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J R Soc Med. 2006 July; 99(7): 374.
PMCID: PMC1484564

Case analysis in clinical ethics

Reviewed by Donal Manning

This book demonstrates clinical ethical deliberation in practice. It takes a complex clinical case and shows how it can be analysed from different theoretical ethical perspectives. The history is presented by a clinical geneticist and includes her own narrative, and those of the two relevant patients, their general practitioners and an oncologist. It relates the story of a young mother, with a strong family history of breast cancer, who is contemplating prophylactic bilateral mastectomy. Unknown to her, but known to the genetics team, her aunt, who has been treated for breast cancer, is a carrier of the relevant gene mutation. This knowledge could allow predictive testing of the young woman—if the result were negative, mastectomy would be unnecessary. The aunt, however, refuses to divulge her clinical and genetic history, despite strenuous attempts at persuasion by the genetics team. The dilemma is whether to breach the aunt's confidentiality in order to provide substantial benefit to her niece, or to respect confidentiality at significant cost to the younger woman.

The case is analysed by experts in several theoretical ethical approaches. These include the mainstream utilitarian and ‘four principle’ perspectives, and approaches which are currently attracting increasing interest, including narrative, virtue and feminist ethics, hermeneutic, post-structural and phenomenological analysis, and deliberative and empirical ethics. Finally, the clinical geneticist and the editors offer clinical and philosophical reflections, respectively, on the exercise.

All chapters are written clearly, even those on hermeneutic and post-structuralist analysis. This should not only enlighten, but also reassure, the clinician reader whose instinctive response to these latter approaches might be one of suspicion.

Though the case history was comprehensive, several ethicists laid emphasis on different aspects of it, requested more information or suggested that some relevant information be teased out in greater detail. This shows how different ethical methodological approaches can lend richness and depth to the analysis of a clinical ethical problem.

Perhaps not surprisingly, the ethicists reached a range of differing conclusions, from justifying breach of the aunt's confidentiality to the opposite conclusion. Several experts acknowledged that neither their own approaches nor the alternatives could solve the dilemma. This is not necessarily a comfort to the scepticist, rather it emphasizes that ethical deliberation serves not necessarily to compute the correct answer, but to ensure that all relevant information and factors have been considered and given due weight.

The book succeeds in its aim of illuminating the wide array of methods and theoretical approaches currently in use in clinical ethics. It would be of interest and value to trainees and career doctors in general and specialist practice.


R A shcroft, A Lucassen, M Parker, M Verkerk, G Widdershoven
246 pp Price £24.99(p/b)£55.00(h/b)
ISBN 0521543150 (p/b) 0521835496 (h/b)
Cambridge: Cambridge University Press

Articles from Journal of the Royal Society of Medicine are provided here courtesy of Royal Society of Medicine Press