treatments. The Deciding report specifically addressed a series of troubling dichotomies (e.g., withholding and withdrawing, killing and letting die) and a series of troubling clinical settings (e.g., seriously ill newborns, orders to withhold attempts at resuscitation, decisions for adults who do not have decision-making capacity, treatment for patients who have permanently lost consciousness). Also, its prose and presentation was specifically designed to be accessible to any health care professional. By chance, the report was released just as the "Baby Doe" case and the federal response to it was unfolding, and it took a much more temperate tone than the official federal response. For these reasons, Deciding was one of the "best sellers" printed by the Government Printing Office, which made it available at cost. It remains a classic reference used in court cases, professional literature, and education.

Securing also had an eager public, since allocation and equity were at least as central to public concern in 1983 as now. However, this report underwent many changes as the commission gained new members in its final months. The central ethical argument stayed largely intact, but many examples and much strong language were excised. The report thus ended up being an academic discourse on the role and function of commissions, rather than affecting the public issue of access to health care.

The National Commission spoke primarily to federal officials responsible for human subjects regulations and to the biomedical research community (including members of IRBs). The President's Commission, on the other hand, chose to address many constituencies (which varied depending upon the topic). As a result, its reports on some subjects were virtually unknown to readers who were concerned solely with other topics, although specialists in bioethics generally kept abreast of-and commented on-the commission's work across the board, just as they had the work of the National Commission. Both commissions considered some reports more important than others, and these same reports were usually regarded as more influential and important by outsiders as well (see background paper by Gray in this volume).

The central characteristics of both commissions were that they undertook to study complex and sometimes quite highly charged topics; they were able to do so in a thoughtful way because they operated outside the usual political channels; and they were influential both because they operated with an official mandate and because they produced reports that were accessible to the intelligent lay person as well as the scientific or ethical expert. The ideal of impartiality, one of the primary characteristics of ethical discourse, may not have been met completely, but the work of these commissions was a serious approximation. They both attempted to examine all sides of the issues and to move beyond the limits of self-interest and advocacy to find broad grounds of agreement on controversial positions.



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