The United States deliberates on biomedical ethical dilemmas in various ways and in a distinctly U.S. context. Individual persons, professional groups, health care institutions, universities, and government organizations have all participated in these deliberations. The Institute of Medicine has gathered together an impressive panel of scholars and has charged them to pause and examine what has been done, who has done it, and whether it has been successful and to suggest future directions. Their report, Society's Choices: Social and Ethical Decision Making in Biomedicine, is unlike any other text in the field of medical ethics, and it partially achieves its goals.

Examining the roots of current controversies and the U.S. celebration of the individual, the text elaborates on the political and legal mechanisms for problem solving, focusing on government and later deciding that the courts have provided more complexity than they wish to tackle. Professional groups and institutions, including institutional review boards and academic health centers, have participated with unique perspectives and disadvantages that are clearly delimited. Public awareness and engagement have also been robust within communities and small groups of individual persons.

The panel has bravely attempted to define some criteria for the success of these diverse efforts. They point out special opportunities and hazards for each of these groups and recognize the reality of unintended consequences. Measuring the process and the outcomes may require a consensus that does not exist, and yet the panel makes an excellent case to support the effort. Unfortunately, after a scholarly discourse, it concludes that success is a matter of res ipsa loquitor.

Bold print recommendations ask for the strengthening and review of current methods, including institutional review boards, hospital ethics committees, the Ethical, Legal, and Social Implications (ELSI) program of the Genome Project, and graduate biomedical educational institutions. The boldest recommendation is for a national commission appointed by the President or Congress of the United States. The panel mourns the passing of the President's Commission and suggests that a similar deliberative body should be established, free of government branch coercion, and that it should be well funded and clearly charged. The authority of such a commission is to come from the required adoption of recommendations by affected government entities or, lacking such adoption, from a public statement explaining why the recommendations were not accepted. The panel recognizes the difficulty of defining the scope of such an agency, admits that some topics (such as abortion) will be off limits, and worries about effectiveness. Some will contend that this goal is self serving for the Institute of Medicine, providing it with a mission for the next decade.

Half of this book is devoted to commissioned papers that elaborate on and sometimes diverge from the essay by the panel. These papers are, for the most part, scholarly and well researched, but they should not have been included in this book. Without them, the message would still be clear, and the book would be smaller and less costly, allowing more persons to have access to its well-written text.

In 1992, the Swedish government decided to address the increasing demands of its socialized health system on the limited resources of their federal coffers. A Priorities Commission was established that questioned individual persons, organizations, and local governments about priorities in health care. Draft documents were prepared, circulated, and examined in public forums, and this led to the publication of Priorities in Health Care: Ethics, Economy, Implementation.

The report is an astonishing example of how a government might make explicit the rules for the distribution of communal wealth toward health care. The authors have carefully avoided rationing or allocation and instead have listed priorities. In this case, the priorities were rank orderings of principles rather than services. Beginning with an ethical platform, the authors ruled that, in Sweden, human dignity would take precedence over need and solidarity, which in turn would take precedence over cost-efficiency. The next level involves the prioritization of political and administrative decisions. Life-threatening diseases take precedence over prevention with documented benefit, which supersedes treatment of less severe acute and chronic diseases. Care for reasons other than disease or injury is excluded. The authors recognize the need to distinguish political prioritization from clinical prioritization, which gives first nod to life-threatening acute diseases and then gives precedence to severe chronic diseases (including palliative care), then habilitation and rehabilitation, and then less severe acute and chronic diseases. The report explicitly acknowledges that refugees and asylum seekers have the last claim on resources. Persons from the United States may disagree with the process, but readers will find the results an enlightening counterpoint to the Oregon experiment.