The pace of change, especially in the bio-medical field, is so breathless, so unremitting that the ethical challenges posed to clinicians mount and change almost daily. But the change is not incremental; sometimes lit is like a quantum leap. The questions may be unlike any that have been faced before. It is therefore timely and gratifying to have a guidebook to help us chart through these treacherous waters.

However, like many of the ethical issues with which clinicians deal, the guide is organized in a rather unique way. It does not, as has been the tradition, structure itself around topics and related issues, but divides into two parts. The first is concerned with issues that primarily confront individuals, and the second is concerned with issues of social policy. This allows for many of the cross-cutting issues to be dealt with in a coherent, pertinent and logical manner, and does not take the guide down some of the more arcane alley-ways of philosophical debate that can lose sight of the practical world and the individuals who inhabit it.

The editors use the distinction articulated by John Rawls that there are issues that concern the personal domain and there are those that may be seen as reasonable and rational to apply to all in the political domain; but for any one person they are not always consistent, and the difficulty faced by individuals in making a choice concerning their own lives shows that it does not always follow in an ordered, objective way. People, and their ethical stances, are not always consistent. It can be a mistake to underestimate the power of dissonance. Personal experience colors our perception of the world. What is sauce for the goose is not always sauce for the gander. Like the truth, medical ethics are rarely pure and never simple.

The contributors are widely experienced and come from a variety of backgrounds and disciplines. They include philosophers (of course), but also lawyers, scientists, theologians, physicians and clinicians and in that way they cover both the theoretical and conceptual issues and the practical applications. The writing reflects this appealing mix. The examinations of the complex and different levels of discourse should appeal to a wide readership.

Our attention is drawn to the fact that what might appear to be straightforward issues have become enormously complex, because the science now allows us to make decisions, but does not indicate whether we should. What becomes possible expands almost daily, and the old cry of the scientist that theirs is not the decision about right and wrong, merely what is good science, is no longer acceptable. Technological and scientific progress is inextricably linked with its ethical implications, and the debate over restrictions to scientific endeavor form an important theme in the guide.

What exactly has death become now that technology can keep the body functioning beyond its natural scope; what does life mean when ever younger fetuses can be kept alive; what exactly is a viable life-form and where do rights begin, what even does ‘mother’ mean when the person who carries the child is not the owner of the egg that was fertilized; what does father mean when sperm can be viable long after the man himself is dead? The difficulties defining and limiting the notion of surrogacy, deciding on when and by whom a decision affecting a person’s life can be taken, clearly affect people on an individual level, but perhaps cannot be left to a case-by-case judgment.

There are also chapters that deal with issues of personal liberty, and the conflicting liberties of all the persons involved. The issue of abortion is explored in detail and used as a touchstone for the general arguments, but the authors do not display a parochial or America-centered attitude to this or other debates. The concern over the legalization of certain recreational drugs, for example, is used to highlight the conflict between individual and communal rights, between freedoms and responsibility and the notion of the victimless crime. Can we be said to live in an individualized world, or are we always part of a collective?

The dilemmas faced in truth-telling by clinicians do not just apply to admitting to mistakes, but broaches the concept of the right to know. At what point does the right to know conflict with the clinicians’ professional duty to cause no harm or to avoid speculation or to advise only when there is evidence?

The guide may be best seen not as a textbook, which is the final definitive word on the subject (although the concepts are well-explained, clearly articulated, referenced in a scholarly way and the editors do a fine job in relating one chapter to another, linking the two sections and making the guide a coherent whole). It may be seen instead, as the title suggests, as a guidebook. It covers a wide range of topics and pints the reader in the direction of further reading; it locates the issues in a context that is helpful for the casual reader and the beginning or intermediate scholar and it makes the journey relevant and intriguing. It could be suggested that some ethical perspectives, such as relational ethics, do not get quite as much attention as the more classical approaches, but the guide is thorough and generally even-handed. Also, the focus is medicine rather than the wider world that might include health care givers who also face the same dilemmas. It seeks to understand the debates rather than provide answers. It is accessible and pertinent. It is a very timely addition to the literature because we all need to think about whether we should do something just because we can.

© 2007 Mark Welch

Mark Welch, Ph.D., Assistant Professor in the Faculty of Nursing at the University of Alberta, Edmonton, Alberta and Co-Director of the PAHO/WHO Collaborating Centre for Nursing & Mental Health

Categories: Ethics