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Journal of Medical Ethics 2000;26:291–295

Book reviews

Physician-assisted end-of-life issues and she and her of the “slippery slope” and to the fellow editors have produced what is, relevance of the Dutch experience in Suicide: Expanding on the whole, an interesting, readable this context. the Debate and topical collection of essays. Finally, contributions on the Whether it succeeds in expanding and achievements and availability of pallia- deepening the debate is, however, tive care, the Oregon law, and on the Edited by Margaret P Battin, itself a matter for debate. alleged distinction between physician- Rosamund Rhodes and Anita Silvers, On the one hand, a number of con- assisted suicide and euthanasia, would New York and London, Routledge, tributions do help to develop the have been valuable. The book does, 1998, 463 pages, £45. debate, particularly Patricia King and however, have useful appendices con- Leslie Wolf’s essay on the perspective taining the text of the Supreme Court This substantial academic volume, of African-Americans, Patricia judgments; the “philosophers’ brief” which seeks to expand the debate on Mann’s on the meaning of death, and submitted to the court, and the physician-assisted suicide, is a signifi- the contribution by Margaret Battin Oregon Death With Dignity Act. cant addition to the growing number herself, which questions the common In short, in some significant re- of edited works on one of the most assumption that physician-assisted spects this volume serves to expand important issues in contemporary suicide should or would be rare. the debate. In others, however, it gives bioethics. On the other hand, the book risks a misleadingly narrow impression of it. The introduction observes that the giving a misleadingly narrow and JOHN KEOWN, essays illuminate the evolving, increas- rather one-sided impression of the Faculty of Law, University of Cambridge ingly “nuanced” American debate in debate. the wake of the landmark Supreme First, although the editors write that

Court decisions upholding laws they aimed to produce a “fairly evenly Children, Families, http://jme.bmj.com/ against physician-assisted suicide. Its balanced” collection, contributors in and Health Care twenty-three chapters are divided into favour of physician-assisted suicide five sections: “conceptual issues”; outnumber those against by around Decision-making “those at risk”; “the practice of medi- two to one. cine”; “the impact of legislation”, and Secondly, only two essays oppose Lainie Friedman Ross, New York, “religious perspectives”. physician-assisted suicide in principle, Oxford University Press, 1998, 197 How, then, is the debate said to be and those for religious reasons. The pages, £30. evolving? Conceptually, the editors book’s failure to include a single claim, both proponents and oppo- philosophical contribution articulat- Over recent years in the UK there has on September 26, 2021 by guest. Protected copyright. nents now appeal to the same values, ing and defending the traditional prin- been increasing emphasis placed on such as autonomy, beneficence, and ciple of the inviolability of human life children taking responsibility for what medical integrity. Politically, patients’ mars the volume. This failure is all the happens to them. This American pub- groups have focused attention on the more unfortunate not only because lication oVers a refreshingly diVerent likely eVects of decriminalisation, par- several essays criticise this principle, view of parental and family autonomy ticularly on “vulnerable” groups such and those criticisms therefore are and advocates a model of constrained as the disabled and racial minorities. allowed to pass unchallenged, but also parental autonomy. Ross argues that Medically, there is greater recognition because the principle of the inviolabil- giving children rights equivalent to of decision making by patients and ity of human life was reaYrmed by the those of adults is “to deny them the relatives and of the inadequate provi- Supreme Court and underpins its rea- protection they need” and render sion of palliative care. Religiously, dif- soning. The volume could easily mis- them “even more vulnerable than they ferent denominations have extensively lead a reader into believing that the presently are”. Her thesis is that whilst examined their respective theological principle no longer plays an important children should be included in the positions. In short, it is claimed that part in the current debate. decision making process, parents the debate is not only “larger and Thirdly, moving from principle to should be responsible for their health louder” but also “deeper and more practice, another omission is the care even after the children have profound”. Dutch experience of euthanasia and achieved some threshold level of com- This well-produced book is cer- physician-assisted suicide, an omis- petency. However, the autonomy of tainly a worthwhile contribution to the sion which is all the more puzzling in the parents should not be absolute. debate. Margaret Battin is deservedly the light of the significance attached Rather it should be constrained by a one of the most well-known writers on by the Supreme Court to the dangers modified principle of respect for

