Irangate, and now Wrightgate have alerted the public to the facile manner in which public officials have viewed their duties and responsibilities. Inside trading and other improprieties within the financial community have surfaced and demonstrated an equal indifference to professional and personal standards of conduct. Whether these behavioral patterns of men and women in positions of power and trust will change is problematic, particularly when personal gain and self-interest seem to dominate all segments of society.

It is ironic that everyone seems to know what is ethical and what is not. For the most part, these ethical canons of propriety have been uncritically accepted as a part of the moral fabric of traditional societal standards inculcated by the home, church, and other socially influential institutions. They are intuitively felt to be right, and although they may not be consistently demonstrated within the individual's personal life and not arrived at through critical reflection, they serve as guides especially in judging the behavior of others. These ethical attitudes are often primarily emotional and convictional responses that are simply true for the individual as uncritically accepted norms. For example, one's attitudes and sense of duty about another race of people would be a case in point. They are often flawed by prejudice and ignorance and are all too often supported by peer groups from which the individual seeks approval. Hence, these attitudes are deeply rooted and difficult to alter.

As a consequence, ethical judgments are viewed by many people as emotive and irrational claims that reflect the subjective prejudices of the individual and have little or no objective truth-value. From this perspective, one ethical judgment is as good as another because, in the final analysis, ethical pronouncements merely indicate the preferences of the proclaimer. Only judgments of fact that are empirically verifiable are those that have any truth or objective value. The implication is that normative judgments of value have, in reality, little or no rational basis, and any serious discussion of ethical issues becomes a stalemate--"no hits, no runs, no errors."

It is true that subjective elements do affect our ethical judgments, but it is likewise true of almost any claim we make. We all make assumptions regardless of what we are considering to be true. If we are at all reflective, we begin our inquiry with assumptions that must be examined and reexamined; nonetheless we must begin somewhere. The western bias for scientific and empirical methodologies, in contrast to the traditional eastern preference for the primacy of the intuitive approach to reality, is illustrative of this fact.

The purpose of this essay is to examine the developing field of biomedical ethics and to suggest a way of doing ethics in one professional area that might serve as a model for making ethical judgments in other fields.

What is Ethics?

Ethics is one of five classical disciplines within western philosophy that harks back to the beginning of ancient Greek philosophy. These are:

1. Metaphysics--What is the nature of reality'?
2. Epistemology--How do we know and what are the criteria for knowledge'?
3. Logic--Examination of the internal consistency of an argument and the relationship between the reasons offered and the conclusions drawn from those reasons.
4. Aesthetics--The nature and beauty of art and what is fitting.
5. Ethics.

As a branch of philosophy, ethics is concerned with evaluating and establishing the criteria for normative judgments of value (good and bad) and judgments of responsibility and duty (right and wrong). Medical ethics is a subset of concerns that involves ethical reflection about decisions and actions in health care and an attempt to resolve the conflict between the ideal and the real in rational and responsible ways. Biomedical ethics is a more inclusive term that expresses concern about the application of new developments in medical science that impinge upon the care of patients as well as other issues. The role of the medical ethicist is to be a catalytic agent in the decision-making process--examining assumptions and facilitating critical dialogue and analysis (linguistic and logical). His or her function is not to make ethical decisions, but as a member of the medical team, to be a resource person applying professional skills to the questions at hand. The job description for the position of "philosopher in residence" at one medical center describes the role of the ethicist well, "... encouraging dialogue, critical reflection, and the assessment of underlying value judgments."

Ethics and the Practice of Medicine

From the Hippocratic corpus to the present, ethics has been an integral part of medicine. It is interesting that the traditional Hippocratic oath (Edelstein, 1967) stressed many of the ethical precepts that are accepted in medical practice to this day. For example,

These ethical standards have been widely accepted by physicians in the West, particularly the dictum, "Do no harm." The first American Code of Medical Ethics was formulated in 1849 and, by and large, was based upon the code of Thomas Percival, an English physician of the early 19th century. The AMA (American Medical Association) Code was a comprehensive statement and included a list of duties of both the physician and the patient. It is interesting that emphasis was placed upon the latter, while today medical ethics codes say very little about the patient's responsibilities. Duties of the physician included responsibility of the physician to other physicians and to the profession at large and duties of the profession to the public and the obligations of the public to the profession. Here again the latter obligation is seldom cited in current statements about medical ethics.

