Contemporary Issues in Bioethics

Part I: Introduction to ethics. Ethical theory and bioethics. Bioethics as a field of ethics. Part II: Moral and conceptual foundations. Concepts of health and disease. Life, death and personhood. Part III: Life and death. Abortion. Euthanasia and the prolongation of life. Part IV: The patient-professional relationship. Patients' rights and professional responsibilities. The management of medical information. Part V: Biomedical research and technology. Research with human and animal subjects. Frontiers in biology and medicine. Part VI: Allocation and health policy. The allocation of medical resources. Health Policy. Index.

Contemporary Issues in Bioethics Tom L Beauchamp and Leroy Walters Encino and Belmont (Calif). Dickenson Publishing, I978.

Case Studies in Medical Ethics
Robert M Veatch Cambridge (Mass) and London, Harvard University Press, I977. As the teaching of medical ethics becomes a fact of life for medical students and others so does the need for source books grow. The three works here under review aim to supply that need. Ethics in Medicine and Contemporary Issues in Bioethics are collected essays and articles topically presented with more of less helpful guidance. Case Studies in Medical Ethics is what the title suggests-and more. It covers much the same ground as the other two books and the author enlists the cases to illustrate his own approach to the study of medical ethics.
Controversy surrounds the study of medical ethics at three points. First, who should teach it? Some argue that only medical practitioners can properly lead discussion of the issues since they alone have the relevant experience. Others, like the Edinburgh Medical Group, while asserting the need for doctors to be involved, maintain that the enterprise is essentially multidisciplinary. These books come from three major American centres for inter-disciplinary study of bioethics (viz Harvard; Kennedy Institute, Georgetown; Hastings Institute, New York). They bear testimony to the benefits to be had from such an approach. The second contentious issue is who are the 'students' of medical ethics? Are they just medics or just the helping professions or is it the whole community-and is the object to arm the laity to do battle with the professionals who conspire against it ? This question as such is not tackled in the books though Ethics in Medicine makes a most valiant attempt at being accessible to a general readership, albeit an intelligent and enquiring readership whereas Case Studies is directed at students of the helping professions. Contemporary Issues, perhaps the best of the three, is unashamedly an anthology of recent essays and essential background material designed to enable the professional to catch up with this burgeoning field of study and to introduce the student to the literature in a systematic way. There may be issues which are only the business of practising professionals and others which are none oftheir concern at all, but the present level of awareness and discussion seems likely to reduce misunderstanding and antagonism provided that it does not result in confrontation between articulate critics and those who must bear professional responsibility. Nor should such study become a platform to malign particular churches, professions or preferences. Ethics in Medicine, with its historical approach, is most overtly eirenic at this point. Its aim is to enable the reader to understand the present dilemmas by tracing their history.
Perhaps none makes enough of the different points at which ethical questions apply. For example, abortion is a problem for the helping professions, but it is a problem first for the woman and her immediate circle. The ethical debate needs to spill over into the community so that responsible decisions can be made at this first level.
A third question is whether medical ethics should be taught from cases or from theory. Sensitive and reflective doctors have for years gained their ethical insights from observation of cases and their skilful management-so why should anything more be needed now ? I suspect there are two reasons: the cases are now more complicated and not all students are likely to be naturally sensitive and reflective. There has also been an erosion of whatever ethical consensus might previously have prevailed. In fact, all three of these books present a mixture of cases and theory. The most practical is Case Studies and the least is Contemporary Issues. In ethics it is just not possible to separate the two, a fact which Veatch asserts as a rationale for his book.
Ethics in Medicine is a massive tome: one hundred and three articles plus illustrative cases for six of the eight chapters and a fairly full index. The articles are wellchosen and are clearly laid out. The arrangement is logical: first the evolution of oath and code, next the principles of ethics and then in six sections the major contemporary issues. One great benefit of any anthology is that obscure material is made accessible: most of the material in this book is American, and therefore not readily available in Britain, Australia or South Africa for instance. Also it is from many different sources it is probably not easily available anywhere. Most helpful in this regard, perhaps, are some quite old items like Frederick II's decrees regarding medical training and practice. Each section is introduced briefly by editors' remarks evaluating the significance of the articles and, although there is no formal bibliography, some of the contributors give quite extensive lists of references.
Contemporary Issues is more tightly edited to a different purpose: to chart the current state of the debate.
The eighty-seven generally shorter readings are juxatposed in debate: the Patients' Bill of Rights, for example, is criticised by Willard Gaylin and the Harvard Definition of Irreversible Coma by Hans Jonas and Robert M Veatch. The method should help the reader to gauge swiftly the relative importance of points at issue and to evaluate persuasive argument. The arguments are adroitly summarised by either Beauchamp or Walters in an introduction to each of the twelve chapters. The introduction is also a narration of some of the history and a distillation of issues. This book gives more weight to philosophical problems and begins with a series of conceptual and theoretical articles with which the reader needs familiarity in order to evaluate the ensuing debate.
