Medicine and the Marketplace: the Moral Dimensions of Managed

J Med Ethics: first published as 10.1136/jme.26.4.293 on 1 August 2000. Downloaded from Journal of Medical Ethics 2000;26:291–295 Book reviews Physician-assisted end-of-life issues and she and her of the “slippery slope” and to the fellow editors have produced what is, relevance of the Dutch experience in Suicide: Expanding on the whole, an interesting, readable this context. the Debate and topical collection of essays. Finally, contributions on the Whether it succeeds in expanding and achievements and availability of pallia- deepening the debate is, however, tive care, the Oregon law, and on the Edited by Margaret P Battin, itself a matter for debate. alleged distinction between physician- Rosamund Rhodes and Anita Silvers, On the one hand, a number of con- assisted suicide and euthanasia, would New York and London, Routledge, tributions do help to develop the have been valuable. The book does, 1998, 463 pages, £45. debate, particularly Patricia King and however, have useful appendices con- Leslie Wolf’s essay on the perspective taining the text of the Supreme Court This substantial academic volume, of African-Americans, Patricia judgments; the “philosophers’ brief” which seeks to expand the debate on Mann’s on the meaning of death, and submitted to the court, and the physician-assisted suicide, is a signifi- the contribution by Margaret Battin Oregon Death With Dignity Act. cant addition to the growing number herself, which questions the common In short, in some significant re- of edited works on one of the most assumption that physician-assisted spects this volume serves to expand important issues in contemporary suicide should or would be rare. the debate. In others, however, it gives bioethics. On the other hand, the book risks a misleadingly narrow impression of it. The introduction observes that the giving a misleadingly narrow and JOHN KEOWN, essays illuminate the evolving, increas- rather one-sided impression of the Faculty of Law, University of Cambridge ingly “nuanced” American debate in debate. the wake of the landmark Supreme First, although the editors write that Court decisions upholding laws they aimed to produce a “fairly evenly Children, Families, http://jme.bmj.com/ against physician-assisted suicide. Its balanced” collection, contributors in and Health Care twenty-three chapters are divided into favour of physician-assisted suicide five sections: “conceptual issues”; outnumber those against by around Decision-making “those at risk”; “the practice of medi- two to one. cine”; “the impact of legislation”, and Secondly, only two essays oppose Lainie Friedman Ross, New York, “religious perspectives”. physician-assisted suicide in principle, Oxford University Press, 1998, 197 How, then, is the debate said to be and those for religious reasons. The pages, £30. evolving? Conceptually, the editors book’s failure to include a single claim, both proponents and oppo- philosophical contribution articulat- Over recent years in the UK there has on September 24, 2021 by guest. Protected copyright. nents now appeal to the same values, ing and defending the traditional prin- been increasing emphasis placed on such as autonomy, beneficence, and ciple of the inviolability of human life children taking responsibility for what medical integrity. Politically, patients’ mars the volume. This failure is all the happens to them. This American pub- groups have focused attention on the more unfortunate not only because lication oVers a refreshingly diVerent likely eVects of decriminalisation, par- several essays criticise this principle, view of parental and family autonomy ticularly on “vulnerable” groups such and those criticisms therefore are and advocates a model of constrained as the disabled and racial minorities. allowed to pass unchallenged, but also parental autonomy. Ross argues that Medically, there is greater recognition because the principle of the inviolabil- giving children rights equivalent to of decision making by patients and ity of human life was reaYrmed by the those of adults is “to deny them the relatives and of the inadequate provi- Supreme Court and underpins its rea- protection they need” and render sion of palliative care. Religiously, dif- soning. The volume could easily mis- them “even more vulnerable than they ferent denominations have extensively lead a reader into believing that the presently are”. Her thesis is that whilst examined their respective theological principle no longer plays an important children should be included in the positions. In short, it is claimed that part in the current debate. decision making process, parents the debate is not only “larger and Thirdly, moving from principle to should be responsible for their health louder” but also “deeper and more practice, another omission is the care even after the children have profound”. Dutch experience of euthanasia and achieved some threshold level of com- This well-produced book is cer- physician-assisted suicide, an omis- petency. However, the autonomy of tainly a worthwhile contribution to the sion which is all the more puzzling in the parents should not be