J Med Ethics: first published as 10.1136/jme.26.1.77 on 1 February 2000. Downloaded from

Journal of Medical Ethics 2000;26:77–79

Book reviews

On Moral Medicine had no place for Joseph questions such as respect for life, par- Fletcher’s situation ethics. Indeed, enthood, childlessness, and contracep- Fletcher should be remembered (now tion, his prose becomes dense, his Edited by Stephen E Lammers and that his warm, joyful spirit has passed rhetoric impenetrable. Gustafson Allen Verhey, Grand Rapids, Michi- from us with death) not so much for justly observes that some of his present gan, Wm B Eerdmans, 1998, 1,004 his now faded system as for his having day disciples are similarly entangled. pages, £32.99 (sc), US$49.00. drawn out of Ramsey his Deeds and (Theologians working in medical eth- Rules in Christian Ethics (1965), in ics should not talk to themselves but The sub-title of this book, Theological which Ramsey restored “love” to with medical practitioners). Perspectives in Medical Ethics, is a theological intelligibility. In contrast stands the writing of Chil- more accurate indication of its con- Paul Ramsey stands high in this vol- dress who, no less firm and comprehen- tents than the title. It is a compen- ume, and rightly so. He was at his best sive in theological conviction, can go on dium, an ordered collection of 128 in The Patient as Person (1970), where to ethical implications in such an area reprinted theological and religious he transcribes his covenant theology as technological assessment, cost in writings, grouped in nineteen chapters into the professional relationship be- risk/benefit analysis, and uncertainty in within three major sections - I. Per- tween doctor and patient and the clear, reasoned, analytical prose. spectives on religion and medicine; II. duties they owed in fidelity to one It is a shame, really, that this review Concepts in religion and medicine; another and to society. After that, when has concentrated on a few professing III. Issues in medical ethics. Most he ventured into the new technologies theologians to the neglect of many writers are from the Judaeo-Christian of reproductive medicine and the like, more who, with theology implicit in world; the Christians are from the he seemed to be more inflamed by their minds but not bubbling out of Roman Catholic, Reformed, Protes- journalists and writers of science fic- their mouths, have contributed to the wide range of issues covered in this tant and Anglican (Episcopalian) tra- tion than attentive to what pioneers http://jme.bmj.com/ ditions. Other religions are referred to like R G Edwards and P C Steptoe volume. Modestly pre-eminent among occasionally in passing, and “the were writing and doing. Ramsey could these stands Daniel Callahan, who, in ancient world” is present in quotation shoot down slogans, like “death with the Hastings Center, established a base for continuing collaborative re- and commentary. The volume is a dignity” (he preferred “serenity”); yet flection on issues in medical ethics as, source-book, for reference. Some in his later, more combative writing he in the last thirty years, they have tum- pieces may be read for pleasure; some could deploy the most untheological bled on the scene. His achievement with surprise - how often do we meet slogan of all, “playing God”, so fore- matched, to some extent, by Edward Thomas Sydenham, Florence Night- closing serious attention to dilemmas Shotter’s pioneer work in UK medical ingale and W H Auden among the in neonatal intensive care. Just tributes on September 27, 2021 by guest. Protected copyright. schools and the Institute of Medical “bioethicists”? - some with toil, a duti- are paid to him in this volume. Ethics - should be on record. ful struggle with web-spun words. O’Donovan praises above all his ar- Let the last word be with a physi- Such a tome cannot be summarised in ticulating “the meaning of justice as a cian, as it ought to be. Thomas Syden- review; it can only be commended or feature of the good of society”; and ham (1624-89) writing on what every Thomasma, though he would balance waved away. This reviewer, from the aspirant to the profession should think depths of his native theological tradi- Ramsey’s “covenantal” with “the sac- seriously about, put into twenty lines of tion, can only commend, but only to ramental character of human per- limpid prose the fundamental theology searchers prepared to work hard. sons”, yet admires him for the rigour of which Barth, Rhaner and their/ kind The present phase in moral reason- his ethical thinking, too often lacking laboured for in thousands. Of his four ing in medical practice began, in Eng- in Protestantism. prescriptions the third is this: “... let land, in the 1950s, with theologians Ramsey, O’Donovan and others in him reflect that he has undertaken the and philosophers, notably I T Ramsey, this volume pay their tribute to Karl care of no mean creature, for, in order R M Hare and B S Mitchell, talking Barth, who has dominated Protestant that we may estimate the value, the with doctors working in fields specific theology and ethics in this century. greatness, of the human race, the only to the discussion. There was no The selections from Barth reprinted begotten son of God became himself a confrontation, because of a long tradi- here illustrate his greatness and his man, and thus ennobled it with the tion in British philosophical theology impossibility. He was a master of clar- divine dignity, and, far more than this, of respect for the empirical. In the ity when expounding his basic convic- died to redeem it” (page 145). USA the theological initiative, coming tion, the centrality of Christ and his rather later, was explosive, controver- resurrection. When he tries to apply G R DUNSTAN sial, because Paul Ramsey’s covenant his theological principles to specific Exeter, Devon J Med Ethics: first published as 10.1136/jme.26.1.77 on 1 February 2000. Downloaded from

