Training Manual on Ethical and Human Rights Standards for Health

Journal of Medical Ethics 2001;27:67–70

Book reviews

Training Manual on are not serious or repeated. Doctors Apart from these admittedly idi- who make the “wrong” decision in an osyncratic comments, I think this is an Ethical and Human ethical dilemma may be acting in per- admirable manual. I hope that in the Rights Standards for fectly good faith and practising per- future Dr Havard will produce an fectly good medicine. The essence of expanded version which will include Health Care an ethical dilemma is that there is usu- more detailed discussion of the an- Professionals ally no simple correct solution. If there swers to the searching questions he were, it would cease to be an ethical poses at the end of each clinical vignette. John Havard, London, BMJ Publish- dilemma and all the medical ethicists and philosophers who have made a ing Group, 1999, 71 pages, £5.00. RAYMOND HOFFENBERG career out of the subject could find something else to talk or write about. Flat 5, 16 Davenant Road, This manual is designed to provide Each problem has to be analysed indi- Oxford, OX2 8BX teaching modules on medical ethics vidually and the solution directed for health care professionals in devel- towards doing the best thing in the oping countries. The author acknowl- interests of the patient or, occasion- Human Germline edges that, although there are com- ally, of others, including the commu- mon themes, their medical ethical Gene Therapy: nity. Perfectly sound and reputable dilemmas are often quite diVerent doctors or philosophers may hold Scientific, Moral and from those which occur in developed opposing and irreconcilable views. In countries and the approach needs to Political Issues the teaching of medical ethics this be somewhat less Western in orienta- point should be emphasised. I failed to tion. Emphasis is properly given to David B Resnik, Holly B Steinkraus find it in the manual, but perhaps Dr topics such as AIDS/HIV and the sta- and Pamela J Langer, Austin, Texas, Havard intended it to emerge in the tus of women and children which cre- R G Landes Company, 1999, 189 case discussions. ate special local problems. Although pages, US$99.00 (hb). universal principles of medical ethics At a personal level I was sorry to are aYrmed, care is taken to avoid the note the adherence to uncompromis- ingly orthodox views about some top- This book provides a worthwhile and trap of imposing “our” views and challenging introduction to scientific solutions on “their” situations. As a ics. Is it not time for us to reconsider our judgment that payment for partici- and moral issues in germline gene teaching aid the manual is well con- therapy. It contains two parts, dealing structed, starting with the enunciation pation in medical research is a bad thing? We allow people to work for with scientific and moral issues re- of general principles, followed by spectively. In the first, scientific part, a money in far more hazardous occupa- comment and a series of well- chapter on what the alternatives to tions, for example deepsea diving, conceived clinical examples, each of germline therapy are is helpful, espe- fishing and underground mining (in which embodies several diVerent ethi- cially in pointing out that many of the South Africa nearly 890 gold miners cal problems. The manual has a goals one might want to achieve by have been killed in the past two years); tendency to mix up examples of pure using germline therapy may be bad medicine—negligence, incompe- why not in far less risky reputable achieved, at a slighter risk, by using tence, rudeness, lack of compassion— medical research? And is the possi- non-genetic technologies such as se- the sort of things that might bring bility of carefully controlled trade in lective embryo implantation and selec- doctors to the attention of the General organs for transplantation so abhor- tive abortion. However, the authors Medical Council in this country; and rent that we cannot even discuss it? In argue that germline therapy may be an examples of clear ethical dilemmas, both cases there is a risk of exploita- option in certain cases in which these resolution of which is seldom easy and tion, but there are ways of minimising alternatives are not viable (page 72). is not necessarily a function of good or this, and there could be clear benefits In the second part of the book, bad practice. I believe a distinction to seriously impoverished people who moral and political issues in germline should be drawn between the two. have little opportunity to find alterna- therapy are discussed, such as the dis- Doctors who practise bad medicine tive sources of money. Are we in dan- tinction between therapy and en- need to be condemned or punished if ger here of doing just what the manual hancement, potential benefits and the oVences are serious or repeated, or purports to avoid, namely imposing harms, rights and responsibilities, jus- given a warning or advised to retrain our set of values on others whose tice, our concept of humanness, and or to work under supervision if they circumstances are quite diVerent? public policy issues.

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The authors present an argument tively forbidden, the authors believe it is such as intelligence, will arouse these from parental rights to the eVect that both unrealistic and wasteful to forbid feelings. This happened when Herrn- parents have a right to use germline enhancements. Instead, they suggest stein and Murray, in The Bell Curve therapy (page 117). This right, how- that we should allow genetic enhance- (1994), claimed that there is a racial ever, may be restricted in order to pre- ments within a genetically “normal” variation in the genetic component of vent harm to others, such as the range (page 135). I think that this sug- intellectual capacity and made contro- children who will result from such gestion has some plausibility, but I versial claims on this basis. This is a therapy. The authors conclude that, should like to make two comments. fitting illustration of the need to do since germline therapy would not be in Firstly, even within the boundaries of precisely what the authors are trying the best interest of children (or further what is genetically normal, germline to do in the present book, namely generations) at this point in time (due enhancements may promote inequality “standing back in contemplation” to various technical diYculties and of opportunity. And secondly, the (page x) about the place of behav- uncertainties), it would be irresponsible authors reject a ban on genetic en- ioural genetics in today’s and tomor- to perform it, although this situation hancements, in part because they be- row’s society. may well change in the future (page lieve it is unrealistic, since governments What is new in modern behavioural 119). and private citizens have strong inter- genetics? First, scientists are able to Under what circumstances, how- ests in such enhancements. But they identify with greater precision, genetic ever, may we say that a child has been provide no reason to believe that a ban links to alcoholism, criminality, thrill harmed by germline therapy? If a par- on enhancements beyond what is ge- seeking, aggression, sexual orienta- ticular child will come into existence netically normal would be invulnerable tion, Huntington’s disease, schizo- whether or not germline therapy is to such pressure. phrenia, dyslexia, anxiety and so on. performed, then, sometimes, it may be After the chapter on justice comes a Second, the potential to identify the harmed by having (had) the therapy chapter on how germline therapy may particular genes or gene complexes performed (if, for example, the aVect our humanness. Amongst other that lie behind behaviours and dis- therapy accidentally causes it to de- things, the authors discuss–and reject– eases looks likely to increase rapidly, velop cancer); it may be worse oV than the view that germline therapy may be thanks in large part to the Human it would be had the therapy not been wrong because it is unnatural. So, while Genome Project. Third, with increas- performed. But typically, the numeri- there are some uses of germline therapy ing gene identification will come the cally same child will not come into that are unacceptable, this is not increasing possibility of gene therapy. existence whether or not the therapy is because they are unnatural, but rather Many of the questions concerning performed (perhaps, if the therapy is because they harm or demean people. how to handle this new technique have not performed, no child is produced, NILS HOLTUG important ethical dimensions. Here, or perhaps the parents do not opt for Department of Philosophy, by means of example, I just want to IVF, or perhaps, if they do, a diVerent University of Copenhagen, mention some of the ethical problems embryo is implanted). In such cases, Denmark that the second point about gene then, it seems that a child is only identification raises. harmed by germline therapy if its life is I believe the central question here is worth not living. And arguably, this Behavioral Genetics. what kind of genetic knowledge we will not be the case very often. The Clash of Culture want to have. There may be an instru- However, the authors prevent them- mental value in knowing what will selves from claiming that a child who and Biology enable us to cure antisocial behaviours would not have come into existence, and diseases; but what is the value— had germline therapy not been pro- Edited by Ronald A Carson and apart from being a prerequisite for a vided, can be harmed by this therapy, Mark A Rothstein, Baltimore and future cure—of identifying genes that because they take existence and non- London, The Johns Hopkins Univer- lie behind traits, behaviours and dis- existence to be evaluatively incompa- sity Press, 1999, 206 pages, £33.00. eases that cannot be changed or rable (page122). So it seems that, cured? According to Allan J Tobin, in according to them germline therapy This book is a collection of essays on this volume, the enthusiasm for seek- can only harm a child if it would exist recent findings in behavioural genetics ing this knowledge seems to be higher whether or not the therapy were and on the appropriate ethical, social among people for whom the infor- performed, and be worse oV if it were and legal reactions to these findings. mation is abstract, compared to peo- performed. But this does not seem to The authors come from various fields. ple for whom it is immediate: “For restrict parental rights much. The collection does not attempt to physicians, genetic tests are like any In an illuminating chapter on justice, answer systematically all the questions other diagnostic tool, but for people at the authors argue that germline therapy it raises, but I believe that the book risk, they lead literally to life-and- may aVect human equality. We can might be of some use in attempting to death decisions. In one case, for imagine a society in which the people systematise and analyse the ethical example, a genetic diagnosis for Hunt- who are able to pay, provide genetic problems in this area. ington disease, delivered over the tele- enhancements for their children, who Behavioural genetics is not in itself a phone, was the immediate stimulus for are then (further) advantaged as com- new field of research. We are painfully suicide” (page 3). pared to children whose parents are not aware of the claims made for the exist- In some cases there may be a able to pay. Germline therapy may ence of genetic factors in behaviour positive value also, for the most imme- aVect the range of opportunities a per- throughout the twentieth century. diately aVected. David C Rowe and son has and so may aVect (lessen) “Eugenics” is today charged with very Kristen C Jacobson claim that the equality of opportunity. While such negative feelings, and there is a risk findings on schizophrenia have been consequences could be avoided if ge- that any claim by modern scientists welcomed as a release for the parents netic enhancements could be eVec- about a genetic basis for behaviour, and particularly for the mothers, who

