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Sub-Saharan Africa is the epicenter of the HIV/AIDS epidemic, and in this issue of the Journal, seven authors discuss the moral, social and medical implications of having 70% of those stricken living in this area. Anton A. van Niekerk considers complexities of plague in this region (poverty, denial, poor leadership, illiteracy, women's vulnerability, and disenchantment of intimacy) and the importance of finding responses that empower its people. Solomon Benatar reinforces these issues, but also discusses the role of global politics in sub-Saharan Africa, especially discrimination, imperialism and its exploitation by first world countries. Given the public health crisis, Udo Schuklenk and Richard E. Ashcroft defend compulsory licensing of essential HIV/AIDS medications on consequentialist grounds. Keymanthri Moodley discusses the importance of conducting research and the need to understand a moderate form of communitarianism, also referred to as 'ubuntu' or 'communalism', to help some Africans understand research as an altruistic endeavour. Godfrey B. Tangwa also defends traditional African values of empathy and ubuntu, discussing how they should be enlisted to fight this pandemic. Loretta M. Kopelman criticizes the tendency among those outside Africa to dismiss the HIV/AIDS pandemic, attributing one source to the ubiquitous and misguided punishment theory of disease. The authors conclude that good solutions must be cooperative ventures among countries within and outside of sub-Saharan Africa with far more support from wealthy countries. Key Words: Africa, AIDS, bioethics, disease, ethics, health care, HIV, plague, research

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. Key Words: abuse and neglect, best-interests standard, children's rights, ethics, medical decision-making, parental rights

The Americans With Disabilities Act (ADA) promotes social justice by protecting disabled persons from discrimination and prejudice. It seeks equality of opportunity for them and protects their well being by giving them fair access to goods, services and benefits. These rights are circumscribed in the ADA, however, by constraints of cost, efficiency, utility, and certain social mores. The ADA offers little direction about how to set priorities when these values come into conflict, or about whether equality of opportunity favors equivalent or preferential treatment for disadvantaged people. Until these ambiguities and potential value conflicts are resolved, a central moral and social problem remains unresolved: How can we demonstrate commitment to the rights and welfare of those with severe disabilities while placing fair limits upon their claims? Five special concerns are discussed: (1) eligibility and the allocation of health care; (2) the meaning of 'qualified but disabled' in employing people with mental disabilities; (3) equal opportunity and problems of envy and malingering; (4) ADA accommodation and public protection through testing and licensure; and (5) ADA protection and problems of backlash. Rather than simply wait to see what courts and administrative agencies decide, we should evaluate the moral conflicts, articulate criteria, and help make some difficult choices on morally defensible grounds. Key Words: disabled, health benefit plans, health care rationing, health care reform, health priorities, health services accessibility, Oregon, Rawls, selection bias, social justice

A panel of scientists, lawyers, consumers and ethicists has recommended that informed consent should precede any procedure that removes tissue samples from a person if those samples could be used in future research. This is especially important if the samples are linked to information that could be used to identify the person who contributed it. In the case of anonymous samples, informed consent may not be necessary but the use of the samples should be evaluated by an institutional review board (IRB). The person contributing the sample should decide whether they want to be contacted in the future and whether they want their identity linked to the sample. The panel also recommended that Congress pass legislation to ensure the confidentiality of the samples and to protect the person who contributed them from discrimination if research determines they have a genetic disorder., Objective.--To develop recommendations for obtaining adequate informed consent in the future when gathering tissue samples that may be used for genetic studies and defining the circumstances under which it is necessary to obtain further consent if tissue samples already in hand are to be used for such research. Participants.--Scientists, ethicists, lawyers, and consumers selected by the National Center for Human Genome Research and the Centers for Disease Control and Prevention to represent a wide array of opinions. Evidence.--Statutes, regulations, and cases and articles on law and ethics. Consensus Process.--Initial workshop, followed by circulation of several drafts of this document with opportunities for comment by workshop participants and others as well as smaller meetings involving participants with widely differing views. Conclusions.--Genetic research using stored tissue samples poses an array of benefits and risks to individuals, researchers, and society. As a result, the workshop participants conclude that (1) informed consent is required for all genetic research using linkable samples unless conditions for limitation or waiver are met; (2) informed consent is not required for genetic research using anonymous samples but may be considered if identifiers are to be removed from currently linkable samples; (3) institutional review boards could usefully review all protocols that propose to use samples for genetic research; and (4) further work regarding these issues is warranted. (JAMA. 1995;274:1786-1792)

