Foreword

sive Cancer Center. The discussions speak to issues shared by general and subspe-cialty medicine. The rapid progress in scientific knowledge and technology in the field of medicine has created many new ethical dilemmas antedating any consensus on older moral issues. Some of these issues are now before the public in referenda, in high-visibility court cases, and in political debate, most prominently in relation to the costs of and access to medical care. For those of us who did post-medical school training in a university medical center and remain affiliated with a university or medical research institute, research in general and clinical research in particular was viewed as an article of faith, as an unmixed blessing, and above reproach. In "Clinical Trials and Physicians as Double Agents," Levine highlights conflicts of interest between the physician as researcher and the physician as trusted healer. Some suggestions are made to protect the patient's rights and to reduce the extent of the conflict in these dual roles of the physician. In his discussion, "Rationing Health Care: Its Impact and Implications for Hematology-Oncology," Duffy reviews the problems of maldistribution and exceedingly high costs of medical care and some of the proposed solutions, including national health insurance, the Canadian health plan, the Oregon proposal, and "inter-generational charity" as possible choices for rationing of medical care. The observations on "Cancer Therapy: Reimbursement of New Therapeutic Technologies" by Williams are based upon his consecutive experiences as clinical investigator, oncologist in private practice, acting chief of a university section of medical oncology, clinical oncologist in an oncology group practice, and director of medical policy for a large health-oriented company. Inevitably, some of the concerns expressed relate to rising health care costs in a period when this nation is either unwilling or unable to underwrite the cost of providing open-ended access to available medical technology for all its citizens. He highlights some of the more costly and controversial new therapies, including high-dose chemotherapy for solid tumors, as well as autologous bone marrow transplantation, hyperthermia for deep-seated non-cutaneous tumors, autolymphocyte therapy, and colony-stimulating factors. He provides some criteria for a rational approach to decision making in this perplexing realm. Some of the most difficult ethical and legal decision making concerns patients at 63 * All rights of reproduction in any form reserved.