www.jmedethics.com Book reviews 69 no longer have to blame themselves does dependency. The human need, want to live in. This will depend upon “for fostering the illness in their for love, respect and dignity, is more individual concrete choices. What we children by their supposed emotional strongly indicative of our dependency should not do, however, is choose “to coldness and inconsistent discipline” than of our autonomy. The real focus devalue the latter part of a normal life (page 14). But in this regard there is a here, I suggest, should be on the span” (Leaman, page 186). slight tension in this book between person, not on autonomy. Institutions which deal with the eld- diVerent contributions. For the book Hostler provides a rigorous analysis erly should certainly invest in this ends with Troy Duster’s chapter, of personal development and what it book. The issues it deals with are cru- which emphasises the danger that might mean in old age. It is worth not- cial: not least of all, the issue of genetic test results might lead to the ing his important final point, that our ageism. In his own chapter, Lesser blaming of parents as the genetic models might determine the facts we convincingly declares that, in dealing source of their child’s disease— can see. Models can be limiting, with questions concerning the ration- children sometimes refer to their whereas our everyday concepts have ing of treatment, although the eVects genetic disease as something their par- more breadth. And Chadwick of ageing might be relevant, chrono- ents gave them—and I fear that this suggests, surely rightly, that “ageing” logical age is not. He concludes, question of guilt and blame will be is multifaceted. It struck me that we passionately and appropriately: “we even more important in the future, need deeper unpacking of the notions should be tough-minded and unsenti- also as far as schizophrenia is con- being considered: what can we say mental, and resist the temptation to do cerned. Provided that no cure is found about the person, about models, or the what will almost certainly do no good, for this disease, may not parents in the everyday use of concepts? simply because we feel we must do future who knew they had the gene for Gavin Fairbairn’s clear use of every- something. But we should not pretend schizophrenia have to explain why day concepts, however, is counterin- that easing or extending a person’s they brought children into the world? tuitive, if not perverse. Allowing some- final years, or months, or even days, is These questions and many others one to die, he says deals death. Well, ‘doing no good!’” (page 211). could do with a more systematic treat- they certainly die if we allow them; JULIAN C HUGHES ment than is the case here, but once and death is a consequence of our again, that is not the ambition of this Consultant in Old Age Psychiatry, Centre for allowing them. But in what sense do the Health of the Elderly, particular volume. we deal them death? They just die. Newcastle General Hospital, Newcastle upon DAN EGONSSON, Furthermore, according to Fairbairn, Tyne, NE4 6BE Department of Philosophy, Lund University killing might venerate life. Sure, it Sweden might end suVering, but only by end- ing life. It perverts language, however, Bioethics: A Christian to suggest that aiming to end life Ageing, Autonomy somehow respects it. This is to vener- Approach in a ate death and that will not go down and Resources well in the dock. Pluralistic Age I was more impressed by the clinical Edited by A Harry Lesser, Aldershot, insights of Winner and Herzberg. I Scott B Rae and Paul M Cox, Grand Ashgate, 1999, x + 245 pages, £39.45 take comfort from Winner’s assertion Rapids, Michigan and Cambridge, (hb). that: “A good clinical service is one UK, Eerdmans, 1999, x + 326 pages, that has a small but definite incidence $24.00/£15.99. We should be passionate about the of discharges that go wrong” (page elderly. This book contains, albeit with 65). We should be on the side of In a morally pluralist, or in Alasdair the occasional lull, some passion, vulnerable elderly people, even if this MacIntyre’s terms “morally frag- adroit philosophical argument and involves some risks. Especially if, as mented”, society it seems almost inevi- fascinating social and political in- Herzberg describes, the alternative is table that people engaging with issues sights. It originates from a conference to sit forlornly “staring blankly at a of bioethics should operate within in 1992 and, despite talk of Mrs budgerigar or television” (page 73). something like John Rawls’s idea of an Thatcher, the book has aged well. The Attfield repeats his point, made pre- “overlapping consensus”—the area in first half deals with autonomy in the viously in this journal, that our moral which there is broad agreement be- elderly; whilst the second considers obligations in medical ethics have an tween people with diVerent compre- the allocation of scarce resources. The international aspect. The point seems hensive worldviews, and in which they shift from ethics, via clinical practice, cogent, but its punch is softened by are able and willing to operate with the to economics and politics is eVected inequity at home. Paul Johnson teases shared criteria of what Rawls calls with little eVort, precisely because of out the complications surrounding “public reason”. There are, of course, the book’s passion. For it deals with lack of fairness in the distribution of those who are uneasy about this real problems that aVect individuals economic resources. As we await the approach, usually because they see and nations. report by the royal commission on moral fragmentation as being more I wonder if autonomy was a Thatch- long term care, his discussion of inter- pervasive and consensus more diYcult erite notion?! We loved it in the generational transfers is illuminating, to achieve, than the Rawlsians believe. individualistic 1980s, but its appeal if disconcerting. Seemingly, what it is From opposite wings Alasdair MacIn- has lessened. It does not solve all our right to do might just have to reflect tyre and Tristram Engelhardt join problems and is, perhaps, a hindrance what is possible. But that conclusion forces to question the viability of the to some elderly people. Dunn links it deserves more philosophical scrutiny. liberal consensus. to being human and to human needs. As Cribb asserts, moral and political There are, of course, problems with I am sure autonomy relates to being decisions on this macro level are deci- an overlapping consensus. People with human, but (as Lamb recognises) so sions about what kind of society we religious convictions often feel that the

