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Michael Parker, Donna Dickenson
359 pp. Price £29.95 ISBN 0-521-78863 (p/b)
Cambridge: Cambridge University Press, 2001 .
Our clinical practice is steered by ethical principles. They guide the decisions we make in our clinics and ward rounds; what we tell our patients, and what we omit to tell them; the research we do. Medical ethics and law are now part of the core curriculum for medicine. The Cambridge Medical Ethics Workbook sets out to be both a textbook and a work of reference. In reviewing it, my plan was to dip in and out, reading subjects that took my interest. For me a book that did not provide a rewarding self-contained read over a cup of tea was likely to remain on the shelf.
The pattern of all the chapters is similar. A brief introduction is followed by a case presentation. This may be based on an individual patient or the resumé of a controversial problem in clinical practice. From the cases it is clear that the authors understand the issues that arise in clinical practice. The discussion is developed by use of short papers, often by authors writing from contrasting perspectives. These form a backdrop of expert opinion against which ‘activity boxes’ encourage readers to develop their own views and draw on their own experiences. The result is a satisfying sense of having thought through the issues oneself. Each section is well referenced.
Some sections are particularly thought-provoking. A short piece introduces the subject of HIV trials in developing countries. Antiretrovirals, given as part of triple therapy, had proved successful in reducing vertical transmission of HIV. In the developing world, however, such treatment remained unaffordable. UNAIDS generated great controversy in deciding to test less complex antiretroviral regimens against placebo in countries that could not afford triple therapy. Many people were outraged: in a developed country, a placebo controlled trial would not be considered ethical if a proven therapy existed. Seemingly, ethical standards were being relaxed because the patients were from poor countries. Two papers putting contrasting views are presented. One by a South African ethicist argues that standards of care in research should be the same wherever the trial is conducted, rich or poor. But a joint statement from the US National Institutes of Health and the Centers for Disease Control and Prevention defends the research, which they partly funded. They claim that, since developing nations have no access to triple therapy, a trial using such a treatment would be unrealistic and therefore unethical. The ensuing discussion is engaging but in my opinion misses the essential point. What is unethical is that so many children are born with HIV when effective preventive treatment exists. If we do nothing to change this, our ethical standards and declarations become suspect. Why are we concerned that individuals in a trial should receive the best standard of care, yet say nothing when those around them are left untreated.
The international perspective is maintained throughout the book. A child's competence to consent to treatment is discussed in some detail. In the UK, case law determines that a ‘differential tariff’ exists. In other words a competent child may consent to treatment, but may not refuse it if an adult with parental responsibility consents on his or her behalf. Under such circumstances consent is meaningless. In Italy the competent child's right to consent and to refuse is enshrined in legislation. In Finland strong legislation demands that the child's voice is heard but this has proved difficult to translate into practice.
The layout of the chapters is odd. I would have liked an introductory chapter that sketched the broader issues. Instead I found this information scattered throughout the text. The book begins with a discussion of the ethical issues raised by developments in modern medicine. Part two examines the care of particularly vulnerable groups such as the elderly and the young. Lastly, in part three the wider ethical themes in healthcare are discussed. One feels it would be almost better to start at the end and work backwards. The section on autonomy, competence and confidentiality is a good introduction to ethics but is hidden away in chapter five. I would have appreciated a short discussion of the history of medical ethics.
This is a book with a great deal to commend it. The discussions are enlivened by an excellent panel of contributors, and the format is engaging. It makes you think—an enjoyable experience over a cup of tea.