Allen Buchanan

Our society has long sanctioned, at least tacitly, a degree of conflict of interest in medical practice and clinical research as an unavoidable consequence of the different interests of the physician or clinical investigator, the patient or clinical research subject, third party payers or research sponsors, the government, and society as a whole, to name a few. In the past, resolution of these conflicts has been left to the conscience of the individual physician or clinical investigator and to professional organizations. The public is no longer willing to allow health care providers to wholly govern their own conflicts of interest for several reasons. These include: new forms of health care financing and delivery that provide innovative and lucrative opportunities for physician or insurer enrichment at patient expense; the increased importance of commercial research support as peer-reviewed governmental research support has decreased; evidence that physicians and clinical investigators too frequently resolve conflicts of interest in their own favor; and a general societal mistrust of authority. This volume represents a multidisciplinary effort, drawing from philosophy, medicine, law, economics and public policy to identify and categorize conflicts of interest in medical practice and clinical research, and, where possible, to offer a mechanism for resolving them. Part I addresses conflicts of interest from a theoretical perspective, offering basic concepts and analytical frameworks. The second part discusses two topics prominent in current health care policy debates--self-referral and financial incentives to limit care. Part III examines conflicts of interest generated by pharmaceutical industry involvement in clinical practice and research. The final section deals with conflicts of interest in clinical research in several contexts, including institutional reviews boards, clinical trials, Cooperative Research and Development Agreements between government and private researchers, brokerage of research subjects by Contract Research Organizations, and cost-effectiveness studies.

Today we are witnessing two dramatic processes: the fragmentation of old states and empires, followed by the emergence of new states and new forms of political association; and the construction of new economies out of the ruins of state socialism. These two processes—the redrawing of political boundaries and the creation of economies—are not independent of one another. In some cases, the desire for a new, more productive economy supplements other motives for state-breaking and state-making. In others, even if the fragmentation of political union results from other factors, such as ethnic divisions or the resurgence of nationalism against a weakened imperial center, the fragments may sort themselves out into new states, federations, or commonwealths, according to what they believe to be maximally productive economic units.

From a moral standpoint, lethal drones are intrinsically no worse as a means of warfare than bombing or sending commandos to kill enemies. From the perspective of their users, they have six major advantages over more conventional weapons: they are often cheaper; their use can be more readily concealed; they allow for more precise targeting, with the potential for less “collateral damage”; their use can involve less serious infringements of sovereignty than invasion by troops; and they may be less likely to provoke widespread hostile reactions by the population of the country in which they are used than military operations involving troops on the ground. But these advantages generate three major risks: of violating sovereignty, of over-using the military option, and of making it more difficult to identify violations of constraints against targeting noncombatants. To deal with these risks, a Drone Accountability Regime is needed that imposes obligations on states, which in turn would be required to impose them on their agents. Since it would be infeasible to negotiate a treaty-based legal regime at present and for the foreseeable future, the Drone Accountability Regime should be informal and should involve transnational actors as well as states. Its key principle should be transparency, helping enable civil society to hold states accountable, and its central agent would be an Ombudsperson with broad authority to investigate situations and publicize her findings. No institution can ensure that states, or operators, are held fully accountable to appropriate standards of conduct, but such a regime could increase the degree of accountability for the use of lethal drones.

Is it right to use biomedical technologies to make us better than well or even perhaps better than human? Should we view our biology as fixed or should we try to improve on it? College students are already taking cognitive enhancement drugs. The U.S. army is already working to develop drugs and technologies to produce "super soldiers." Scientists already know how to use genetic engineering techniques to enhance the strength and memories of mice and the application of such technologies to humans is on the horizon. In Better Than Human, philosopher-bioethicist Allen Buchanan grapples with the ethical dilemmas of the biomedical enhancement revolution. Biomedical enhancements can make us smarter, have better memories, be stronger, quicker, have more stamina, live much longer, avoid the frailties of aging, and enjoy richer emotional lives. In spite of the benefits that biomedical enhancements may bring, many people instinctively reject them. Some worry that we will lose something important-our appreciation for what we have or what makes human beings distinctively valuable. Others assume that biomedical enhancements will only be available to the rich, with the result that social inequalities will worsen. Buchanan shows that the debate over enhancement has been distorted by false assumptions and misleading rhetoric. To think clearly about enhancement, we have to acknowledge that human nature is a mixed bag and that our species has many "design flaws." We should be open be open to the possibility of becoming better than human, while never underestimating the risks that our attempts to improve may back-fire.