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part of their comprehensive worldview son with full attendant rights (page Two concluding comments: First, that is outside the “overlap” includes 176). Is it really true that the Bible the authors give little if any indication the most constructive and important attributes personhood to the unborn of how their “distinctive biblical in- contributions that their beliefs have to from the beginning of pregnancy? As sights” might commend themselves to oVer. They are convinced they have far as I can make out, the Bible does others in a pluralistic situation. This is distinctive insights and truths that not in fact address this question, or a pity, because others, like Bill May or should aVect practice in positive ways. make unambiguous and universal as- Paul Ramsey, have shown interest- They want to contribute these to pub- sertions one way or another. It is per- ingly, for example, how biblical con- lic debate because they consider them haps good to remember with embar- cepts such as covenant may helpfully valid and true, but they often feel that rassment that the Genesis 3 account of illumine the doctor-patient relation- this is not allowed. Theologians who the Fall as the origin of the pains of ship. In bioethics today there is a operate in terms of natural law or childbirth was sometimes used as a widespread openness to well-argued believe in a rational common morality, justiﬁcation for denying pain relief to insights from wherever they may have little diYculty in operating in mothers in labour. come. We all perhaps still need to bioethics along with others; similarly, a In other places Rae and Cox argue learn how best to conduct medical number of theologians, mostly Protes- more theologically, and assert that ethical debate in the condition of tants such as Paul Ramsey, James fundamental to a Christian approach today’s pluralism, and here Rae and Gustafson and Stanley Hauerwas, are general revelation, common grace, Cox’s careful accounts of views and have eschewed natural law, but en- and the dominion mandate at crea- cases can be valuable. Second, Rae gaged very constructively in debates tion. This brings them very close to and Cox seem rather reluctant to face on bioethics. natural law thinking. And this is head-on the ethical ambiguity some- Rae and Cox are Bible-based evan- indeed where they come out, with times involved in the practice of medi- gelicals who attempt to move directly sensible procedures for handling cine. In some situations there is no from the Bible and biblical narratives bioethical quandaries, and some well- clearly right or good way forward; one to bioethical conclusions in ways that argued positions on euthanasia, has to act without the assurance of the are sometimes rather problematic, physician-assisted suicide and abor- rightness of the action. Perhaps it is even to other theologians. It is not tion. Sadly, their brief treatment of the precisely at the point of ambiguity that easy, for example, to see how poetic appalling injustices of the American the most important contribution of biblical statements about God “know- health care system does not lead to a theology is to be made. ing” people in the womb, or being sustained biblical or theological cri- D B FORRESTER involved in conception really lead to tique, or any suggestion that things New College, Mound Place, the conclusion that “the fetus is a per- might be diVerent. Edinburgh EH12 6DZ

www.jmedethics.com Journal of Medical Ethics 2001;27:206–214

Book reviews

Building Clouser, in a response co-authored Ethics Codes in with Bernard Gert denies that his Bioethics– framework has the flaws he identifies Medicine— Conversations with in the principlist approach, and he Foundations and further refines the definition and Clouser and Friends critique of principlism. Achievements of on Medical Ethics The second major group of papers Codifications since is concerned with the pedagogics of Edited by Loretta M Kopelman, medical ethics. What is the purpose of 1947 Dordrecht, Kluwer Academic Pub- teaching medical ethics (making Edited by Ulrich Tröhler and Stella lishers, 1999, 250 pages, £72.00. medical students good problem- solvers or good people)? What are the Reiter-Theil, Aldershot, Ashgate, 1998, 357 pages, £39.95 We sometimes forget that medical eth- core elements of the curriculum? And, ics has a history, and that many of the what is the best method of teaching? issues we discuss today have already The editor of the book, Loretta This book is a collection of essays been discussed many times previously. Kopelman, has written one of these which originate from two, mainly As the field grows older, and the papers, and she puts her finger on the European, workshops in 1996 on eth- pioneers retire, we are, however, given dilemma of how to define the goal of ics codes before, and especially after, some opportunity to recognise that medical ethics teaching. Can we really the appearance of the Nuremberg there is in fact such a history, and that say that we only provide students with code in 1947. The book has previously we could learn much from paying problem-solving skills within the field been published in German, and a attention to it. A number of histories of ethics, and that we do not care number of contributions have been of bioethics have been published, and whether they use these skills for good translated from the original German collections centred around the work of or bad purposes? Will we not have to and French manuscripts. major figures are also starting to admit that we also (at least partly) aim The majority of the 26 papers cover the development of ethics codes from appear. at making some of them better per- the Hippocratic oath to the present The present volume is a collection sons? time, but some papers look at possible of papers centred around a critical This book is more successful than codes for new areas such as predictive discussion of the contribution of K most in the genre of Festschrifts.It medicine and resource allocation in Danner Clouser to the development of contains a fair number of personal bioethical theory, and to the teaching health care, and some discuss the anecdotes about K Danner Clouser, of bioethics. The authors include Tom more general questions of the but they are never allowed to substi- Beauchamp, Dan Callahan, Al Jonsen, importance and transcultural validity tute for a frank and critical assessment H Tristram Engelhardt, Bob Veatch, of ethics codes. The papers are gener- of his contributions to medical ethics. and other well-known names from the ally well written and clearly argued. first wave of American bioethics. The The responses from Clouser are also There are no serious translation er- contributions, and the responses from very well written and contain impor- rors, but there are a number of minor Clouser, fall in to two groups. The first tant clarifications of his position. I annoying translation problems, as group is concerned with Clouser and have therefore no hesitation about when the names of ancient Greek Gert’s famous critique of principlism recommending the book. It will be doctors in a French contribution are (a term they initially coined in a 1990 especially valuable for three groups of not translated but given in their paper). Tom Beauchamp and Bob people, those interested in: 1) the his- French form (“Celse” for “Celsus” Veatch argue in separate papers that tory of bioethics; 2) the discussion etc). the critique is misguided, partly be- about the theoretical basis of medical Very few of the historical papers cause it misinterprets the views of ethics, or 3) the problems inherent in contain findings that have not been principlists, partly because Clouser’s teaching medical ethics. published previously, but by being own ethical views seem to be open to collected in one volume they make the exactly the same kind of critical argu- history very easily accessible. The ments concerning lack of theoretical SØREN HOLM most philosophically interesting pa- foundation, lack of problem-solving Institute of Medicine, Law and Bioethics, pers are those that discuss the legiti- power, and underdetermination of the University of Manchester & Centre for macy of ethics codes and the transcul- ethical framework. Not surprisingly, Medical Ethics, University of Oslo tural validity of such codes. These

