Bioethics in the Clinic is the latest
offering by New Zealand neurosurgeon and philosopher Grant Gillett, whose
previous output includes the comprehensive Mind
and its Discontents, as well as other more straightforwardly philosophical
works. Being Grant Gillett must be a busy life; speculating about the content
of the brain while stitching it up, reflecting on the structure and physiology
of the philosophical problems discussed in seminars. Gillett is one of the few
who can truthfully claim, unlike the pet shop owner in the Monty Python sketch:
"I don’t have to do this job, you know! I’m a qualified brain
surgeon!" Students must have some anxiety that Gillett remembers which
doctoral role he is performing.

In Bioethics in the Clinic
Gillett provides a broad discussion of medical ethics, beginning with a
philosophical critique of traditional ethical theory and an exploration of
narrative ethics.  This is followed by a
range of applied ethical analysis of perennial issues such as informed consent,
and uniquely contemporary issues such as stem cell technology and cloning. The
book is not for the newcomer to philosophy, although it is accessible to anyone
with a passing acquaintance with Wittgenstein and Aristotle. Gillett explores
medical ethics from a Hippocratic perspective, drawing heavily on classical
writings. He argues that an ethically motivated practitioner, left to pursue
the Hippocratic ideal of service, will produce not only ethical, but clinically
sound health care not because she has followed a set of rules such as those of
evidence based medicine, but because the moral imperative of medicine, coupled
with the naturalist tradition, will lead to the Hippocratic path. That can be a
hard case to argue given the climate of distrust of professionals, neatly
captured by Gillett’s discussion of the National Womens’ Hospital experiment in
New Zealand. An historically grounded ethics would have to acknowledge, as
Gillett does in discussing HIV / AIDS as a postmodern illness, that ethical
frameworks are not absolutes; they must fit the times. In that sense the
litigious ethics of the 1990s may have been right for that time, if not right
for the present.

The first section explores philosophical ethics, including ethical
principles, values, the Hippocratic tradition and truth. Gillett employs a
skeptical approach, refusing to accept that medical experts occupy a position
of privilege in ethical debate. Within the narrative approach, the doctor is an
interpreter, rather than a detached authority; interpretation is a discursive
process requiring the skill of attending. Patients are understood as presenting
with ‘broken stories’ rather than diseased bodies. This positioning renders
traditional ethics problematic. Medical experts cannot solve problems in
isolation from the lives in which those problems are experienced. Having
undermined the reassuring certainty provided by reducing ethics to a
utilitarian balancing act, or a set of comfortable rules, Gillett explores a
range of issues such as informed consent, medical heroism, and the medical
gaze. He is particularly critical of institutional responses to ethical problems,
arguing that audit and monitoring regimes, while a necessary protection for
patients, have the potential to undermine medical practice by creating a
climate of suspicion. There is something of a romantic longing for the doctor
as an involved, caring fellow traveler, rather than a purveyor of scientific
and sanitized cure. The science of medicine is there, but in the background,
wanting to be of service, rather than confining healthcare decisions to those
dictated by science. This approach is applied to Gillett’s own practice as a
neurosurgeon, exemplified by case in which he made a decidedly ‘unscientific’
intuitive decision not to operate. He argues that such decisions have to be
made at times, although they cannot be accounted for by rules of evidence or
logic. Later he extends this reasoning to the intuitive anxiety many people
feel about cloning. There is no science to it, but Gillett urges respect for
such intuitions. 

The remaining two sections consider ethics at the ends of the life
continuum. Gillett argues convincingly against active euthanasia, and in favour
of life ending decisions to withdraw interventions such as artificial
ventilation. He argues in favour of stem cell surgery, but is equivocal on the
issue of cloning. The criteria for decision making, located within the
narrative framework of the book, is the best possible understanding of the life
story of the patient. Such an approach releases patients and clinicians from
the uncertainty of narrow deontological or utilitarian reasoning (or the
illusive certainty of rigid moral codes). The three appendices are a welcome
addition for those who need revision of basic philosophy, or who want to know
more about how Gillett interprets Wittgenstein and Aristotle.

Gillett asks searching questions, and is not content with easy answers.
While arguing for narrative ethics he does not valorize that approach to the
complete disregard of ethical rules or the principles of beneficence and
autonomy. On many difficult issues he appeals to a right to autonomy, although
contextualizes that within the patient’s narrative. In providing an alternative
to ethical principlism, Gillett draws heavily on postmodern theory, especially
that of Foucault and Lacan. There is less acknowledgement, even for the
purposes of critique, of feminist theorists such as Gilligan, or the nursing
theory of ethic of care. It is true that such theory often reduces to a duty,
but it also contains a narrative thread that is worth considering in any
attempt to argue an alternative to traditional bioethics. There are times when
Gillett struggles to contain his disdain for some of his contemporaries.
Principlists like Beauchamp and Childress are dismissed rather scornfully, as
is the mechanistic ethical grid of Seedhouse. Gillett owns to being a
philosophical magpie, drawn to whatever idea or concept will shed light on his
questions. However reading this book you get the sense that Gillett is less
territorial than your average magpie. He is willing to concede that his
preferred narrative approach is no more a stand alone theory than its rivals,
but vigorous in defending the necessity of a narrative approach in order for
principles to have meaning.

There is plenty to
keep New Zealand readers engaged. Many of the illustrations are drawn from
recent New Zealand experience, although the examples are always chosen to make
a more general point. There are plenty of uses of Maori language too, although
I would not agree with Gillett’s use of tino
rangatiratnga to represent ‘having a story to live by’.  The book is written with a good deal of
humor.  Philosophers frequently look for
amusing illustrations to ease the way through difficult areas of argument. In
this Gillett is more successful than most. Heard the one about the surgeon and
the anesthetist on the airplane? I won’t spoil it for you.     

Bioethics in the Clinic is a clearly
written, passionately argued, and a deeply felt treatise on ethics. If there is
a fault it is that Gillett cannot resist the asides and qualifications that a
more pedantic writer might omit. But the tone of the book is engaging, and
there is a sense that Gillett is happy to sacrifice some of the niceties of
style in the cause of communicating his ideas.

This book comes
highly recommended to all health practitioners, and especially to those whose
work brings them into contact with the margins of health care, where standard
care can have major ethical implications. That includes most health
practitioners. Readers will not find a set of easy answers, but they will
benefit from the broad perspective offered, and perhaps feel relieved that they
can share some of their ethical burden with the person who brought it to them:
the patient.

© 2006 Tony O’Brien

Tony O’Brien RN, M.Phil, Senior Lecturer, Mental Health Nursing,
University of Auckland, a.obrien@auckland.ac.nz

Categories: Ethics, Philosophical