78 Book reviews

Suicide: Right or condemns absolutely from a religious realistic examples may appeal more to perspective, and what he terms instru- our perhaps over-concrete minds. Wrong? (second mental self-killings, which he regards as For my own part, I must leave with edition) more ambiguous. Glenn Graber ex- a confession. I was perplexed to read plores a definition of rational suicide, in the chapter on the Catholic view, a and Joseph Kupfer links an appraisal of quote from St that Edited by John Donnelly, Amherst, the definition of suicide with the next “whoever takes his own life, sins New York, Prometheus Books, 1998, section on its moral interpretation. against God, even as he who kiss (sic) 335 pages, £14.99 sc. Part three: is suicide moral? Is it another’s slave, sins against that slave’s rational? is perhaps less philosophical in master ... .” This curious juxtaposition John Donnelly is a professor of philos- tone. It begins with an article by Edwin of sex and violence provided what I ophy at the University of San Diego in Shneidman taken from the American felt were fascinating avenues for California. This volume is one of a Journal of Nursing, which assumes that speculation on the Catholic mind. It series on contemporary issues of topi- preventing suicide is inherently justi- only gradually dawned on me that it cal public interest ranging, for in- fied, and one by Thomas Szasz on the was merely a misprint. stance, from animal experimentation: ethics of suicide, taking the opposite TIM HELME the moral issues, to sexual harassment: stance. Victor Cosculluela takes a less Consultant Psychogeriatrician confrontation and decisions. There is polar position. Milton Gonsalves elabo- Margate, Kent a separate title in the series on Eutha- rates a traditional theistic position nasia: The Moral Issues edited by the against suicide, whereas David Holley series editors, Robert Baird and Stuart explores and questions the relevance of The Problem of Rosenbaum. This one deals specifi- the metaphor of divine property rights Mental Deficiency: cally with the subject of suicide. in the debate. Richard Brandt adopts a After a comprehensive introduction, utilitarian position, whereas Philip De- Eugenics, Democracy the book is set out in three parts. Part vine argues for the logical opaqueness and Social Policy in one: some historical background con- of death, making utilitarian considera- tains nine chapters with a careful tions unsatisfactory. Joyce Carol Oates Britain, c 1870-1959 selection of contrasting viewpoints, decries the romanticising of suicide in both ancient and modern. Seneca and the arts, denying the notion of death as Mathew Thomson, Oxford, Oxford St Thomas Aquinas, Hume and Kant, liberation. Robert Weir provides a cau- University Press, 1998, 351pages, give way to a more parochially Ameri- tious defence of physician-assisted sui- US$90.00. can perspective in the recent contribu- cide in some cases. This section ends tions. An interview with Jack Kevor- with a discussion of whether suicide is a This book covers an important period kian is balanced by an article by right, with contrasting perceptions by in the development of specialist social, Herbert Hendin, professor of psychia- Leon Kass and Margaret Battin. health and educational services for try and Director of the American The second edition has been up- people with learning disabilities in Foundation for Suicide Prevention. dated and expanded, and contains a Britain. Historically, the term