www.jmedethics.com Book reviews 207

papers raise some fundamental ques- themselves”. Adoption of this Millian are sometimes caricatured: are we tions about the legitimacy of codes principle, which is argued for in the really supposed to believe that “many produced by oYcial representatives of introduction, along with the adoption influential religions and conservative (a segment of) the medical profession. of principles of equality (that the groups” have the “ultimate aim” of Can codes regulating the conduct of needs and interests of all should be criminalising premarital sex (page one party in an essentially two-sided taken into account) and of responsibil- 85)?! doctor-patient or researcher-research ity for the welfare of one’s fellow But the best of the book is in chap- participant relationship be formulated beings, raises, it may be said, three ters two to seven. Chapter two does an without taking account of the views of questions: who is a person (and there- excellent job of refuting the paternalist those on both sides of the relationship? fore to be taken into account); when is arguments against allowing voluntary And, can codes produced by Western a person suYciently competent, and euthanasia (this does not settle the medical associations be transferred to when do people have to sacrifice some issue, though, because there are vari- other areas of the world without liberty to help or protect the welfare of ous other arguments). Chapter three modification? A very interesting an- others? Chapter 1 tackles the first of successfully refutes the arguments for swer to the last question is given in a these questions, following the defence medical paternalism as a general social paper by Robert Baker. He argues that of the principle of liberty in the intro- policy: particularly impressive is the the reason the Nuremberg code has duction; chapters two to four deal with identification of emotional blackmail transcultural validity is not primarily issues raised by the second question— and dishonesty as being as coercive as that it is based on some set of univer- whether voluntary euthanasia should legal or physical control. Chapter four sal moral norms, but that it is a resolu- always be opposed on paternalistic is, regrettably, more sketchy, but tion of a universal set of conflicts. grounds, whether a general pro- makes a start in identifying the princi- Baker argues that wherever medical gramme of coercion in patients’ own ples of a form of health education that research takes place in its modern interests can be defended, and what incorporates respect for liberty and form there will be conflict between the form of health education is ethically autonomy. interests and rights of researchers and justifiable; and chapters five to seven research participants, and that these Chapters five to seven, on issues to deal with issues involving the line do with both individual liberty and inevitable conflicts can base a claim to between individual liberty and social transcultural validity. Transferring social welfare, involve surveying the welfare—preventive medicine, treat- issues rather than pursuit of a sus- Western codes is therefore not neces- ment of AIDS, and decision making sarily a problematic form of cultural tained argument, even though many on health issues. arguments are discussed. Chapter five imperialism, but a necessary corollary The weakest chapter is the first, of transferring Western forms of medi- demonstrates very well the number which adopts the view of Harris, and complexity of issues raised by cal research practice. Singer and others that self conscious- The book is a valuable and up to preventive measures. Chapter six sets ness defines personhood, so that to kill out very clearly issues involved in date resource for anyone interested in a non-self conscious being—for exam- the relationship between ethics codes, meeting the needs both of those ple. a fetus, or a person in a permanent infected with AIDS and those who legal regulation and medical practice vegetative state—is to do no wrong to wish not to be infected. Chapter seven, and research. Its usefulness as a refer- that being. The problem is that no in contrast, is an argument for liberal ence and teaching tool could, how- argument is given: there is only abuse utilitarianism in medical decision ever, have been greatly improved by of the alternative position—to suggest, making, as a framework that can com- the provision of an index. Despite the on page 20, that those who take the bine meeting individual needs and the lack of an index, however, it should be potential personhood of the fetus seri- needs of society in a way that is an essential part of the library of any ously think that there is somehow an institution involved in teaching medi- adult “in” the fetus, is ridiculous—and impossible if a libertarian, socialist or cal ethics. the pointing out of its dangers, such as communitarian framework is adopted. Once again the argument is skilful but SØREN HOLM making it impossible to justify abortion even to save life. But Häyry’s view too short, and fails to deal with oppos- Institute of Medicine, Law and Bioethics, ing views in their most convincing University of Manchester & Centre for Medical has the danger of giving us no reason Ethics, University of Oslo for not killing neonates whose parents form. reject them: the issue cannot be settled Hence, the demerits of this book are in this way. that it ties liberalism too closely to a Individual Liberty and The defence of “Mill’s principle” is dubious theory of what a person is, better, but still insuYciently argued, and it is too short, so that neither the Medical Control though space may have made this defence of the liberal principle nor its inevitable. Many good arguments are application is fully developed. The Heta Häyry, Avebury Series in Phil- given, but full justice is not done to the merit is that within these limits it osophy, Ashgate, Aldershot, 1998, opposing view, which is not simply makes a good argument for the princi- vi+102 pages, £29.95. “moralist”, but based on the ideas ple of liberty and some real progress in that: (a) “Millians” are working with showing how it should be applied in This is a short but very interesting too limited a notion of harm; (b) one specific areas. In short, this is a book, which repays study. It is essen- cannot harm oneself without also valuable contribution to medical eth- tially a defence and an application to harming others, and (c) even compe- ics which one may hope the author will medical ethics of the principle of liberty tent adults are not always the best develop further in future publications. (page 12), that “the liberty ...ofcom- judges of what will harm them. A petent, well-informed, free agents defence of libertarianism must deal HARRY LESSER must be . . . maximally protected in with these more subtle objections, and Centre for Philosophy, matters which concern only or mainly not only the cruder ones. Even these University of Manchester

www.jmedethics.com 208 Book reviews

Practical Decision the idea was a good one and overall I problematic because the fact that thought it was a useful exercise. Devet- female circumcision is left with much Making in Health tere claims to “approach health care less attention means the reader may Care Ethics: Cases ethics from the perspective of an ethics get the false impression that the prac- of the good rather than an ethics of tice of female genital mutilation and Concepts obligation . . . more specifically ...Ar- (FGM) is not very widely spread or istotle’s ethics of the good” (page 21). has less serious consequences than Raymond J Devettere, Washington This is more obvious when he discusses male circumcision. In reality, however, DC, Georgetown University Press, theory and I found myself disappointed FGM is still extensively practised in 2000, 639 pages, £25.25, $35. not to find virtue-theory-in-action diVerent parts of the world and due to more evident in the case discussions. If its radical nature its physical, mental My colleagues and I in Birmingham this had been achieved it would cer- and social eVects are usually even are always on the lookout for an tainly have made the book more more devastating than those of male undergraduate textbook for our medi- distinctive. This said, the text is a circumcision. This important fact is cal students, which was why I agreed welcome contrast to principlism. undermined in the very first chapter of to review this book. By and large it is The main disadvantage of this book the book, in which the trauma of male pitched at an undergraduate audience as a textbook for UK undergraduates circumcision is emphasised by the and covers many of the areas that one is that all the legal references are based claim that the diVerences between might expect to find in a UK under- on US legislation and cases. Of course, male and female circumcision are graduate medical course (consent, this does not mean that the references mainly man-made rationalisations of making decisions for the incompetent, are not useful or interesting: the the issue rather than based on the per- end-of-life issues, beginning-of-life is- ethical discussion generated is applica- sistent structural gender inequality. sues, research, transplantation and ble and it is proper that students The study starts with the historical medical genetics). It also has a chapter should have an awareness of the origins of the tradition of circumcision, V V on managed care, which is less rel- di erences in approach in di erent showing how the justification for the evant to a UK audience but is legislatures. Nevertheless, this is a sig- practice has varied from religious and interesting none the less. (The case nificant disadvantage. Students are cultural demands to a number of study for the chapter on James Adams unlikely to buy more than one medical medical explanations. The first article who, it is alleged, lost both his hands ethics text and I fear, therefore, that by Nahid Touba brings out the social and feet as a result of delays caused by this book is unlikely to be adopted as a connections of diseases by focusing on managed care, is a harrowing but salu- set text outside the USA. It is, the role that the practice of circumci- tary reminder of the weaknesses of however, worth buying for a library sion has had in medical history. telephone health care consultations and certainly worth a look for teachers Removal of the male foreskin has been and the dangers of trying to cut costs of medical ethics—and I do mean believed to cure insanity, masturba- using protocols in emergency situa- medical ethics, despite its title. For my tion, epilepsy, cancer of the penis and tions). Other issues (for instance, HIV colleagues and I back in Birmingham even cancer of the cervix of the future and mental health) make an appear- it looks like another summer revising wives of the circumcised boys as well as ance within chapters. There are many our own course materials. sexually transmitted diseases and par- interesting cases and the commentary HEATHER DRAPER ticularly phimosis (either as a disease on these is generally useful and struc- Centre for Biomedical Ethics, or as a cause of other diseases such as tured in a way that would facilitate University of Birmingham cancer). Even presently the relation teaching and—perhaps more impor- between circumcision and HIV/AIDS tantly these days—independent learn- is still extensively studied and debated. ing. For instance, in his case analysis Male and Female This shows that while opinions on the Devettere has the subheading “situ- Circumcision: diseases that circumcision is to be used ational awareness” where he lists the to prevent or to cure has changed facts and ethical aspects of each case. Medical, Legal and throughout the times, circumcision as This is a fine example to students of Ethical such has persistently maintained its how to organise their thoughts around place as a medical practice. ethics issues and how to pick out the Considerations in While the book gives lots of atten- important points of the cases. Pediatric Practice tion to the traditional religious and There is perhaps more in the way of cultural justifications of circumcision, moral theory than we could expect (at it also attempts to explain why the Edited by George C Denniston, Birmingham at any rate) undergradu- practice has persisted this long in ate medical students to engage with— Frederick Mansfield Hodges and modern societies such as America. but this is perhaps a problem with our Marilyn Fayre Milos, New York, Articles by Van Hower and Paul M medical students rather than the book! Kluwer Academic/Plenum Publish- Fleiss, for instance, note that justifica- The overview of ethics is thorough ers, 1999, 547 pages, US$155.00. tions for the routine operation of without being overly detailed. In Chap- circumcision in North America are ter three, for instance, Devettere in- The book is an exploration of the usually based on alleged medical concludes a long section called “distinc- medical, legal, moral and cultural ditions. Thus, the practice has gained tions which can mislead” and whilst I aspects of the practice of circumcision. stronger rational justification than is did not agree with the way some of the The title suggests that the book will generally given to the religious or tra- distinctions were drawn—for instance cover both topics, male and female ditional demands of many other cul- is the diVerence between the reasonable circumcision. This, however, is mis- tures. The same was earlier true in the and the unreasonable really based on leading. The main focus of this collec- case of female circumcision in which a whether the action is ethical or not?— tion is on male circumcision. This is form of clitoridectomy was used both

