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Ethics and Community in the Health Care Professions
  1. Richard E Ashcroft
  1. Lecturer, Centre for Ethics in Medicine, University of Bristol

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    Edited by Michael Parker, London and New York, Routledge, 1999, 207+ix pages, £14.99 (pb).

    This is the latest contribution to the excellent series on professional ethics issued by Routledge under the general editorship of Ruth Chadwick. The origin of the collection was a three-day conference at Blackpool organised by Michael Parker and Ruth Chadwick for health care professionals, social workers and ethicists on ethics and community. Some of the chapters in the collection were papers read at that conference, while others were prepared specially for this volume. The contributors are predominantly philosophers, but there are also essays from a health service manager, a senior doctor and a mental health service user. Most of the contributors are British, but there are contributors from Finland, the Netherlands, Canada and the United States. Areas of the health and social services covered include genetic counselling, mental health, care of the elderly and health services policy and management generally.

    Given that most health care ethics tends to be individual-centred, if not frankly individualistic, and that group allegiances (membership of families and social, cultural or economic groups) are often treated as if they were necessarily distorting or irrational factors in decision making, the topic of health care and communities has been somewhat marginal in recent medical ethics. Exceptions have been within feminist scholarship (with its general focus on relationships and solidarity) and in mental health (where the theorists, users, and practitioners have been debating the merits of care in community or institutional settings for many years). The recognition that individuals come in groups, and have bonds and affinities that are not always merely elective, can only benefit thought and action in health care ethics. But this recognition should be cautious.

    Community affiliation has been a powerful device in “identity politics” since at least the 1960s, in the women's, black and gay liberation movements. The language of community has now become very widespread, perhaps to the point of banality (the “intelligence community”, anyone?) Its political significance is very complex, linking as much to conservatism, nationalism and cultural exclusivity as to claims for liberty, equal treatment and respect, and social solidarity. Many readers of this book may also reflect on the dramatically various readings of Hegel, the father of communitarianism, that have dominated political thought in Europe, from Marx to Habermas on the left, and from Bismarck to Oakeshott and Fukuyama on the right. This diversity of thought suggests that whatever else communitarianism may offer, it won't make health care ethics easier to do, or create more consensus about method or policy, than the currently dominant liberal individualism!

    The opening chapter by Michael Parker very nicely sets the stage, discussing the relative strengths and weaknesses of communitarianism and liberalism as theories of ethics, and as positions within political philosophy. The most important contribution of this book as a whole is the reinsertion of health care ethics within political philosophy, a tendency that could usefully be followed through elsewhere in the field. His reservations about the usability of communitarian and liberal models tend to be borne out by the other authors. Of particular interest are those papers, notably those by Vivien Lindow, Chris Heginbotham and Donna Dickenson, which point out the rhetorical significance of appeals to community as a norm, especially in the absence of effective communities in fact. All the contributions are of a high standard of scholarship, and as a whole the collection is to be commended. Some of the papers have a weakness in that they offer only a redescription of some well-known problems, and do not suggest practical improvement in policy. For example, it can help us as philosophers to know why relationships are important and not secondary to individual wellbeing, but it hardly clarifies matters for the family trying to decide about nursing home care with and for their ailing grandparent. Perhaps the debate is mis-conceived: communitarians argue that liberals are systematically blind to relationships, to everyone's cost; and liberals argue that communitarians are unable to offer public reasons for their choices, to everyone's cost. As Michael Parker argues in his paper, what we really need is a better theory and practice of public reason.

    The contributions to this book are uniformly clear and well written. They are readable and will be stimulating to health care professionals and to philosophers and policy-makers. The collection hangs together as a book better than most such volumes and can be read from beginning to end with profit. It would be a useful textbook for a course on ethical issues in community and health care.

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