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292 Book reviews persons which takes account of the A Philosophical ing to show is that while at first sight specific limitations of children’s com- these essays may appear to be some- petency. Disease: Bioethics, what disparate, they actually have a The author herself suspects that she Culture and Identity connecting theme. I am not sure will be criticised for not according though whether Wittgenstein’s later enough respect to competent children Carl Elliott, New York and London, work provides an adequate resource and that her interpretations may for this task, although its general Routledge, 1999, 188 pages, £12.99. permit of wider parental autonomy relevance is clear. than many readers will find accept- To see why this is so it may be help- Bioethics became established as a dis- able. She addresses each anticipated ful to refer to Stephen Toulmin’s criticism systematically and argues her tinct discipline in the United States in work, which has been influential in the case cogently and carefully, presenting the 1960s. The paradox is that it arose development of Elliott’s thinking. argument and counterargument, liber- in part from a general background of Toulmin has made the bold claim that ally annotating and referencing her criticisms of biomedicine at that time, text, and pointing out areas where but has largely followed the traditional the philosophy of medicine has a spe- information is scant or questionable. pattern of biomedicine in being reduc- cial role to play, not just in medicine She recognises that parents’ concep- tionist and orientated to pragmatic but also in philosophy. Now if this is to tion of what is best for their family may problem-solving. So for some thirty be fostered successfully I think that a not be what others would perceive as years the theoretical debate within greater range of ideas will be required best and that indeed their beliefs and bioethics was mainly about which than can be derived from Wittgen- values may even limit opportunities ethical theory, principle, or combina- stein’s work alone, and this is the pro- for children. Nevertheless she believes tion of principles to subscribe to; gramme within which Elliott’s ideas that their autonomy should be ques- whilst in practice many came to see would seem to fit most comfortably. tioned only if their decisions are disre- bioethics as a new medical subspe- However, one significant development spectful of the child’s developing cialty, with hospital ethicists as profes- in taking this forward is missing in personhood; it is not for the state to sional experts. Elliott’s book. This concerns the define ideal parent-child relationships However, this mainstream develop- current growth of interest in phenom- or goals. ment of bioethics has not gone unchal- enology and hermeneutics, particu- The model of constrained parental lenged, and there have always been larly in relation to the philosophy of autonomy promoted in this scholarly those advocating other approaches. the body, which would seem to herald The Centre for Philosophy and Health work allows flexibility and breadth of a fruitful engagement between the Care here in Swansea has been a good application which, the author con- Anglo-American and Continental tra- example of this, having consistently tends, makes it practical as a decision ditions in philosophy, broad enough to concerned itself with many of the making model across a wide range of accommodate Wittgenstein, as well as health care situations. In the second issues that Elliott raises. These focus the diverse range of other approaches part of the book she tries out the on the question of whether any

which are now emerging, and will no http://jme.bmj.com/ model in various practical contexts: systematic philosophical theorising, or research, organ donation, medical precise arrangement of principles, doubt be added to in future. treatment, and adolescent sexual ac- could ever provide definitive answers None of this is intended to diminish tivity. She concludes that it oVers a to deeply troubling medical dilemmas, the importance of Elliott’s book, viable alternative to the best interests because of the inevitability of moral which both reflects as well as being an standard and is particularly useful in disagreement. Such dissident voices important contribution to, this ongo- situations where interests compete tended to be rather isolated until a ing debate. If work such as Elliott’s and conflict. Underlying her position decade ago, but since then have gains the prominence it deserves it will is a respect for parents as individuals increased very significantly in num- signal the end of the worst features of with their own needs, interests and bers and in a variety of diVerent ways, bioethics, by demonstrating the cen- on September 26, 2021 by guest. Protected copyright. rights, a fact which she sees as too though united in challenging the tral importance of a more reflective often ignored. Parental and family earlier orthodoxy . encounter between medicine and phil- autonomy deserve a wider latitude of Elliott does not then provide any- osophy. The individual chapters are tolerance than they commonly com- thing entirely novel, but rather uses themselves full of imaginative observa- mand. several examples to demonstrate how tions relevant to the particular issues This slim volume deliberately in- a range of these innovative approaches selected, for example organ donation V vites challenge. The author concludes can provide a di erent perspective on and drug treatment for depression. familiar issues. He has accomplished with the hope that the book will Also it is part of Elliott’s argument that this by selecting from and expanding promote dialogue on how health care too much work in philosophy is either decisions should be made for children on some of his own papers which were published during the 1990s. He has trivial or unnecessarily technical or even if readers disagree with her both, and this book is neither of these. “process or substance”. Many will thus converted them into a series of It should be required reading both for indeed disagree with some of her essays which form the central chapters health care professionals who have an thinking, but she should certainly suc- of the book. Narrative ethics and interest in ethics, and for all those pro- ceed in stimulating debate. virtue ethics are the most notable approaches he adopts, but he has also fessionally engaged in bioethics and HAZEL E MCHAFFIE added an introduction and conclusion the philosophy of medicine. which are explicitly informed by Witt- Research Fellow, Medical Ethics, University of DAVID GREAVES Edinburgh genstein’s later philosophy, with the Deputy Director of Research, Institute of Medi- aim of providing coherence to the Centre for Philosophy and Health Care, cal Ethics book as a whole. What he is attempt- University of Wales Swansea