www.jmedethics.com Book reviews 209 in Europe and in America either for Introduction to detailed discussion and citation than hygienic reasons or as a medical cure that provided. For example, abortion for masturbation and for mental disor- Medical Law is discussed in four pages and sup- ders such as hysteria. Since both male ported with seven references, despite and female circumcision were prac- Peter Marquand, Oxford, the substantial research and discus- tised by qualified doctors for allegedly Butterworth Heinemann, 2000, 125 sion which abortion has generated in legitimate medical indications in the pages, £15.99 (pb). this jurisdiction and elsewhere by Western countries, they were not con- ethicists, lawyers, doctors, feminists sidered to be the same brutal and Peter Marquand is a medically quali- and those of other professions. More intervening mutilations of the human fied solicitor who understands the extensive citation to related research body as they were seen to be elsewhere informational needs of medical profes- and additional academic texts which in more primitive societies. This shows sionals. Thus, it is not surprising that comprehensively discuss the subject that the medicalised nature of Western the topics covered in this book are matter of the briefer chapters would culture itself can give legitimisation to those most likely to be of practical use extend the relevance of this publi- even violent and unnecessary physical and concern to medical and ancillary cation to, for example, postgraduate interventions of the human body in professions. This publication is clearly students. the name of science, progress, normal- a guide, and not an exhaustive text, on However, this guide should be ity and health. current legislation and case law relat- praised for what it is. It explores the In this context particularly worthy ing to medicine. As a guide, it admira- parameters of medical law with the of note is the comparison between the bly achieves its objective of providing appropriate amount of detail for those United States and Europe in the case an overview of contemporary issues of who seek a broad understanding of the of male circumcision. The study relevance in the medical field. legal principles which govern the shows how in the United States, due to Marquand’s research summarises interface between the legal and medi- the widespread diVusion of the “scien- the fundamental principles of, and cal systems. The book does not aim to tific myth”, the medical data with legal responses to, the standard topics generate provocative critical legal de- counter-results was deliberately ig- covered in medical law texts such as bate nor does it explicitly include an nored or misinterpreted. For instance, clinical negligence, consent, capacity, ethical component. Rather, it provides withholding or discontinuing treat- the latest reports from European a firm grounding in how the law has ment, confidentiality and abortion. medical research on the issue were been constructed, and how it responds Additional subjects not ordinarily cov- neglected in order to maintain the to issues of fundamental ethical sig- ered in such texts include: the coro- practice even when it was already rap- nificance such as discontinuing treat- ner’s inquest, drugs and prescribing idly disappearing in Europe. An addi- ment and treating the person who and postmortem examinations. The tional explanation for the maintenance lacks capacity. Thus, it provides a solid preventive potential of this book and framework for understanding the state of the practice in modern, market- its practical value, are evident in the oriented American society is found in of medical law in England and Wales chapters which address risk manage- in 2000, thereby contributing to the the commercial exploitation of chil- ment, defending a negligence claim, dren through circumcision. Physi- accuracy of those debates. What Mar- and expert testimony in civil cases. quand promised, Marquand delivered cians, in cooperation with transna- Marquand has successfully tional biotechnology corporations, in a concise, entirely comprehensible, achieved a goal which may appear and aVordable volume. look for the sales of marketable deceptively simple, but is in fact products made from harvested human formidable, and will be widely appre- KATE DIESFELD, JD foreskins, that can be used in the ciated. Educators who have developed pharmaceutical industry. 654 C Mt Eden Road training for non-lawyers will under- Mt Eden, Auckland 5 In this book the legal and ethical stand the diYculty in disseminating New Zealand aspects of the practice of circumcision current, succinct, and relevant legal as well as its physical, mental and information in an accessible format. social consequences are, for the most Accordingly, this book is essential Biomedical Ethics part, discussed from medical and reading for the undergraduate and the empirical points of view rather than set continuing professional education of Reviews, Is There a within a wider framework of philo- doctors, nurses, psychologists, health Duty to Die? sophical ethics. Nevertheless, the book care workers, and allied professionals. takes a clear ethical stand against the Also, it will be of particular value to Edited by James M Humber and practice and the articles show plausi- those professional bodies which are Robert F Almeder, Totawa, New Jer- bly how little factual basis the religious developing their own professional and cultural justifications of the prac- guidelines, often in the absence of sey, Humana Press, 2000, 221 pages, tice have, even in cases based on legal training. It lacks, however, suY- US$49.50. medical rationalisation. All in all, the cient detail to be a definitive manual book is useful not only for medical for medical professionals, as is ac- At the heart of this book is the idea professionals but also for philosophers knowledged in the foreword, which that we would all be better oV were we and ethicists. warns that the guide is not a substitute able to recognise the harder, slower, for legal advice. more expensive and more unjust dying DR SIRKKU KRISTIINA HELLSTEN One concern, which may be ad- which the continued development of Head of Philosophy Unit dressed by that warning, is that the modern medicine oVers. The proposal University of Dar es Salaam book does not consistently address is perhaps not so much a duty to die as Dar es Salaam some procedures which are frequently a duty to refrain from unfair or exces- Tanzania undertaken and which warrant more sive use of health care resources and to