The teacher, student, professional and general reader will find this an easy book to handle: the arrangement of material, clear introductions, suggested reading lists for each chapter and the editing of otherwise long articles are all helpful. It's a pity, however, that the editors did not include an index.
At first sight Robert M Veatch's Case Studies in Medical Ethics is quite different from both of the previous books. But appearances in this case are deceptive. The book is more than a collection of one hundred and twelve interesting cases. There is extensive commentary by both the author and by selected specialists; a masterly compression of ethical theory in a fourteen-page introduction, careful annotation of references and an extensive (though mainly American) bibliography. Two appendices reproduce most of the important Codes of Medical Ethics and Guidelines for Experimentation.
Dr Veatch will be known to readers of thisJournal as a significant contributor to the field of medical ethics. As Senior Associate at the Hastings Institute in New York he has been involved in teaching ethics to medical students at Columbia University and to students from such disparate fields as law, dentistry and divinity. He brings to the cases the freshness of perspective of a non-medic and the judgment of one who is thoroughly at home with the material. The book is in fact an argument. It develops slowly and even tediously. Their apparent presuppositions inform the argument: all medical judgments have ethical content; ethics is an essentially practical science; and there is no one ethical approach which is always best. No doubt in some circles these prejudices would find ready acceptance. They are, however, debatable. One consequence of his position is that routine unthinking medical custom is subjected to absurdly close scrutiny, as in case 45. Dr Huntington tells four-year-old Michael that if he looks into the light of the aphthalmoscope he will see 'a doggie'. Seduced by the lie Michael co-operates. Later the clever Dr Huntington gives Michael a sweet to suck while the syringe is prepared and promises 'It won't hurt a bit!' Such deception is good medicine. But the author asks 'Suppose Dr Huntington reflects upon the long-range impact on Michael of the petty deceptions he uses and decides that, on balance, the short-range benefits, including the establishment ofa cordial relation between Michael and the medical community, outweighs any longrange harm done to Michael, but he also decides that if all physicians used these techniques for all their patients, it would contribute to a general mistrust of the medical profession.' Fortunately this sentence is probably the worst in the book, but such earnestness runs the risk of trivialising the issues of truth-telling and the doctor/patient relationship. It reveals the difficulty of maintaining all medical judgments are value-laden. It may also be an argument for restricting the medical ethics debate to those who are within the profession.
But consider Dr Veatch's audience: it is for medical students and students of theology, dentistry, social work, biology, nursing and law that he is writing. The argument of the book is that proper professional care involves ethical reflection, that such reflection will lead the professional to value principled consistency and that mere pragmatism (and even utilitarianism) will not suffice. The apparent pre-suppositions of the book are thereby undermined: ethics is not just a practical science; there is a sizable theoretical component. Nor are all ethical theories as good as one another; utility is subject to principled scrutiny. The author enlists the support of several scholars we have met already in the other books under review: Daniel alahan and William Gaylin on Duty to Patient and Society', Sissela Bok and Marc Lappe on 'Abortion' and E Tristram Engelhardt and James Gustafson on 'Psychiatry and Control of Human Behaviour'.
The cases are generally wellchosen and representative and the scope is almost encyclopaedic but this book would be heavy-going for most undergraduates unless they had some philosophical background. As a source-book for a case orientated course in medical ethics it would be invaluable. It bears the marks of having originated as a set of lecture notes but the breadth of the author's competence and his informed sensitivity to current debate make it worthwhile though heavy reading.

COLIN HONEY
Medical Sociology in Britain: A register of research and teaching Edited by Sara Arber London, British Sociological Association Medical Sociology Group, I978. This is the third volume of its kind to appear since I970. The increasing size of successive volumes shows that sociological studies have now become accepted as a respectable research area in medicine. A state of symbiosis has been attained. But the small, young associate is still largely dependant upon the vast and venerable organism upon which it feeds when it comes to funding, and in spite of its relative importance, the medical sociology group is the largest sub-section of the British Sociological Association, it is worth remembering how financially insignificant these kinds of activities are when compared with the costs of bio-medical research.
Such a volume cannot provide the results of investigations but it is a useful indicator of the areas which are currently attracting attention and a directory ofthe places where studies are being initiated.
Changing directions for research are clearly dictated by current issues of social and health policy. Following on the belated realisation that prevention might possibly be cheaper than cure, health education has attained a prominence it hitherto lacked and now appropriately heads the list of topics. Nursing research increases with the growth of academic self-consciousness within the profession. Demographic realities have dictated the relatively weighty effort going into the general study ofchronic illness and disability.