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Book reviews 293

Medicine and the be found in either increasing non- The Goals of profit organisations or in a re- Marketplace: the enforcement of the physician’s advo- Medicine: The Moral Dimensions of cacy role. Non-profit organisations Forgotten Issue in have not always been altruistic nor Managed Care patient-centred and must realise a Health Care Reform profit, no diVerent than for-profit Kenman L Wong, Notre Dame, institutions. To Wong the diVerences Edited by Mark J Hanson and Daniel Indiana, University of Notre Dame between for-profit and non-profit are Callahan, Washington, DC, Press, 1998, 232 pages, $32.00 illusory and health care an industry Georgetown University Press, 1999, that is “far too complex to be run by 239 + xiv pages, $55 hb. Health care in our society has reached missionaries and candy-stripers”. a critical point in its evolution. Nu- However, Wong is not an unrestrained The dominant theme in health care merous articles have decried current free market champion. “A restrained and its ethics as we move into into the approaches to health care reimburse- marketplace is necessary to protect the new century looks likely to be how to ment by focusing on their negative rights of all parties.” The question is allocate scarce health care goods fairly. impact on patient relationships. How- how the two, “business and medicine, Many ingenious proposals have been ever, few have reflected on the en- whose missions apparently follow devised for determining how to choose croaching import of business ethics on widely diverging paths”, can be inte- between funding service A and service these relationships. Kenman Wong’s grated eVectively. B, how to fix on appropriate levels for book Medicine and the Marketplace is a Wong supports a view of health care funding individual services, and how critical first beginning of this reflec- business ethics called stakeholder to decide who will receive a service tion. Wong engages in a comprehen- theory. He believes that “a stakeholder and to what extent. Yet it would not be sive ethical assessment of managed approach can be formulated” to sup- controversial to assert that none of care and the impact of business ethics port essential values in health care. these proposals has met with wide on obligations to patients. As Wong Wong feels that managed care organi- acceptance and trust. One of this rightly observes, the ethical discus- sations should be “held to behavioral remarkable book’s premises is that the sions concerning health care and its standards which are consistent with reason for this general failure is that economics, focus on obligations of the objectives of service to the com- rationing proposals duck the question: physicians not those of institutions or munity through the provision of qual- “What is medicine for?” To pursue other health care professionals. How- ity health care” and correctly observes this question seriously is to sail into ever, health care institutions are in- the tension between the two roles of waters less familiar to Anglo- creasingly interposed between the health care institutions, ie, businesses American readers than those of medi- physician and patient and their deci- and delivering health care. However, cal ethics, namely, those of philosophy sions are based on business ethics. The “adequate moral grounds ... cannot be of medicine. The idea is that by book begins by reviewing the history obtaining some (or a better) answer to http://jme.bmj.com/ found in the traditional understanding of business and medicine. To describe this question we will be in a much bet- either of medical or of business ethics. medicine as being free from the world ter position to prioritise services, that The traditional patient-centered ethic of money is patently wrong. However, is to say, to determine which of two is unrealistic and irresponsible” and he there is increased concern about the services better fulfils the purpose or sees hope in an “enlightened stake- foundational morality of the current purposes of medicine. managed care approach to reduce holder approach” as an ethical frame- This strategy has obvious interest. health care expenditures. The tension work to govern the behaviour of man- Yet it has an equally obvious diYculty. is that “the traditional ‘good’ for busi- aged care organisations. While medical ethics has by now a ness has been and continues to be Although Wong takes a very impor- relatively stable set of methods and on September 26, 2021 by guest. Protected copyright. profit, while the ‘good’ for medicine is tant first step in an analysis of business perhaps some results which claim the wellbeing of patients”. ethics in health care, stakeholder moderate public acceptance, philos- Wong describes the moral typology theory does not provide the ethical ophy of medicine is more varied and of managed care as six ethical views in framework he hopes for. It does contentious, both as to method and two categories. Those critical of man- provide an important first step, ie, results. This being so, it might be aged care are:1) patient-centred pur- identifying stakeholders, however, it thought perverse to seek solutions to a ists; 2) market reform purists; 3) does nothing to help rank stakeholder problem, even a large and diVuse one, explicit rationers, and those in support interests, which is the critical tension by translating it into a harder one that of managed care are: 4) for-profit in health care today. For example, how is still less definite in its scope. The managed care champions; 5) non- do we rank the interests of patients ground-breaking work of Norman profit organisational supporters, and against those of the health care Daniels arguably suVers from this 6) cautious managed care supporters. institution? Wong’s book is a critical defect, in that having determined that Wong’s criticism of each of these and important first step in the debate needs are the fairest basis for allocat- approaches is well presented and his on managed care and the discussion of ing health care, his account of need discussion illustrates that “a simple business ethics in health care. It has defeated attempts to operational- dichotomy, for and against managed should be read by anyone interested in ise it. care, obscures the moral (and practi- medical ethics. If one considers the history of cal) issues of the managed care medicine, and if one compares the debate”. JOHN F PEPPIN diversity of health care systems and Wong realises that the answer to Center for Bioethics, Pain Management and “philosophies”, it could be that much limited health care resources cannot Medicine, Des Moines, Iowa, USA. of what passes for philosophy of