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refrain from imposing excessive bur- have the right to something which is the body, technology, and the state. All dens at the end of one’s life on family necessary to sustain our lives. Spellecy of this provides a backdrop to an or friends. On the global scale, Battin suggests a duty more akin to a debt of examination of the link between the invites us to consider a huge inter- gratitude, which might be owed, but social and political aspects of organ national deal to be struck between the which it would be improper to de- transplantation and its scientific and wealthy First World and the develop- mand. This book, the seventeenth technical aspects, which is covered in ing Third World. Backed by figures on annual volume of “Biomedical Ethics part two. life expectancy in diVerent countries Reviews”, achieves its aim of discuss- The second part provides an in- and by some financial information, ing in an accessible, enjoyable and depth study of procedures for the Battin is persuasive in identifying the informative way a question of management of donors and distribu- wrong of excessive, expensive life- importance to most of us. tion of cadaveric organs throughout prolonging health care in a world JAMES GILBERT Europe, drawing attention to the way where basics such as clean water, inex- Consultant in Palliative Medicine regional political diVerences within pensive vaccines, and ordinary family Royal Devon & Exeter Healthcare NHS Trust Germany aVect the procurement of planning and reproductive health care organs and the medical profession’s are unavailable to so many. In short, response to the public debate on “we ought to die sooner so they could Recovering the transplantation. In this context Hogle live longer”. But this is only a part of recounts how the media in Germany the deal. The two other necessary ele- Nation’s Body provided sensational coverage of ments are a) mechanisms to convey medical scandals during the past dec- the savings from a person’s earlier Linda F Hogle, New Brunswick, ade. First, was the Erlangen experi- death in the First World to fund health Rutgers University Press, 1999, 241 ment in 1992, involving the postmor- care and related measures that would pages, US$22.00 (pb). tem ventilation of a woman in order to increase life expectancies in the Sec- preserve the life of her fetus. The fetus ond and Third Worlds and b) the Drawing upon the disciplines of aborted after six weeks, but during this identification of the health-related bioethics, anthropology and politics, time confusion reigned over the mean- obligations of people in the Third Linda F Hogle examines the use of ing and diagnosis of brain death, and World to those in the First. We insist, human body parts for transplantation the incident evoked memories of Nazi for instance, that the rain forest ought and research in modern Germany. She medical experiments. The second not to be cut down, that the sea and focuses on German attitudes to organ scandal followed media revelations in the air should not be polluted in the transplantation and the fears ex- 1994 concerning the routine selling of way that happened in the developed pressed by doctors and the public tissues from cadavers in hospitals, world’s early industrial development regarding utilitarian justification of the which intensified public distrust of and that nuclear weapons should not use of body parts taken from the doctors and a general feeling of proliferate. Although it is acknowl- vulnerable to benefit others. powerlessness in the face of big indus- edged that this line of argument In modern Germany, argues Hogle, try, the state and the medical profes- depends on the future existence of organ transplantation and practices sion. Under headlines such as “Plun- eVective international redistributive relating to the use of human body dering the dead”, the media published structures, our attention is drawn to parts have developed under the photographs of piles of bones, artificial this as a lack of vision, a lack of politi- shadow of the history of medicine hip joints and large containers of cal will rather than a flawed argument. during National Socialism. This can human brains, resembling the piles of As Battin hoped, the deal outlined did be seen in the recent controversy over human hair, bones, etc, displayed strike this reviewer as more of a real brain death, where the spectre of “lives when the concentration camps were challenge to our moral selves than a not worth living” has been invoked in liberated. The third scandal recounted silly thought experiment. the context of decisions to declare by Hogle involved revelations about Of the subsequent eleven chapters, death and authorise removal of body the use of human cadavers as crash each written by a diVerent author, six parts. Ethical tensions were also re- test dummies, which was sensationally are sympathetic to the claim that there vealed following the unification of East reported in 1998. Each scandal is a duty to die. At the national level it and West Germany: the former East- emerged with a barrage of media cov- is suggested that public policy could ern state regarded human bodies as erage. According to Hogle, reaction to achieve significant redistribution of state property and the Western state these stories was informed and influ- resources and at the family level, emo- endorsed the opportunities for profit- enced by the history and memory of tional as well as financial burdens based medicine. National Socialism and it is partly this might be reduced. In the first part of the book Hogle history and memory that has been At least three contributors cast discusses various cultural meanings of responsible for the decrease in organ doubt on the existence of a duty to die “the body” in German history, includ- donation, in Germany, by relatives and one (Tong) argues that it is not ing an account of how the body has throughout the 1990s, which contrasts even safe to posit such a duty, given been handled at death, various uses of with other European countries and the societal inequalities which might make the body, (where she points out that US. Throughout her extensive surveys any imposition of such a duty unfair. the use of bodies and their parts for and interviews with German medical Having been taken on an interesting healing is not a new phenomenon), personnel, Hogle notes, however, that and for the most part well-written tour German funeral customs, and the the essential characteristic of German of this question, in the last two unique history of the body under organ procurement practices is the chapters a somewhat diluted and per- National Socialism. This is followed “need to preserve an image of not vio- haps more plausible conclusion is by a discussion of legal notions of lating the dead” (page196). oVered; that although we may not have bodily integrity and new ways of This is an extremely well researched a duty to die, sometimes we do not regarding the relationships between book and is one of the first serious

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attempts to understand the complex what is a “reasonable patient”, this resource. As the authors them- varations in ethical attitudes to the Ulrich—in a very readable manner— selves say, it is often the collaborative dying and the newly dead in contem- explores fundamental principles of dimension, the need for teamwork, porary Europe. medical ethics and explains the extent which poses the most interesting and to which these are met by the terms of important ethical challenges. DAVID LAMB the act. This is a very readable book, This is the second edition of the University of Birmingham although it’s tempting to suggest that book, just three years after the first and it may be a little overenthusiastic in it has already had two reprints. This terms of what this legislation can edition is the result of feedback from The Patient achieve. None the less, if read by readers and the responsiveness of the Self-Determination health care providers it should point authors to changes in the delivery of them towards the rationale for the leg- health care and in consumer expecta- Act: Meeting the islation and remind them of its poten- tions, most of which seem to have Challenges in Patient tial importance. some ethical implications. Three significant changes have been S A M MCLEAN Care made. In the first place, the subtitle has Professor of Medical Law been amended from A good compan- Lawrence P Ulrich,Washington, Institute of Law and Medical Ethics ion to A companion for all specialties, Georgetown University Press, 1999, School of Law, University of Glasgow which is more descriptive of the book’s 351 pages, £46.75. potential. Secondly, three new chapters have been added. They are: The This is an extremely readable and Palliative Care Ethics: relative-professional relationship, chap- interesting contribution. The author a Companion for all ter 3; Reply to critics, chapter 13, which takes the reader through the Patient discusses emotional care and patient Self-Determination Act in some depth, Specialties (2nd ed) autonomy and touches on euthanasia, but doesn’t make any attempt to look at and Quality and value of life, chapter its provisions in real detail. This cannot Fiona Randall andRSDownie, 14. The third change in this new be taken as an omission, as the purpose Oxford, Oxford University Press, edition is the introduction at the start of of the book is to explore the principles 1999, 305 pages, £21.95 (pb). each of its 14 chapters of a brief literary underpinning the legislation and to quotation, which focuses one’s mind on explore its ethical content. The main purpose of a book review is the underlying philosophical issue. In that respect, this is a very to convey to the reader the essence of The successful partnership of a interesting exercise. On one view, the the book’s content, thereby facilitating clinician and philosopher in writing Patient Self-Determination Act did an assessment of its relevance for this book demonstrates the benefits of very little to change the current law in specific interests. Book titles alone are such collaboration and the bringing V the United States. The legislation is usually inadequate and/or misleading together of di erent modes of designed primarily to ensure that on and sub-titles are used to be more thought. The same benefits also find entrance to any federally funded facil- informative. In this case, the subtitle, A expression in the many examples from ity, patients are made aware of the companion for all specialties, is not the real world of caring which illumine facility’s policy on advance directives only relevant but incredibly important. the pages of the text. and withholding and withdrawing Without it, the book might easily be In his foreword, Dr Derek Doyle treatment. Thus, the legislation does ignored by those who neither work nor expresses his satisfaction, which I not directly tackle whether these have a special interest in palliative care, share, that the authors focus on daily polices are appropriate, but rather it and more particularly in the care of ethical issues and problems, such as makes a contribution to the infor- dying patients. The target readership information giving and confidentiality mation which all patients will have for this book is very much wider than etc and not on the dramatic ones. when they make a decision about that. The authors, one a consultant in Their work is truly reality-oriented which facility to enter, and also it may palliative medicine and the other a pro- and shows due regard to the ever encourage them to take account of fessor of moral philosophy, have pro- pressing problem of limited resources. these policies in their participation in duced a profound treatise on many This book represents a superb addi- their own health care. Ulrich reads the aspects of health care by raising ethical tion to the literature on health care legislation as making a significant issues which permeate all specialties. ethics. It demonstrates the need for contribution to the rights of patients to In their preface, they present a rough experience, wisdom, common sense, self determination, as well as making outline of their book, which is divided sensitivity and professional integrity, the informed consent process more roughly into three parts. Chapters 1-5 all of which are ingredients of a high meaningful. To an extent his views on are the more general and express a quality service, though rarely amena- this could be taken as aspirational basic philosophy of palliative care. ble to quantitative measures. rather than necessarily real. None the Chapters 6-12 deal with a range of The authors deserve our gratitude less, the way he reveals the capacity of clinical topics and chapters 13 and 14 and serious attention. I have no the legislation to achieve these goals raise wider and more challenging philo- hesitation in recommending their makes for a very interesting analysis of sophical issues. This is not so much a book to every person who has the the ethical, social and legal back- textbook on ethics as a springboard for responsibility and privilege of giving ground to the legislation. discussions, seminars and other small any form of health care to another. In leading us to the conclusion that group activities which aim to stimulate LISBETH HOCKEY one ancillary, but in his view, benefi- thinking. Mixed groups, representing Consultant in Nursing Research cial, outcome of the legislation might various specialties, including lay carers, 1/2 Silverknowes Road be a move towards the assessment of would benefit enormously from using Edinburgh EH4 5NX