The most recent "AMA Principles of Medical Ethics'' (see Appendix A) was revised in 1980 and states seven general ethical principles along the traditional lines of the responsibility of the physician to the patient, society, and the profession and to the professional betterment of one's self. The AMA also periodically publishes Current Opinions of the Council on Ethical and Judicial Affairs, which provides more complete guidelines than the principles cover. In addition, the American College of Physicians publishes an Ethics Manual, which is a comprehensive statement of the physician's responsibilities, as well as comments about such ethical issues as patient autonomy, quality of life, care for the hopelessly ill, genetic counseling, resource allocation, transplantation, and the relationship between medicine and the law.2

During the Carter administration, the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research was appointed. This distinguished body of appointees, representing a wide segment of the lay and professional community, held hearings throughout the nation and consulted with leading persons within the professions. As a result of their study, 16 volumes were published that covered a wide range of ethical issues in medicine and biomedical and behavioral research) Research study centers focusing on ethical issues in the whole area of new developments in biomedicine have emerged within the past 20 years (sec Appendix B), and many universities throughout the nation offer advanced degrees in medical ethics. As a result, biomedical ethics has become a recognized field of research and study and is considered a legitimate academic discipline.

The current interest in medical ethics, as a discipline in its own right, was prompted by a number of events:

Other events could be mentioned as influencing the increasing emphasis upon the ethical aspects of health care, such as the increasing cost of health care, allocation of limited medical resources and the criteria upon which these decisions are made, new developments in genetic medicine, and possible alteration of the germ line in species. All of these and many more events have focused our attention more and more on ethical issues. Almost all U.S. medical schools have programs in medical ethics, and approximately one-third to one-half have one or more full-time persons teaching courses and consulting in the field.

The Need for a Conceptual Framework

One of the problems in discussing ethical questions with those not trained in philosophy is to keep the discussion on a high level of analysis. There is a tendency to fall into the anecdotal trap in which one case elicits the citing of another and another, and supposedly out of this exchange there would come a decision for judgment that was closely reasoned and could bear the weight of argument.

I do not want to be misunderstood. Experience and case studies are helpful in determining a preferred choice of therapy for a patient, but ethical reflection involves more than a kind of free association from which conclusions are drawn. Also, there is a tendency within the medical community to reduce ethical questions to clinical questions. A few years back I interviewed a prominent neurosurgeon at the University of London about a research project in which I was engaged. At the close of our session I asked, "Would it be possible to make rounds with you tomorrow?" Thereupon he replied, "We are not going to discuss ethics." I reminded him that he would be making value judgments about one form of therapy being better than another, and that these ,judgments involved the language of ethical discourse. He saw my point immediately and said, "Meet me at 9:30 in the morning." l spent a delightful three hours with him and his staff.

In my view, what is needed in the formulation of ethical judgments is a conceptual framework and some formal structure for making medical decisions that would provide decision makers with conceptual tools by which they can evaluate their own thought processes. If one believes that one ethical judgment is its good its another (a popular notion today), then any reference to ethics as a rational discipline becomes irrelevant. One of my colleagues was asked by a student, "Why should I read Kant?" My colleague replied, "Because he is smarter than you are."

On a more serious note, I am suggesting that a knowledge of classical ethical theories enables one to test one's own thinking against what scholars in the field have thought about what constitutes our duty and how we determine right from wrong. In educating medical students, we do not shy away from theories that relate to a better understanding of medical practice: there is a body of knowledge that we assume is important for the student to know. Why should not the same be true in the field of medical ethics? We all function within implied theoretical structures that arc often in conflict. In one situation we may bc very pragmatic, bordering on the opportunistic, while at another time we are very principled and in another context very legalistic. Consistency in making our moral judgments, it seems to me, is a virtue and is a part of what we mean by being responsible. Let us now look at a framework for making our decisions.

An Ethical Work-Up

It must be assumed that before there can be any serious consideration of specific ethical issues in health care, a thorough clinical workup must be done. There is no substitute for an adequate data base. Such information makes possible the responsible pursuit of modes of therapy that will be most beneficial to the patient. Herein lie many ethical issues concerning what constitutes adequate data: How many tests should be given, do the costs of these tests have a bearing upon the rationale for requesting these data, and so on? As the refinement of diagnostic techniques increases, the physician is faced with greater responsibility for selecting those tests that will be most fruitful in choosing the appropriate mode of therapy for the patient. Beyond this primary element, in what constitutes a physician's clinical responsibility, are other factors that are involved in milking ethical judgments.

