There
are many books on bioethics. Yet few
books offer a comprehensive analysis of the political framework within which
bioethical decision-making occurs in a liberal constitutional democracy. While written from within a US background
this book is nevertheless applicable to readers from any Western democracy.

Thomas
May is Associate Professor and Director of Graduate Studies in Bioethics at the
Center for the Study of Bioethics at the Medical College of Wisconsin,
Milwaukee. He develops his argument over a series of seven chapters. May notes how a person’s right to make
independent decisions is a key feature of a liberal society and this has
significant impact upon patient autonomy and constraints to the actions of
health care professionals. However,
this right rests upon an assumption – what some would call a norm – of an
individual being competent. As readers
of Metapsychology will aware
significant challenges exist when people do not have the competence to make
adequately informed decisions. Hence,
William May explores the importance of healthcare ethics committees and ethics
consultants to inform and assist decision-making within modern health care
facilities.

Chapter
1, appropriately entitled, “The Liberal Framework”, sets itself clearly within
a US context. It makes a very interesting
contrast between the individual rights focus of the USA and Japanese cultural
history with emphasis on a family authority. 
In so doing he points out that:

Healthcare, as a
social practice, is bounded by the fundamental political context within which
it exists. In short, the role that
moral beliefs play in bioethics will be limited, in a social context, by the
political rights of individuals. (Page 5).

As
May notes, respecting patient autonomy in a liberal society often involves
recognizing negative requirements as being less intrusive than positive
ones. For example the emphasis on a
patient’s right to refuse treatment.

In
Chapter 2, May discusses “patient autonomy and informed consent” utilizing the
first of many case studies which are of great assistance in making the point
being discussed. An important dimension
to informed consent is the emphasis upon adequate disclosure, recognizing the
role of the notion of what a “reasonable person” would require. Yet he also recognizes the five general
bases for potential exceptions to informed consent: threats to public health, medical emergency, therapeutic
privilege, waver of informed consent by the patient and lack of competence.
These are discussed in a critical and accessible way.

As
May notes in the next chapter, perhaps one of the most important developments
in health care has been an increased emphasis on patient autonomy. This is discussed in a chapter entitled
“Patient Responsibility for Decision-making”. 
In my experience as a consultant in the area, May offers an important
insight about the fact that:

…
the “standards for competency” offered in the biomedical ethics literature
often “smuggle” concerns about the merit of a patient’s decision into the idea
of competency preempting the patient’s judgment by assessing that the patient
lacks the capacity to make decisions because the patient’s decision is not a
“good” decision. (Page 33)

While
May focuses his discussion on individual cases, I couldn’t help reflecting that
other examples were to be found when cultures clash with regard to contested
notions of the “right” decision. May
also goes on to identify the challenges associated with “the incompetent
patient" and the way in which a liberal framework, based upon the notion
of a competent adult independent decision-maker, does not adequately provide a
“correct” mechanism. This insight is an
important contribution to the literature in itself. Too often we can take for granted the social and political
context within which decisions are made. 
This book makes clear that this can be problematic for some of the most
disadvantaged people – those that don’t fit the norms of competence.

In
Chapter 4, May discusses the role of “advanced directives” as extending
autonomy for patients. He also notes
how this has been addressed at a federal level in the US through the Patient Self-determination Act 1990. It is worth noting here that some other
Western countries with differing political ethos have not tended to pursue this
within the health care system to the same extent as the USA. May’s critical exploration of advanced
directives, including incorporating work that is critical of his own, is to be
applauded.

An
understanding of the role of the history of paternalism, and yet the liberal
obligation of tolerance, informs Chapter 5 “Beneficence, Abandonment, and the
Duty to Treat” which argues that the negative rights granted to patients in a
liberal society impose claims requiring healthcare professionals to respect the
autonomous decision of the person. May
establishes beneficence as a core feature of the physician-patient
relationship. Strangely he does not
discuss other healthcare professionals but certainly this could also be seen to
obtain. He also suggests that a liberal
society can establish a minimal duty to treat, though he restricts this to the
special circumstances of a physician-patient relationship and where there is
insignificant or even no cost imposed on the person required to provide
aid. Readers from other Western
countries will find that their own social and political context will provide
them with an alternative perspective with regard to this discussion, which is
dominated by a US conception of healthcare. Chapter 6 discusses the “Rights of
Conscience in the Physician-Patient Relationship” with the situation of a
Jehovah’s Witness being an excellent example with which to start the
chapter.

May
concludes in Chapter 7 in making the case for healthcare ethics committees and
consultants within the liberal framework. 
This is in itself an important contribution to the literature and will
be of particular interest to readers from some non-US countries with little
experience of ethics committees having a role regarding treatment
decisions.

Hence,
May’s book is a helpful overview and introduction to the political framework of
bioethics decision-making within a liberal society. I did however find myself raising a couple of questions. Firstly, there is uncritical use of the
terminology “patient” and yet little justification for that terminology. Certainly there is a leap from the
discussion of individuals or people in the political literature to its
application within the healthcare system. 
The terminology “patient” is hardly agreed upon and has its own power
relations worthy of exploration. Secondly,
the book also would have benefited from some cross-cultural analysis. Written from within a US context about
largely US notions of a liberal framework some noticeably different readings of
liberalism are to be found in a variety of Western societies. The incorporation of these within the book
would have strengthened not only the analysis but also the critical reflection
that this book seeks to foster.

However,
there is no doubt that this book marks an important contribution to the
literature. It will be of particular
interest to readers of Metapsychology
because it touches explicitly on the issues of perceived and actual lack of
competence, substituted decision-making, advanced directives and the important
roles of ethics committees and consultants. 
It also shows how some of the dominant norms utilized within notions of
the liberal society inherently disadvantage people who do not fit criteria for
autonomy. May’s book will be of interest to a wide scale of readers, from
philosophers to politicians, including bioethicists, patient advocates and
indeed healthcare professionals. Undergraduate and postgraduate students alike
in bioethics, public policy, politics and a variety of health care disciplines
will find it worthwhile. Well worth the investment of time and money.

©
2002 Christopher Newell

Dr. Christopher Newell is
Senior Lecturer in Medical Ethics, School of Medicine, University of Tasmania,
Australia.

Categories: Ethics