mental http://jme.bmj.com/ There is a chapter by Joseph Fletcher, new appendix with excerpts from the deficiency had wide currency but con- the situation ethicist, and another by Supreme Court’s 1997 decision on temporary synonyms include: mental Celeste Fremon, based on an interview physician-assisted suicide. For the handicap, mental retardation and de- with Bruno Bettelheim, the child medical reader, the appendix is well velopmental disorders. By 1870 faulty psychologist, shortly before his suicide. worth the inclusion. For instance, concepts of genetics were beginning to The section is closed by a report of the Justice Stevens describes a patient’s give support to the eugenics move- Council on Ethical and Judicial AVairs “interest in dignity, and in determining ment. For example, the French psy- of the American Medical Association the character of the memories that will chiatrist, Morel, had described his on physician-assisted suicide. survive long after her death”, which “theory of degeneration” wherein on September 27, 2021 by guest. Protected copyright. Part two: when do we call it suicide? seems to go beyond the judicial under- mental disorders did not diVer in kind includes six chapters which attempt to standing in the Tony Bland case in but only in severity. Accordingly, neu- clarify the limits of the concept. This is England in which, in his persistent veg- roses, psychoses and mental defi- no easy task, and Donnelly’s own defi- etative state, Tony Bland was deemed ciency were increasingly severe mani- nition, which he describes as “some- to have no interests of any kind. festations of the same inherited what tentative” runs to a sentence of As an introduction to the subject of process through the generations. This almost two hundred words. A paper by suicide for the general reader, or theory was compatible with Lamarck- William Tolhurst includes an interest- undergraduate student, this book has ian genetic concepts which asserted ing distinction between strong and much to recommend it. It is scrupu- that characteristics acquired by the weak intentions, with the assertion that lously careful to be fair to opposing individual could be inherited by his or suicide must be strongly intentional. viewpoints and successfully maintains her descendants. Increasingly, the One by Suzanne Stern-Gillet on the its philosophical detachment. It pro- mentally ill and mentally deficient rhetoric of suicide contains a discussion vides an eminently appropriate synop- were seen as causes of society’s ills of the 1981 IRA hunger striker, Bobby sis of the arguments. However, its very rather than as consequences of disad- Sands, and the manipulation of the detachment may make it less useful for vantage. This was fertile ground for concept for political ends. R G Frey clinicians seeking ethical or moral dis- the formation of policies of wholesale considers whether a death has to be cussions of more practical signifi- segregation and sterilisation of the self-inflicted to qualify as suicide. Ter- cance. We seldom see platoon com- mentally defective. The former had ence O’KeeVe, in another study of manders throwing themselves on extensive application in Britain whist deliberate self-starvation, distinguishes grenades or submarines in danger of the latter was rejected (but accepted in between genuine suicides, which he sinking, so moral critiques of more Germany and some parts of the USA). J Med Ethics: first published as 10.1136/jme.26.1.77 on 1 February 2000. Downloaded from