Risks/Benefits

A consideration of these factors is essentially a utilitarian or teleological ethical approach to the decision-making process. By and large, this is the first question that is posed in milking a judgment about the most desirable mode of therapy for the patient. Utilitarian theories fall broadly into two types:

1. Act utilitarianism insists that the right action is determined by the effects of the action in this particular circumstance. This is often called situation ethics and affirms that each situation must be evaluated on its own terms and that no general moral principle is equally applicable in all circumstances.

2. Rule utilitarianism holds that acting in the best interests of all concerned is a moral mandate that is not determined solely by each particular circumstance. Rather, actions must be judged by the principle of social utility and the effect of that action upon society.

The justification for mercy killing might be argued on an act utilitarian basis in that it would relieve the intolerable suffering for the terminally ill patient. The rule utilitarian would emphasize the effect of such action upon society as a whole and the precedent it would set for the future. Most of us think primarily in terms of the effect that our actions have upon ourselves (egoistic utilitarianism) and the effect that our actions might have upon other persons (universalistic utilitarianism).

Personal interests are often in conflict with our sense of professional responsibility and duty. The western tradition in medicine has stressed that the interests of the individual patient are primary, but now that we are faced with limited medical resources, particularly in the case of the terminally ill, we are confronted with the dilemma of the needs of others who might benefit more than those whose death is imminent. By and large, physicians have resisted thinking in these terms and have resisted the rationing of health care. They have viewed their role as being the individual patient's advocate and have left the larger societal question for the legislator and politician. These practical questions are unavoidable if we are to make an adequate ethical assessment of the health care needs of the society. The application of utilitarian principles is helpful in clarifying our own position regarding these matters. Of course there are weaknesses in the use of utilitarian criteria for our choices. All too frequently, decisions are predicated upon short-term effects, which when viewed in the long term, may neither be in the interests of the individual nor society. Therefore, monitoring our choices by a consideration of alternative ethical postures is helpful as we attempt to be as responsible as possible in choosing one form of action over another (see Smart and Williams, 1973).

Moral Duty

In its more radical form, this approach to ethical choice stresses those moral principles that constitute our highest duty and to which there are no exceptions. Therefore. a consideration of consequences should not be a factor in making moral decisions. This is called deontological ethics. There are elements of this emphasis in our western religious tradition in its stress on our absolute duty to God and his commandments--a divine command ethic.

The classical expression of deontological ethics is in the moral philosophy of Immanuel Kant. He believed that there were universal moral obligations that were binding on everyone and that were an "inexplicable fact of experience" (Kant, 1956). This sense of our highest duty (the categorical imperative: see Kant, 1959) was in contrast to sensate or affective experiences, including desire and impulse. His familiar statement regarding the primary nature of this experience bears repeating: "Two things fill the mind with ever new and increasing admiration and awe . . . the starry heavens above me and the moral law within me" (Kant, 1956, p. 166). In fact, the primacy of moral experience formed the basis for his beliefs about the nature of the self, the existence of God, and the immortality of the soul.

Two formulations of the categorical imperative are particularly relevant to our discussion: (1) the principle of respect for persons as ends in themselves and not as mere means and (2) the principle of universalizability, which insists that all similar cases should be treated in similar ways. A derivative of the former principle is a respect for all persons and their autonomy translated into medical ethics as the right of giving informed consent and the principle of patient autonomy. The latter principle expresses a concern for justice and equity in decisions about health care.

It is interesting to note that when the U.S. National Commission was established in the 1970s to study ethical issues related to research with human subjects, they agreed that three ethical principles--which reflect a deontological ethical stance--should guide their deliberations: (I) respect for the dignity of other persons. (2) beneficence, and (3)justice. These same principles are reflected in the undergirding moral assumptions that constitute responsible medical practice. As Charles Bosk (1979) points out. the norms of clinical responsibility are a part of the character of responsible medical practice, such as honest interpretation of reliable data, keeping the patient's interests foremost in the decision-making process, openness and candor and the duty for full and honest disclosure, and the right of the patient to know. Thus deontological ethics and the duties of the physician are not based necessarily upon the good consequences such actions might bring, but rather upon the inherent nature of these duties as being the right and good thing to do in and of themselves.