Human Immunodeficiency Virus (HIV) seroprevalence studies use anonymous tissue samples obtained in hospitals and clinics without donor consent. This can be justified as a response to a public health emergency, but should not be seen as setting a precedent for waiving consent whenever samples are anonymous. The following recommendations grow out of this discussion: (1) Studies using anonymous tissue samples should not be automatically exempt from consent requirements, and consent should not be waived simply to avoid anticipated refusals, low participation rates or self selection bias. (2) The consensus on informed consent favors fulfilling as many of the elements of informed consent as reasonably possible, so studies should be assessed individually to determine if any or all elements of informed consent should be modified or omitted. (3) There is a need for greater regulation of the research use of tissue samples. (4) Investigators seeking approval to waive consent or modify elements of informed consent should document the sort of new findings that they believe would effect their calculations about the benefits and burdens to subjects who are enrolled in the study, and institutional review beards should indicate whether they agree with the investigators' analysis. Key Words: AIDS, Consent, Ethics, HIV, Notification, Privacy, Research, Screening, Surveillance.

'Applied' is a technical term describing a variety of new philosophical enterprises. The author examines and rejects the view that these fields are derivative. Whatever principles, judgments, or background theories that are employed to solve problems in these areas are either changed by how they are used, or at least the possibility exists of their being changed. Hence we ought to stop calling these endeavors 'applied', or agree that the meaning of 'apply' will have to include the possibility that what is applied may be changed. The so-called applied fields of philosophy, therefore, are not derivative. The strongest cases to the contrary are the foundationalist views that what we apply is epistemically privileged. Different foundationalist views take different principles, judgments, or background theories to be epistemically privileged. Strong and weak versions of each of these fuondationalist views are considered but none establish these fields as derivative.

The medical humanities program has 50 contact hours with medical students in the required curriculum, well-subscribed fourth-year electives, and programs for residents, fellows, and faculty. Course content is summarized by year. Several crucial decisions in the program's first year have affected its nature and development. (Author/MSE)

This paper reviews the work of several authors, D.W. Brock, D. Callahan, L. Churchill, L.M. Kopelman, R. Tong who consider assumptions and arguments about how to allocated health and dental care to children fairly. They use various approaches including feminist, rights based, and principled considerations, applying general notions of duty or justice to the issues of children's access to basic health and dental care. Two discuss these issues in relation to the work of David Hume. These authors consider children's greatest unmet health needs, including that of dental care, often mistakenly regarded as medically unimportant in terms of children's wellbeing, opportunities, and self-image. They review possible age bias against children in the allocation of health and dental care, the gap between what we say and do where children are concerned, and whether some fundamental shift in social thinking needs to occur. Key words: Brock, Callahan, Churchill, Kopelman, Tong, children, health care, dental care, children, resource allocation, ethics, justice

Children around the world suffer from poor health outcomes due to a lack of basic health and dental care, even in affluent countries. Yet duties exist to provide children these services when a society can afford to do so based on the importance of promoting (a) social utility, (b) autonomy and equality of opportunity, (c) children's well-being or best interest due to their vulnerability, and (d) compassion, sympathy, empathy and solidarity. In addition, (e) these considerations show that, in general, if competent adults should have access to federal- or state-funded health care goods, services, or benefits, then so should children. This argument has limitations; nonetheless, it can help identify systematic biases against children in federal- or state-supported health care programs and gain children access to better basic health and dental care. Key words: children, dental care ethics, health care, Hume, justice, resource allocation

A complex problem exists about how to promote the best interests of children as a group through research while protecting the rights and welfare of individual research subjects. The Nuremberg Code forbids studies without consent, eliminating most children as subjects, and the Declaration of Helsinki disallows non-therapeutic research on non-consenting subjects. Both codes are unreasonably restrictive. Another approach is represented by the Council for the International Organizations of Medical Science, the U.S. Federal Research Guidelines, and many other national policies. They allow research ethics committees or institutional review boards to authorize studies with acceptable balances of likely benefits and harms, but neither clarify how to balance them nor explain the meaning of pivotal concepts, like 'minimal risk.' Paths to the improvement of balancing or consequentialist approaches include (1) improving standardizing of risk assessment, (2) rejecting crude utilitarianism, (3) identifying and justifying normative or moral judgments, and (4) acknowledging extra-regulatory thresholds and deontological or non-negotiable duties to children. Key words: benefit, children, ethics, harm, justice, research, risk, utilitarianism

To the Editor.-- I disagree with Dr Kopelman's analysis of the 21-year-old "Baby Doe" rules and her call for the American Academy of Pediatrics (AAP) to withdraw what she characterized [...]

To the Editor.-- I write to correct 1 factual error in the excellent review by Kopelman and Murphy (1) regarding the 407 panels and use this case to highlight a [...]