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294 Book reviews

medicine rests on a confusion be- graduate seminar on philosophy of to issues of reproductive ethics should tween exegesis of the goals of medi- medicine or health care reform. be guided by the principle of procrea- cine as historically and culturally con- tive autonomy. According to this princi- structed and the attempt to divine the RICHARD ASHCROFT ple, competent members of society trans-historical essence of medicine. Lecturer, should be left to make their own We think we are doing the latter, when Centre for Ethics in Medicine, University of decisions about how, when and where in fact we are generally able to do only Bristol to reproduce. Only when there is a the former. This insight has proved compelling reason—such as evidence very useful in the historiography of of significant harm—should the state science and in political philosophy, The Future of Human be allowed to intervene in such decision and so I think it would prove in the Reproduction: Ethics, making. theory of medicine. Harris’s justification for this princi- This volume reports on a Hastings Choice and Regulation ple draws on the writings of Ronald Center-coordinated international pro- Dworkin, who has argued that pro- ject to devise a core set of goals of Edited by John Harris and Soren creative autonomy should be regarded health care which would better answer Holm, Oxford, Clarendon Press, as a democratic liberty just as freedom the question: “what is medicine for” 1998, 254 pages, £35.00. of speech and racial equality are. in a way that would make health care Dworkin—and Harris—maintain that reform able to proceed along humane It is often the case that the subheading procreative autonomy is a freedom not and rational lines. The book opens of a book is more revealing than its title. just for those who live in societies, with a description of the project by the The Future of Human Reproduction is not such as the United States, with written editors, and is followed by a consensus really about the future of human repro- constitutions, but for anyone living in statement on the values, and their duction. Apart from John Harris’s pro- a democracy. meaning, of contemporary health jections into the future, most of the One suspects, however, that this care; the description summarises the book is concerned with the present of elegant defence of procreative au- views of the project participants. This human reproduction. The subheading, tonomy would not wash with a statement is followed by the position instead, tells us more. Harris and number of the other contributors to papers prepared by each participant Holm’s collection is about choice; the book. Marie Fox, for instance, group in the project. Participants were about who should decide and why, doubts whether choice is such a good drawn from 14 countries, including about whether the state should regulate thing after all. Fox thinks that “femi- the UK, the USA, China, Chile, Swe- our choices and even about whether nism must be prepared to abandon its den and Germany. Predictably, most choice is such a desirable thing after all. sacred cows” and accept that the of the papers are American, but the This theme fits well into today’s notion of choice has not served wom- volume is pleasing in not being merely debate on medical ethics in general and en’s interests. Choice has made a reflection on the failed Clinton reproductive ethics in particular. women look self-serving and has Choice is no longer viewed as necessar- encouraged conflict between a woman