Take truth telling as an example. This principle is based upon the assumption that the patient has a right to know about his or her condition, the mode of therapy that is deemed appropriate, the attendant risks and benefits, as well as the right to refuse the recommended treatment. In other words, deception is a violation of the principle of the physician's obligation to tell the truth and the patient's right to know. Let us suppose that a physician decides--based on his or her fear that the patient will become addicted if given a pain relief medication--to give a placebo for the pain. The physician's intentions are, it could be argued, what he or she believes to be in the best interests of the patient, so the patient is told that "this pill will help you." The physician fails to identify that the antecedent to the words "this pill" is "placebo" and may even tell the patient there is evidence to show that this remedy has been effective in many previous similar cases. (The latter statement would be true, because placebos are 30-40 percent effective.)The patient, of course, assumes that it is some form of pain medication or drug, while the doctor knows that it has no medicinal effect other than possibly releasing a chemical agent produced by the body itself (endorphin). Is such an action ethically justifiable?

From the deontological point of view, the answer is no because a fundamental ethical duty to tell the truth has been negated by deception. Kant would point out that lying is never justified because it violates the principle of respect for persons as ends in themselves. The context for his argument is in regard to our duty to keep a promise. Within the medical setting, deception is a violation of the fiduciary relationship assumed to exist between the physician and the patient.

In contrast, the consequentialist might argue that the physician has acted in the patient's best interests and that because the results are salutary, the physician's decision is justified. Or one might argue--from the same ethical position--that the risk of deception is greater than the benefit derived because of the danger that the patient might sometime in the future know that it was a placebo, and as a result, the physician would lose his or her credibility and the patient's confidence. Thus the effect upon the doctor-patient relationship would not be worth jeopardizing. Both are forms of utilitarian arguments, although the conclusions regarding the ethics of such an action are different. The obvious danger of defending the use of a placebo is that, more often than not, the decision is based upon expediency: "It might work--let's try it." Such superficial thinking is unwarranted if we are concerned about our duty to take our moral ,judgments seriously.

Does a deontological ethical approach make any exceptions concerning what constitutes our highest duty'? On one hand, if we accept the Kantian model, his formulation of our duty consists of absolutes. On the other hand, W. D. Ross, a British contemporary philosopher, speaks of a prima facie duty and one's actual duty. The former is a self-evident duty, other things being equal, such as fidelity, keeping a promise, gratitude, justice, and so on. However, because we experience a conflict between our prima facie duties, our actual duties may be determinative as we weigh the merits of one duty over another. It is clear that in actual experience it is impossible to claim that there can be no exception to moral rules or principles because of the complexities of moral choice.4 In Sissela Bok's (1978) book Lying (which is a discussion of moral choice in private and public life), she holds that if one chooses to deceive, the responsibility for defending that choice of breaking the duty of truth telling rests with the person who elects to deceive.

As I view it, the problem is to keep a balance in our ethical judgments. To forget the relevance of our moral duty, or to think only of consequences, would be overly simplistic and would short-circuit the difficult process of making responsible decisions. Some years ago, after a lecture on professional ethics to a public audience, the head of one of the nation's large corporations said to me, "You will find that the greater the responsibility, the more difficult it is to make the right decision." The process of making responsible choices is often agonizing, particularly in health care when life and death decisions often have to be made in concert with the wishes of the patient, the desires of the family, and the professional standards the physician believes should be maintained.

Civil and Criminal Law

Laws reflect the prevailing will of society regarding actions that are believed to protect the rights of the individual and the interests of society. Any adequate approach to moral choice must include a consideration of law. With regard to difficult health care decisions, the physician is confronted by conflicting court decisions. For example, a New York Court of appeals ruled that nasogastric feeding of a 77-year-old patient who was severely demented and bedridden for 3 years had to be continued over the protestations of her daughters and the patient's consistent opposition, when she was well, to continuing care under such circumstances. In contrast, the federal district court in Rhode Island approved removing a gastrostomy tube that had sustained a patient for over two years. This was a precedent-setting case because she was in a state facility--the first decision of its kind by a federal court (Society for the Right to Die, 1988).