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HIV and dimensions, and considers some cen- Bioethics is Love of tral themes in health care ethics: Is the AIDS—Testing, individual or society responsible for Life: an Alternative Screening, and their health? Can health care workers Textbook be advocates for third party interests, as Confidentiality well as caring for their patients? There Darryl R J Macer, Christchurch, New is a thoughtful essay on compensation Zealand, Eubios Ethics Institute, and consent in relation to transfusion- Edited by Rebecca Bennett and associated infection, and another on 1998, 158 pages, £12 (pb). Charles A Erin, Oxford, Oxford Uni- whether a fiduciary relationship can be versity Press, 1999, 285 pages, both an ethical approach and a legal Love of life is the theme running £35.00. concept. These chapters provide a con- through the eight chapters of this ceptual underpinning to the more book, which cover theories of bioethics, the language of love, self love If I have any objection to this book, it formal exploration of the very thorough coverage of testing, screening and (embracing autonomy, selfishness, is to the title, in that it might narrow and altruism), love of freedom, loving the audience that would benefit from confidentiality—in clinical and public contexts, as well as in research settings. relationships, animal ethics, and envi- it. Although the title is formally quite ronmental ethics. Love of life, says accurate in describing the contents, it There is a very nicely argued chapter near the end on the categories of people Macer, is the “simplest and most all underplays the relevance of the argu- encompassing definition of bioethics, ments set out herein to a very broad who might want to know the status of a person with HIV, and whether they and it is universal among all peoples of range of clinical arenas, for which the world” (page 1). This vision of love HIV/AIDS can be a notable example. should. It is, however, rather invidious to select out individual articles when so as a basis for a universal bioethics is This fascinating series of essays cover- part of a more ambitious project ing the topics in the subtitle and much many are excellent. Similarly, picking out specific aspects of the debate could intended to inspire the creation of a more, shows how valuable AIDS has global community wherein all indi- been as a worked example of a series of distort the impression of the impact of the whole, which I found to be deep as viduals overcome diversity and work interdigitating core issues in medical towards a perfect whole. To this end ethics, as it has been in so many areas well as broad (hence I took an uncon- scionable time reading it for this the author attempts to cover a vast of clinical medicine, public health and range of religious beliefs and cultural public policy. Although the authors review!) Of course there is plenty with which traditions. and editors underplay this wider The opening discussion will be relevance, I found myself, despite my one could take issue and I could not agree with all the views set out, despite familiar to Western bioethicists, as it own substantial involvement in HIV covers deontological and teleological and AIDS over the past twenty years, their persuasive style and scholarly tone, but that is the essence of a book theories, ranging across a broad spec- constantly wanting to cross-refer to trum of recent bioethical writing. The other clinical areas. Perhaps readers of of this sort. A few chapters seemed slightly remote from clinical reality, author concludes that the “inner this review, who are minded to read, or motivation and strength of ethical even to reread, this book might take but that distance was mostly used to good eVect. One chapter (purportedly behaviour comes from love” (page such a perspective. giving “an American perspective”) 27). The main objection to an ethical The editors have managed, by their seemed inclined to rewrite the brief system based on love, claims Macer, is choice of authors, to organise a very history of AIDS from a rather dis- found in the tradition embracing Plato broad range of perspectives. While the torted personal and distant view; this and Kant, who saw emotions and feel- styles, compass and approach taken by was really the only weak chapter in the ings as a distraction. Despite a wealth the authors are quite variable, this is book. I don’t think most of my Ameri- of literature relating to love, and the generally a benefit and not a problem, can colleagues would recognise this as fundamental role it plays in the as it enables the reader to appreciate a fair national perspective. I found it public’s conception of ethics, Macer the diversity of views that can legiti- polemical and a barely recognisable complains that it has been largely mately be taken on the same moun- account of what actually went on; it ignored in recent bioethics. This is due tain. The format is not an artificially might better have been subtitled “the to academic snobbery, claims Macer, polarised debate (though there are personal perspective of an American which is bound up with a desire plenty of polar views and opposing lawyer”. amongst bioethicists to have a mo- perspectives to be found), but rather a I heartily recommend this outstand- nopoly on prescriptive ethics! series of thoroughly reasoned perspec- ing volume to anyone interested in There is an interesting chapter on tives, usually set out according to a medical ethics, whether or not their the boundaries of love towards ani- clearly defined system of reasoning. primary interest is concerned with mals, where “love” signifies an ethical The introductory chapter by the HIV/AIDS. It explores the rich per- commitment. But on the question editors is a valuable guide to the issue spectives that this terrible pandemic whether causing harm or suVering to itself and to the chapters and their has given us on contemporary medical other animals is bad, Macer appears to perspectives (and is worth rereading at ethics. follow the route taken by several West- the end). ern bioethicists who attempt to weigh I must applaud the authors and edi- ANTHONY J PINCHING evidence in support or against claims tors for a truly informative exploration Department of Immunology that fetuses are persons. By analogy, if of some very big issues in medical eth- St Bartholomew’s & The Royal London School evidence is produced that some ani- ics. The breadth of the coverage is sub- of Medicine & Dentistry Queen Mary, mals have “person traits” or “signs of stantial, encompassing ethical and legal University of London love” then harming them is wrong.