health reforms. However, while careful http://jme.bmj.com/ and interesting consideration is made ily a good thing. Instead, it is often and her fetus. Fox suggests that the of the diversity of European views, and regarded as problematic, bringing with picture of the “selfish, amoral woman produced by choice discourse” means of the relations between diVerent it dilemmas, confusion and even guilt. At the very least, choice means valuing that feminists must change their tack. medical traditions (notably Western one thing over another. As Jonathan One course of action might be, Fox allopathic medicine and Chinese Glover observes in his impressive chap- argues, to communicate with oppo- medicine), little attention is paid to the ter on eugenics: “As soon as we start nents, rather than demanding things philosophical issues thrown up by choosing at all, we enter a zone of great from them. medicine in the poor world. This is the moral diYculty where there are impor- In the context of fertility treatment, only weakness—and it is a consider- tant boundaries to be drawn”. it is often easier to argue for limits on September 26, 2021 by guest. Protected copyright. able one—in the volume. Given that Many of the contributors to The upon procreative liberty because of Callahan’s critics have often argued Future of Human Reproduction are quick the children that it aims to produce. that his attempts to place limits on to observe that, contrary to popular So, whilst Marie Fox is unconvincing, medical need are unwittingly com- perception, reproductive choice is not those contributors who suggest that plicit with attempts to limit care given universally respected, particularly when policy in assisted reproduction should to the poor, this omission is surprising. reproduction is assisted. Margaret Bra- be guided by the interests of the One cannot, I suggest, have a philos- zier, for instance, notes that UK legisla- children born, rather than the interests ophy of medicine without a political tion governing in vitro fertilisation of the parents, have a better case. In economy to match. leaves little room for reproductive their challenging chapter, Bateman Overall, however, this is a remark- autonomy, especially when it comes to Novaes and Salem suggest that as- able volume: rich, of high scholarly access to services. Marie Fox demon- sisted conception has modified wom- standard, intriguing, and readable. strates how choice in abortion is limited en’s role in reproduction. Such high- The strengths of the book by the law; Simone Bateman Novaes tech interventions mean an increased —philosophical and cultural sophisti- and Tania Salem remind us that frozen concentration upon the embryo and a cation, a clear eye as to the applicabil- gametes are often the property of the weakened role in decision making for ity of its proposals, and a strong sense clinic; and Harris observes that as far as the woman having treatment. of the historical and political nature of cloning and gender selection are con- Bonnie Steinbock thinks constraints medicine—make it a book which cerned, reproductive choice is severely upon reproductive liberty may not be should be read with profit by anyone limited. such a bad thing, although she is con- interested in this area. In particular, it For Harris, this lack of choice is cerned that such limits are not the would make a useful textbook for a troubling. He argues that our approach preserve of the state. Steinbock