Many similar conflicting decisions could be cited. The physician is in an untenable position when the courts are not clear in their judgments or are in conflict with each other at various levels of the court's supervision. A physician in California requested that the district attorney assure her that she would not be prosecuted if she removed the respirator from a comatose patient: he replied that he would not make any judgment before the fact. She removed the respirator and no charge was made against her.

Barber v. Superior Court (1983) is the only case on record in which physicians were charged with homicide after removing all life-sustaining measures, including nutrition and fluids at the request of the family. The physicians involved were finally cleared of these charges by the court of appeals, but only after an agonizing experience on the part of all involved.
The patient has the moral and legal right to decide the extent and type of care he or she desires. In the event the patient is incompetent to make this decision, the physician in consultation with the family should make the best professional judgment possible with the patient's best interests foremost in their minds. Being overly cautious often is an attempt to avoid the best ethical choice. Malpractice suits arc on the increase, in part because of specialization within the medical profession. Specialization often prevents long associations between the "family doctor" and patients, associations that in the past nurtured the traditional fiduciary relationship. Also, the litigious climate of our society has fostered the plethora of lawsuits against health care providers. (In England it is unlawful for an attorney to take a case on a contingency basis. Patient grievances, for the most part, are adjudicated by an appointed body of arbitrators outside of the normal setting of the courts.)

This litigious climate is a reality, but it should not paralyze members of any profession from following the best professional standards they know. Journalists who have not revealed their sources under the threat of imprisonment have demonstrated great moral courage in their fidelity to the highest standards in their profession and serve as role models for what it means to be a professional.

Intention/Motive

It is difficult to discern our own motives behind any given action, let alone determine the intentions of another person. Perhaps the biblical maxim, "Judge not that you be not judged," is applicable in this regard. However, the examination of our own motives is fundamental if we are to appraise adequately the ethical dimensions of our choices. The view is commonly held that the primary motivation for every individual is self-interest that is somehow rooted in our biological and psychological nature. Freud's skepticism about any action being primarily altruistic has influenced, in a negative way, our present attitudes. It is doubtless true that mixed motives motivate our behavior and our choices. It is not my intention to get into the quagmire of this debate, only to make the point that a responsible analysis of what constitutes our ethical responsibility includes taking an honest and serious look at our motives. In biblical Greek, the word kardia refers to the seat of emotions, desires, and basic wants.

The primacy of the duty to serve humankind has been a long-standing tradition in the profession of medicine. The complexities of modern life and the social as well as financial pressures that impinge upon the lives of physicians add to their burdens. This is likewise true of other service professions, such as teaching and the ministry. Physicians are in a unique position, however, because they are dealing with not only life-and-death matters, but also with the intimate lives of people, which affect innumerable other aspects of their lives.

A Concluding Word

This essay has examined at least five aspects of the anatomy of an ethical situation and reviewed, although superficially and briefly, some of the ethical theories that should be considered in making our choices. No one perspective is adequate. No one view of what constitutes our duty is adequate; rather, responsible ethical judgment considers the many--and often conflicting--duties we have. Therefore, we must weigh the merits of these responsibilities in the light of the highest ethical standards we know. The conceptual ethical framework I have suggested, I believe, is helpful in this process.

1See Reiser et al. ( 1977. pp. 3-76) for an excellent discussion of the "ethical dimensions of the physician-patient relationship through history."

2Copies of these publications may be obtained from the Subscriber Service Division. American College of Physicians, 4200 Pine Street. Philadelphia, PA 191114.

3Order from U.S. Government Printing Office, Washington, DC 20402.

4See Beauchamp and Walters (1989. pp.1-72) for an excellent survey of ethical theories as they impinge upon biomedical ethical analysis. I found this a very helpful source in preparing this essay. Also see Frankena (1973) for helpful interpretations of classical ethical theories.

References

Beauchamp, T. L., and L. Waiters. 1989. Contemporary Issues in Bioethics, 3d ed. Belmont, California: Wadsworth.

Bok, S. 1978. Lying. New York: Random House.

Bosk, C. 1979. Forgive and Remember. Chicago: University of Chicago Press.

Cook, R. 1977. Coma. Boston: Little.