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This position has been dubbed “per- process of deliberation if we are going cannot aVord a communication di- sonism”: it is frequently employed to to achieve the discernment needed for vide. Greene argues here that we can’t mark the boundaries of moral obliga- balancing claims of individuals and leave science to the scientists but have tion to fetuses, animals and patients claims of communities. And such bal- to engage in active debate about the with severe neurological disorders. ancing of individuals, professional values that will guide our choices in Personism, it might be argued, is as institutions and communities is also the fast developing and promising area arbitrary as speciesism and many an important component of the theses of human genetics. While not dodging other “isms” where a particular group oVered by the other authors. Tschudin a caution about a possible “slippery is said to be entitled to preferential encapsulates the wisdom of nursing slope” in expanding reproductive treatment. philosophy in her essay, Ethics and technologies, Greene reiterates the Macer is to be commended for a holistic care, which maps out the con- bases for genuine citizen autonomy in rather ambitious attempt to bring ceptual connections between develop- the area of reproductive options: together a wide range of religious ment of skills for self awareness, awareness and informed debate. It is beliefs and diverse ethical traditions, listening and ethics. These links are refreshing to read in Greene’s analysis but the overall impression is that the often ignored in bioethics writing and that the problems are not in human book attempts to cover too much yet contributions from nursing philos- cloning as such but in how we in soci- ground. ophy allow the necessary expansion of ety will perceive and value “clones” who might result from this reproduc- DAVID LAMB a humane and person-centred framework for health care ethics. tive process which is likely to be much University of Birmingham Four of the essays by Denis Cusack, closer to realisation than Greene (medical law) Marcus Webb (psychia- predicts. try), Patrick Hanafin (law) and Sheila This is a readable and provocative Medical Ethics and Greene (psychology) home in on the book of essays which might not the Future of Health question of patient autonomy and challenge professional bioethicists but institutional policies and legislation would be an exemplary text for any Care arising in questions about involuntary study group, lay reader or adult treatment in psychiatric institutions, education centre motivated to develop Edited by Kenneth Kearon and the right to die, abortion legislation, the level of public debate so strongly Fergus O’Ferrall, Dublin, Ireland, genetics and implied transformations called for in this fine book. Columba Press, 2000, 168 pages, in our understanding of “persons”. DOLORES DOOLEY £7.99. These four essays are particularly comprehensive and provocative in Lecturer in Philosophy & Medical Ethics, Public lecture series do not always, calling for responsible and sustained Department of Philosophy public debate as a medium for educat- National University of Ireland Cork, unfortunately, result in a published Ireland volume of interdisciplinary, informed ing a wider public about the exercise and well argued papers. Medical Ethics of deliberative democracy in applica- and the Future of Health Care has tion to health care policy formation. Genetic Information: succeeded, however, in doing just this. Cusack’s essay, Autonomy and con- A public lecture series was organised sent, recognises the value of autonomy Acquisition, Access, by the Adelaide Hospital Society, while remaining sceptical of the desir- Dublin, Ireland in 1999 to facilitate ability of full implementation in ad- and Control better public understanding of com- vance directives, or patient rights to plex issues in health care confronting information regardless of a doctor’s Edited by Alison K Thompson and citizens and carers. The book assumes wish to invoke “therapeutic privilege”. Ruth F Chadwick, New York, Kluwer correctly that the Republic of Ireland Cusack wants to believe that the Academic/Plenum Publishers, 1999, is now indisputably a pluralist society, health care provider has a right to be 348 pages, $115 (hc). discomforting to some readers who “trusted” and that he or she should might look to the book for absolute enjoy the privilege of self regulation. News that the first draft of a map of answers and certainties. They would One response to Cusack is to argue the human genome had been com- be disappointed because the essays that there is no natural right to be pleted was received with great excite- show rather that it will be public trusted and, as with leadership, trust ment but fears persist about how this debate and reasoned, imaginative ap- must always be earned. knowledge will be used. Such con- proaches to decision making in health Hanafin’s essay, Legislating the cerns were the basis for an inter- care that will replace the comforts of right to die, is outstanding in its com- national conference held in Preston, traditional certainties. prehensive perspective on the right to England in December 1997. The Coming from the internationally die and the impact of what seems an issues addressed were non-existent recognised philosopher of principlism, abstract right on institutional and cul- when many of those attending the James Childress, the nurse ethicist, tural ideologies which are deeply conference were born, but they are Verena Tschudin and representatives embedded in Irish state policies, the among the most pressing ethical prob- from obstetrics and gynaecology, mid- Irish constitution and ecclesiastical lems we face today. They are philo- wifery, legal medicine, psychiatry and traditions. The superb accuracy of sophically challenging, and the way we psychology the essays are accessible Hanafin’s analysis makes clear that deal with them will have far reaching and informative without over- ethics cannot be relevant if it remains consequences for both individuals and simplifying complex ethical issues. aloof from cultural, social and identity society. The proceedings of the confer- Childress’s essay, Bioethics on the contexts. In the final essay of the book ence are now available in this book . brink of a new millennium, calls for the reader is reminded of C P Snow’s Thirty authors, almost exclusively the inclusion of imagination in the Two Cultures and his injunction that we from Western Europe and North

www.jmedethics.com 214 Book reviews

America, have written about the im- the rules of the market place, but in so of dealing with them. A journey portant issues of eugenics, insurance, far as they have a redistributive role, through it leaves the reader better able the eVects of market forces and the this should not be the case. He argues to dissect the ethical issues in genetics question of patents, public awareness that necessities such as health care are today. not commodities and that public pro- of genetics and a variety of psychoso- LENORE ABRAMSKY cial and ethical concerns. Readers vision is required for health and welfare. Tangwa, the only contributor North Thames Perinatal Public Health Unit, with a theoretical bent will find them Northwick Park Hospital, dealt with more satisfactorily than will from Africa, says very succinctly that, Harrow, Middlesex those more interested in applied medi- “...itdoes not seem morally right or cal ethics. This is the inevitable result even ordinarily fair to . . . reward or of there being no contributors from punish people on the basis of involun- the coal face such as genetic counsel- tary biodata”. lors, medical doctors, actuaries, or This issue of the unfairness of the Correction “consumers”. So while I read with genetic lottery comes up again and interest, I kept my cardigan on to ward again. Holtug argues that if people are A review of the Training Manual on oV the chill of the ivory tower. disadvantaged (genetically or other- Ethical and Human Rights Standards for A fundamental question examined wise), we should compensate rather Health Care Professionals which ap- was that of the extent to which genetic than punish them. He points out that peared in the journal’s February 2001 information is special compared with this implies more than just health care issue mistakenly identified its pub- other health information. Holm ar- and also looks at the question of where lisher as the BMJ Publishing Group. The publisher is, in fact, the Com- gues (at some points more convinc- one draws the line between correction of a problem and enhancement. I wish monwealth Medical Association and ingly than at others) that it is not spe- that more contributors had considered the manual is available from the Com- cial since other health information can this very delicate and complicated monwealth Medical Association at also be predictive of the future health problem. Holtug goes on further to BMA House, Tavistock Square, Lon- of a person, of that person’s oVspring look at the question of responsibility don WC1H 9JP. and of his/her other relatives, and that and considers how responsible an other health information can be as individual is for failure in a career if it personal and sensitive as genetic is due to: (a) lack of talent, (b) lack of information. He goes on to argue that eVort, or (c) a decision not to pursue Books: information and a uniform regulation of all health- that career. He points out that any of orders related information is better than a these may be due to genetic endow- specific regulation of genetic infor- ment and/or environmental influ- If you wish to order or require further mation. ences. It could be argued logically that information regarding the titles re- The question of what to do about whatever we do is, by definition, what viewed here, please write or telephone genetic information and health insur- we had to do, and it is puzzling that in the BMJ Bookshop, PO Box 295, ance is a crucial one which is dealt our society we hold the individual London WC1H 9JR. Tel: 020 7383 with at length. Insurance is essentially responsible if the causes are thought to 6244; fax: 020 7383 6455; Internet: a form of betting. Is it “fair” if the be environmental but not if they are www.bmjbookshop.com; email: [email protected]. European insured person knows how the dice are thought to be genetic. Again, I wish loaded when the insurer does not? Is it customers should add 15 per cent for more attention had been given to this postage and packing, other overseas “just” to punish someone with higher problem. customers should add 30%. Payment premiums or no insurance cover be- As one would expect in a multi- can be made by cheque in sterling cause that person has done badly in authored book, the style and accessi- drawn on a UK bank or by credit card the genetic lottery? Is it acceptable for bility vary enormously from one chap- (Mastercard,Visa, or American Ex- insurers to force genetic tests and ter to the next. Some I found press, stating card number, expiry date unwanted knowledge on people? Lem- extremely interesting while others and full name. (The price and availa- mens argues that to the extent that failed to engage me at all. Overall, the bality are occasionally subject to insurance contracts are commodities, book presents some important ques- revision by the publishers.) these questions should be subject to tions and explores philosophical ways