Book reviews 79

As the title suggests, this book of developmental origin, for example, sity has recently founded an Austral- mainly addresses the history of social habitual criminals and inebriates. How- ian Institute for Health, Law and Eth- and political aspects of mental defi- ever, utilitarian concerns and the just ics. Again, the law school at ciency during the time period covered, use of finite resources were commonly has established a flourish- rather than developments of bio- applied to define services rather than ing postgraduate course in law, medi- medical knowledge in this domain concepts of individual rights. Through- cine and ethics under the direction of over that time. out the book, continuities with periods Associate Professor Loane Skene. This scholarly work makes good use before and after the subject matter are Professor Skene has been one of the of a wealth of original source materials discussed. Indeed, despite rhetoric of movers and shakers in this movement as well as more widely available “person-centred services”, the lives of and in her most recent book she is able published books and articles. This first people with learning disabilities are still to draw on a vast fund of legal and major historical work on the problem all too often governed by administrative medical experience. The book is very of mental deficiency presents a com- convenience which diminishes au- much a compendium of information plex, multilevel and interactive model tonomy and predisposes to co-existent bearing upon the rights and duties of which belies many of the more simplis- mental illness. doctors and their patients and it is tic accounts of this subject. The first This book is of considerable interest directly practical in its aim of enabling two chapters deal with parliamentary to historians of health and social poli- all the parties involved in health care and civil service responses to mental cies, especially those interested in situations to find out where they deficiency. Chapters three to five cover mental health in general and learning stand. The author eschews any theo- the approaches adopted by profes- disabilities in particular. Furthermore, retical speculation about the larger sional, voluntary and pressure groups I would recommend it to mental controversial ethical issues and for the (including the astonishingly under- health workers, given the strength of most part concentrates on the state of reported development of community its coverage of relevant ethical issues. the law about the questions she care for this population in the inter-war The account of the history and ethics discusses—consent to medical treat- period). Chapter six describes the local of problems relevant to this population ment, the doctor’s duty to provide administration of policy according to may well prove of relevance to other information, confidentiality, with- ideology, need and resources. Chapter vulnerable and potentially disenfran- drawal of treatment, etc. seven presents a fascinating account of chised groups such as those who For the most part Professor Skene is the “micropolitical” interaction be- acquire handicap, disabilities and in- concerned with Australian situations tween social services, families and peo- tellectual impairment later in life. and legal decisions but she also discusses relevant UK cases and opin- ple with learning disabilities them- DERMOT ROWE selves. This is thrown into contrast ions and her book would have consid- Department of Psychiatry, erable value for doctors and their with the development of the burgeon- Oxfordshire Learning Disability NHS Trust ing Welfare State in chapter eight. patients, and lawyers, in the UK and The Mental Deficiency Act of 1913 other countries. and its consequences are described in Law and Medical The book, as I have said, is a model of detail, including the well-known pitfalls a practical compendium but, as a http://jme.bmj.com/ philosopher I would have liked to see a of confusing “moral” criteria with psy- Practice: Rights, little more attention given to the larger chometric and psychopathological crite- Duties, Claims and ethical issues, especially on the vexed ria for the compulsory detention of questions that arise a propos the with- patients. This led to large numbers of Defences drawal of medical treatment. These young mothers who were not married questions have been at the centre of and young men with minor oVending Loane Skene, Sydney, Butterworths, much recent discussion in Australia. behaviours being admitted to mental 1998, 299 pages, A$ 54. Again, Professor Skene says nothing handicap hospitals for long periods. Vic-

about the special problems (regarding on September 27, 2021 by guest. Protected copyright. torian political philosophy accentuated The interdisciplinary conjunction be- consent, the examination of women the freedom of the individual within a tween law, medicine and ethics has patients, the use of information gained framework of rights and responsibilities. been a notable development over the in research etc) involved in medical This explains, to some extent, the para- last twenty or thirty years, particularly treatment of indigenous Australians doxical unity of conservative and pro- in the UK and common law countries and New Zealanders. No doubt there gressive politicians in support of the such as Australia, New Zealand and are as yet very few legal cases in this area policies of segregation and, in many Canada. Many law schools in Aus- but we may be sure that it will be an cases, even sterilisation. The mentally tralia now have flourishing centres and important focus in the very near future. defective were seen as less autonomous institutes where law and medicine and However, one cannot cover every than intellectually intact individuals and ethics are brought into dialogue with issue and there is no doubt that thus as having fewer rights and respon- each other and there are also a number Skene’s book admirably succeeds in its sibilities. Diminished freedom was justi- of statutory bodies serving the same main purpose. It will certainly be wel- fied at the same time as society’s duty of purpose. in Mel- comed by doctors and lawyers and, care to these individuals was recog- bourne, for example, has been the not least, by intelligent patients. nised. Therefore, they were subject to home of the Centre for Human MAX CHARLESWORTH policies which curtailed their liberty but under the guidance of Pro- Author of Bioethics in a Liberal Society, were aVorded greater resources than fessor Peter Singer (soon, alas to move Cambridge University Press, 1997, and many of their peers who presented with to Princeton) and Dr Helga Kuhse, co-founder of the Australian similar social problems which were not and the law school at the same univer- Bioethics Association