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Alastair Campbell, Grant Gillett, Gareth Jones
297 pp. Price £19.95 ISBN 0-19-558445-7 (p/b)
Oxford: Oxford University Press .
Medical Ethics aims to provide ‘a practical introduction to the ethical questions doctors and other health care professionals can be expected to encounter in their practice’. Divided into three parts, the opening section, Foundations, begins with a brief overview of the main discourses that have come to characterize western secular moral philosophy. An important omission is the failure to explore critically the assumptions underpinning the rationalistic outlook that unites these otherwise diverse ethical frameworks. There then follows an excellent chapter on the ‘healing ethos’. After surveying the variant forms that the doctor—patient relationship has historically taken—ranging from the sacred (as in the Hippocratic Oath, for example) to the paternalistic and, more recently, the consumerist models—the authors propose that a ‘covenant model’ might profitably be adopted, for it is only a formulation of this type that ‘does justice to the religious or humanistic convictions of those who choose medicine out of a sense of vocation and a desire to help those in need’.
The New Zealand flavour to the book (each of the three authors has at some time been based at the University of Otago) offers many useful insights. This is most evident in the chapter on Health Care Ethics in Diverse Cultures, in which the authors display much respect and sensitivity for indigenous Maori cultural norms; also evident is their understanding of the very considerable impact of European colonialism which has, as in so many other parts of the world, irreparably fractured cultural narratives developed and nurtured over the centuries. But a willingness to appreciate the responsibility that must come from belonging to what has arguably been one of the most intolerant of world-views should not, they contend, lead to the other extreme, of uncritically embracing moral relativism. Here they draw on the (rather tired) example of female genital mutilation, contending that even though many African women view the procedure as an integral aspect of their identity it cannot be justified since it is ultimately oppressive. More illuminating for western-trained clinicians might have been an exploration of some of the moral uncertainties in a more mundane issue such as the treatment of the elderly. For many who come from traditions in which the extended family network is the norm, the western practice of discarding frail parents into nursing homes is utterly inhumane; the argument that many elderly people prefer not to be ‘a burden’ on their children is simply indicative of the way in which a capitalist individualistic culture has successfully institutionalized such moral wrongs, as is the case in those patriarchal African societies that continue to sanction female genital mutilation.
The section on Clinical Ethics is concerned with the broad range of concerns that one would expect to find in a text of this kind—ethical considerations and controversies at the beginning and end of life, tissue and organ transplantation, and the many issues that have arisen in the aftermath of the HIV pandemic. But there are also a few surprises, including very thoughtful discussions on the concept of personhood in those with advanced dementia and a section on ‘the blessing of mortality’.
In the final section, Medicine and Society, are considered issues to do with research ethics, the concept of justice in health care provision and medicine and the law. There is also a very interesting critique of the evidence-based medicine movement and the ways in which a narrow understanding of scientific orthodoxy may simultaneously curtail innovation and devalue the artistic dimension to the craft of healing.
This is in summary an elegant, scholarly and sensitive introduction to western medical ethics. By building much of the text around case histories, the authors successfully render the at times intricate discussion into a form that is engaging and challenging. In this third edition the book should continue to enjoy broad-based appeal amongst health professionals. In addition I hope it will be sampled by at least some of our patients, for a common recognition of the complexity and uncertainty inherent in ethical health care provision is essential if we are to promote a covenant relationship that has as its essential feature ‘a promise to show active concern for the other’.