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Book reviews 295

suggests that judges would be acting the Warnock Report, which identified clusion: children should have com- irresponsibly if they ignored evidence issues arising from the increasing use plete information about their biologi- that a child born of, say, surrogacy is of human reproductive technologies. cal origins. Some of the arguments in likely to be psychologically impaired The authors of the original collection favour of this stance are: as a result. After all, she says, “no one felt that the rights of children to The children will find out anyway, is harmed or deprived by not being information about their origins had either inadvertently from a family brought into existence”. not been addressed satisfactorily by member or friend, or in the course of Guido de Vert takes the concern the committee chaired by Warnock, their lives through the health care sys- about the welfare of others one stage which indeed supported a policy of further. He argues that there are three donor anonymity. This policy of ano- tem, especially with the increased use parties to consider in assisted repro- nymity was incorporated into the of genetic testing; those writing as duction: the woman (or couple), the Human Fertilisation and Embryology “donor oVspring” report sensing that embryo/child and the doctor. Accord- Act (1990). Ten years on, this new something was diVerent in their fami- ing to de Vert, the doctor “has his own collection revisits the issue, oVering lies (for example family resemblances responsibility for the consequences of powerful arguments, anecdotes, and and circumstances of one’s birth are his acts”. He therefore has a duty to some research supporting the au- never mentioned). consider whether his patients will thors’ position that with regards to The children have a right to know— make good parents and, if he is not information about origin the interests several authors refer to the section in convinced of their suitability, to refuse the United Nations Convention on the to provide treatment. of the children created by donor Rights of the Child which claims for The recurrent problem here is insemination should take precedence evidence. Fisher and Sommerville, in over those of their infertile parents or children the right to a name, national- their chapter on postmenopausal the gamete donors who enabled their ity, knowledge of parents, and right to women, as well as Steinbock and de creation. preserve one’s identity. Vert, all worry that there is little data We have learned from the practice It is damaging to family relation- showing what harm might be inflicted of adoption that for some people ships to begin and exist on a founda- on children born of assisted reproduc- knowledge about their biological tion of dishonesty. Stigmas attached to tion. Such a lack of evidence of harm origins is crucially important if they these practices are thus reinforced and should, arguably, make these con- are to have a strong sense of their own perpetuated. Practices in other coun- tributors abandon the notion of lim- identity. Every day it becomes clearer tries, and data from Sweden, suggest ited access to assisted reproduction. that knowledge of family medical his- that there should be little diYculty But they do not. Ultimately, it is only tory, including genetic information, recruiting gamete donors who are Harris who is prepared to stick by the may be necessary during one’s life in willing to be identified. This addresses order to make choices about one’s principle that reproduction should be the main argument against total open- own health, medical care, and deci- an autonomous activity, free from out- ness, which is that no one would be side interference unless a significant sions to procreate. Current practice— willing to donate. chance of serious harm can be demon- and legislation from most countries, http://jme.bmj.com/ strated in advance. as reviewed in the appendix of this This is just a sampling of the In his introduction, John Harris book—supports parents in secrecy, arguments presented in this work; suggests that the eclectic group of not just about the identity of the others are grounded in the contribu- contributors to the volume reflect the donor, but about the very fact that tor’s discipline or personal circum- central theme of choice. An extension the child was created with donated stances. That this book manages to of that theme might be to choose to gametes. present this wide variety of perspec- read the book or to choose not to. The interdisciplinarity of the au- tives in less than 100 pages is to its From my point of view, however, read- thors of the various essays in Truth and credit and the editors should be con- ing it is the right choice to make. the Child contributes to the success of gratulated for the consistent quality of on September 26, 2021 by guest. Protected copyright. JULIET TIZZARD this book, which is published by the all contributions. Director, Progress Educational Trust, London British Association of Social Workers. How powerful are the arguments Contributors include an anthropolo- presented in Truth and the Child? Very gist, a paediatrician, a sociologist, a powerful indeed, if we may judge from Truth and the Child 10 psychiatrist, a clinical geneticist, social the fact that the British government years on: Information workers, and academic lawyers. Very has recently announced plans to interesting and valuable are contribu- change the law guaranteeing donor Exchange in Donor tions from a family with two adopted anonymity and thus conferring on V Assisted Conception children; from two “donor o spring”; children conceived with donated gam- from an egg donor; from a mother of etes the right (once they become children conceived by donor insemi- adults) to trace the donor. Edited by Eric Blyth, Marilyn nation, and from a mother of twins Crawshaw and Jennifer Speirs, Bir- born following a surrogacy arrange- mingham, British Association of Social ment. These are voices often left out of CHRISTINE HARRISON Workers,1998, 83 pages, £5.95. the medical and ethical discussions of Department of Pediatrics and Joint Centre for these issues. Bioethics, University of Toronto, and Bioethics The original Truth and the Child was The arguments presented by the Department, The Hospital for Sick Children, published in 1988 after publication of contributors all lead to the same con- Toronto

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