absolute. debate. Margaret Battin is deservedly the light of the significance attached Rather it should be constrained by a one of the most well-known writers on by the Supreme Court to the dangers modified principle of respect for www.jmedethics.com J Med Ethics: first published as 10.1136/jme.26.4.293 on 1 August 2000. Downloaded from 292 Book reviews persons which takes account of the A Philosophical ing to show is that while at first sight specific limitations of children’s com- these essays may appear to be some- petency. Disease: Bioethics, what disparate, they actually have a The author herself suspects that she Culture and Identity connecting theme. I am not sure will be criticised for not according though whether Wittgenstein’s later enough respect to competent children Carl Elliott, New York and London, work provides an adequate resource and that her interpretations may for this task, although its general Routledge, 1999, 188 pages, £12.99. permit of wider parental autonomy relevance is clear. than many readers will find accept- To see why this is so it may be help- Bioethics became established as a dis- able. She addresses each anticipated ful to refer to Stephen Toulmin’s criticism systematically and argues her tinct discipline in the United States in work, which has been influential in the case cogently and carefully, presenting the 1960s. The paradox is that it arose development of Elliott’s thinking. argument and counterargument, liber- in part from a general background of Toulmin has made the bold claim that ally annotating and referencing her criticisms of biomedicine at that time, text, and pointing out areas where but has largely followed the traditional the philosophy of medicine has a spe- information is scant or questionable. pattern of biomedicine in being reduc- cial role to play, not just in medicine She recognises that parents’ concep- tionist and orientated to pragmatic but also in philosophy. Now if this is to tion of what is best for their family may problem-solving. So for some thirty be fostered successfully I think that a not be what others would perceive as years the theoretical debate within greater range of ideas will be required best and that indeed their beliefs and bioethics was mainly about which than can be derived from Wittgen- values may even limit opportunities ethical theory, principle, or combina- stein’s work alone, and this is the pro- for children. Nevertheless she believes tion of principles to subscribe to; gramme within which Elliott’s ideas that their autonomy should be ques- whilst in practice many came to see would seem to fit most comfortably. tioned only if their decisions are disre- bioethics as a new medical subspe- However, one significant development spectful of the child’s developing cialty, with hospital ethicists as profes- in taking this forward is missing in personhood; it is not for the state to sional experts. Elliott’s book. This concerns the define ideal parent-child relationships However, this mainstream develop- current growth of interest in phenom- or goals. ment of bioethics has not gone unchal- enology and hermeneutics, particu- The model of constrained parental lenged, and there have always been larly in relation to the philosophy of autonomy promoted in this scholarly those advocating other approaches. the body, which would seem to herald The Centre for Philosophy and Health work allows flexibility and breadth of a fruitful engagement between the Care here in Swansea has been a good application which, the author con- Anglo-American and Continental tra- example of this, having consistently tends, makes it practical as a decision ditions in philosophy, broad enough to concerned itself with many of the making model across a wide range of accommodate Wittgenstein, as well as health care situations. In the second issues that Elliott raises. These focus the diverse range of other approaches part of the book she tries out the on the question of whether any which are now emerging, and will no http://jme.bmj.com/ model in various practical contexts: systematic philosophical theorising, or research, organ donation, medical precise arrangement of principles, doubt be added to in future. treatment, and adolescent sexual ac- could ever provide definitive answers None of this is intended to diminish tivity. She concludes that it oVers a to deeply troubling medical dilemmas, the importance of Elliott’s book, viable alternative to the best interests because of the inevitability of moral which both reflects as well as being an standard and is particularly useful in disagreement. Such dissident voices important contribution to, this ongo- situations where interests compete tended to be rather isolated until a ing debate. If work such as Elliott’s and conflict. Underlying her position decade ago, but since then have gains the prominence it deserves it will is a respect for parents as individuals increased very significantly in num- signal the end of the worst features of with their own needs, interests and bers and in a variety of diVerent ways, bioethics, by demonstrating the cen- on September 24, 2021 by guest.

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