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On Moral Medicine
  1. G R Dunstan
  1. Exeter, Devon

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    Edited by Stephen E Lammers and Allen Verhey, Grand Rapids, Michigan, Wm B Eerdmans, 1998, 1,004 pages, £32.99 (sc), US$49.00.

    The sub-title of this book, Theological Perspectives in Medical Ethics, is a more accurate indication of its contents than the title. It is a compendium, an ordered collection of 128 reprinted theological and religious writings, grouped in nineteen chapters within three major sections - I. Perspectives on religion and medicine; II. Concepts in religion and medicine; III. Issues in medical ethics. Most writers are from the Judaeo-Christian world; the Christians are from the Roman Catholic, Reformed, Protestant and Anglican (Episcopalian) traditions. Other religions are referred to occasionally in passing, and “the ancient world” is present in quotation and commentary. The volume is a source-book, for reference. Some pieces may be read for pleasure; some with surprise - how often do we meet Thomas Sydenham, Florence Nightingale and W H Auden among the “bioethicists”? - some with toil, a dutiful struggle with web-spun words. Such a tome cannot be summarised in review; it can only be commended or waved away. This reviewer, from the depths of his native theological tradition, can only commend, but only to searchers prepared to work hard.

    The present phase in moral reasoning in medical practice began, in England, in the 1950s, with theologians and philosophers, notably I T Ramsey, R M Hare and B S Mitchell, talking with doctors working in fields specific to the discussion. There was no confrontation, because of a long tradition in British philosophical theology of respect for the empirical. In the USA the theological initiative, coming rather later, was explosive, controversial, because Paul Ramsey's covenant theology had no place for Joseph Fletcher's situation ethics. Indeed, Fletcher should be remembered (now that his warm, joyful spirit has passed from us with death) not so much for his now faded system as for his having drawn out of Ramsey his Deeds and Rules in Christian Ethics (1965), in which Ramsey restored “love” to theological intelligibility.

    Paul Ramsey stands high in this volume, and rightly so. He was at his best in The Patient as Person (1970), where he transcribes his covenant theology into the professional relationship between doctor and patient and the duties they owed in fidelity to one another and to society. After that, when he ventured into the new technologies of reproductive medicine and the like, he seemed to be more inflamed by journalists and writers of science fiction than attentive to what pioneers like R G Edwards and P C Steptoe were writing and doing. Ramsey could shoot down slogans, like “death with dignity” (he preferred “serenity”); yet in his later, more combative writing he could deploy the most untheological slogan of all, “playing God”, so foreclosing serious attention to dilemmas in neonatal intensive care. Just tributes are paid to him in this volume. O'Donovan praises above all his articulating “the meaning of justice as a feature of the good of society”; and Thomasma, though he would balance Ramsey's “covenantal” with “the sacramental character of human persons”, yet admires him for the rigour of his ethical thinking, too often lacking in Protestantism.

    Ramsey, O'Donovan and others in this volume pay their tribute to Karl Barth, who has dominated Protestant theology and ethics in this century. The selections from Barth reprinted here illustrate his greatness and his impossibility. He was a master of clarity when expounding his basic conviction, the centrality of Christ and his resurrection. When he tries to apply his theological principles to specific questions such as respect for life, parenthood, childlessness, and contraception, his prose becomes dense, his rhetoric impenetrable. Gustafson justly observes that some of his present day disciples are similarly entangled. (Theologians working in medical ethics should not talk to themselves but with medical practitioners).

    In contrast stands the writing of Childress who, no less firm and comprehensive in theological conviction, can go on to ethical implications in such an area as technological assessment, cost in risk/benefit analysis, and uncertainty in clear, reasoned, analytical prose.

    It is a shame, really, that this review has concentrated on a few professing theologians to the neglect of many more who, with theology implicit in their minds but not bubbling out of their mouths, have contributed to the wide range of issues covered in this volume. Modestly pre-eminent among these stands Daniel Callahan, who, in the Hastings Center, established a base for continuing collaborative reflection on issues in medical ethics as, in the last thirty years, they have tumbled on the scene. His achievement matched, to some extent, by Edward Shotter's pioneer work in UK medical schools and the Institute of Medical Ethics - should be on record.

    Let the last word be with a physician, as it ought to be. Thomas Sydenham (1624-89) writing on what every aspirant to the profession should think seriously about, put into twenty lines of limpid prose the fundamental theology which Barth, Rhaner and their/ kind laboured for in thousands. Of his four prescriptions the third is this: “... let him reflect that he has undertaken the care of no mean creature, for, in order that we may estimate the value, the greatness, of the human race, the only begotten son of God became himself a man, and thus ennobled it with the divine dignity, and, far more than this, died to redeem it” (page 145).

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