Edelstein, L. 1967. Ancient Medicine, O. Temkin and C. L. Temkin, eds. Baltimore, Maryland: Johns Hopkins University Press.

Frankena, F. 1973. Ethics, 2d ed. Englewood Cliffs: Prentice-Hall. Harvard Medical School. 1968. A definition of irreversible coma:

Report of the Ad Hoc Committee of the Harvard Medical School to examine the definition of brain death. J. Am. Med. Assoc. 205:337 340.

Hastings Center. 1987. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying. A Hastings Center Report. Bloomington: Indiana University Press.

Kant, I. [1788] 1956. Critique of Practical Reason. Tr. by L. W. Beck. Indianapolis, Indiana: Bobbs-Merrill.

Kant, I. [1785] 1959. Foundations of the Metaphysic of Morals. Tr. by L. W. Beck. New York: Bobbs-Merrill.

Reiser, J., A. J. Dyck, and W. J. Curran, eds. 1977. Ethics in Medicine. Cambridge: MIT Press.

Smart, J. J. C., and B. Williams. 1973. Utilitarianism For and Against. Cambridge: Cambridge at the University Press. Society for the Right to Die. 1988. Conflicting decisions on tube-feeding: N.Y. High Court and R.I. Federal Conrt. Soc. Right to Dic Newsi. Winter: 1, 4.

Society for the Right to Die. 1989. Patients' rights in the courts. Soc. Right to Die Newsl. Spring: 1, 4-5.

APPENDIX A


American Medical Association Principles of Medical Ethics*

Preamble

The medical profession has long subscribed to a body of ethical statements developed primarily for the benefit of the patient. As a member of this profession, a physician must recognize responsibility not only to patients, but also to society, to other health professionals, and to self. The following principles adopted by the American Medical Association are not laws, but standards of conduct which define the essentials of honorable behavior for the physician.

1. A physician shall be dedicated to providing competent medical service with compassion and respect for human dignity.
2. A physician shall deal honestly with patients and colleagues, and strive to expose, those physicians deficient in character or competence or who engage in fraud or deception.
3. A physician shall respect the law and also recognize a responsibility to seek changes in those requirements which are contrary to the best interests of the patient.
4. A physician shall respect the rights of patients, of colleagues, and of other health professionals, and shall safeguard patient confidences within the constraints of the law.
5. A physician shall continue to study, apply, and advance scientific knowledge, make relevant information available to patients, colleagues, and the public, obtain consultation, and use the talents of other health professionals when indicated.
6. A physician shall, in the provision of appropriate patient care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide medical services.
7. A physician shall recognize a responsibility to participate in activities contributing to an improved community.

*American Medical Association. Chicago. 1980. All rights reserved. Reprinted by permission.

APPENDIX B

Bioethics Research Centers †

American Society of Law & Medicine
765 Commonwealth Avenue
Boston, MA 02215
Publications:
American Journal of Law & Medicine
Law, Medicine & Health Care

The Hastings Center
360 Broadway
Hastings-on-Hudson, NY 10706
Publications:
The Hastings Center Report
IRB: A Review of Human Subjects Research

The Institute for the Medical Humanities
The University of Texas Medical Branch
Galveston, TX 77550
Publication:
The Institute for the Medical Humanities Chronicle

The Kennedy Institute
Georgetown University
Washington, DC 20057
Publications:
Kennedy lnstitute Newsletter Journal of Medicine and Philosophy

Center for Christian Bioethics
Division of Religion
Loma Linda University
Loma Linda, CA 92350
Publication:
Update

Center for Biomedical Ethics
Rose Medical Center
4567 East Ninth Avenue
Denver, CO 80220
Publication:
Front Lines

Center for Biomedical Ethics
University of Minnesota
Box 33 UMHC
Harvard Street at East River Road
Minneapolis, MN 55455
Publications:
Bimonthly newsletter
Reading packets: "Topics in Biomedical Ethics"

Center for Bioethics
St. Joseph Health System
440 South Batavia Street
Orange, CA 92668
Publication:
Ethical Currents

Society for Health and Human Values
925 Chestnut Street
Philadelphia, PA 19107
Publication:
Notes

Journal of Medical Humanities and Bioethics
Published by Human Sciences Press

Bioethics Reporter
Published by University Publications of America

† Prepared by Alexander M. Capron and J. Wesley Robb.





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