The National Commission is an example of an advisory body that was housed within the agency it advised and had an action-forcing mandate. The commission published several effective reports on specific topics and summarized its thinking in The Belmont Report (1978), which clearly enunciated the underlying ethical principles that should guide research involving human subjects. Whether or not due to National Commission reports, the incidence of gross abuse of research subjects appears to have diminished subsequent to their publication. The requirements that the commission's recommendations be published in the Federal Register and that DHEW respond in writing within 180 days proved useful in the implementation of the recommendations.

The President's Commission, on the other hand, is an example of a commission convened to examine issues that spanned the concerns of several agencies-not only human subjects research, but also aspects of medical practice. With a prodigious output of reports, many of which have influenced thought in ethics, law, and subsequent legislation, the President's Commission can be considered overall to have been an effective societal mechanism for deliberation about social and ethical issues in biomedicine.

A MULTILEVEL APPROACH TO BIOETHICS DELIBERATION

After considering all of these factors, the committee concluded that the most effective method for dealing with complex ethical and social quandaries would be a capacity for response at multiple levels of society. The committee therefore proposes strengthening the multitiered system of public deliberation at local, institutional, professional, community, state, and national levels, and particularly recommends filling a key gap through reestablishing a supra-agency ethics commission at the national level. The recommendation for a multitiered system rests on the conviction that capacities for public ethical deliberation (through academic experts, health professionals, religious communities, secular agencies, and an increasingly informed and interested public) have blossomed in all regions of the country. At the same time, certain contemporary ethical quandaries, including many ramifications of molecular genetic research, can best be considered for the nation as a whole through a supra-agency national commission. Two supra-agency models presented by the committee are a single national commission with a broad mandate and a set of national commissions, each with a more focused charge. The recommendations elaborate on the elements proposed for the multitiered system and the features the committee deems desirable for any new national commission. In general, the committee believes that decisions about public policy should occur as closely as



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